HomeMy Public PortalAbout10405 LA ROSA DR_Building__ IT
WORKERS'COMPENSATION DECLARATION T•
hereby affirm that I havecertificate of consent self' APPLICATION FOR BUILDING PERMIT
insure, or o certificate of Workers' Compensation Insurance,
or a certified copy thereof (Sec. 3800, Lab )
G COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No S�� //7/Company fi
BUILDING
Certified copy is hereby turn6 FOR APPLICANT TO FILL IN ADDRESS'zo Q C- tl�
Certified copy is filed with the county building inspec- BUILDING
tion department. .ADDRESS 6.s
LOCALITY
NEAREST
Date [� /� �Applica /h� CITY ZIP CROSS ST.
CERTIFICATE OF EXEMPTIONOMPENSATION FR WOE E �q NO. OF BLDGS. /� ASSESSOR
CINS ANCE SIZE OF LOT 7W� NOW ON LOT (./ MAP BOOK PA
GE PARCEL
(This section need not be completed if the permit is for oneUSE ZONE MAP +�
hundred dollars ($100)or less.) TRACT -43 n BLOCK LOT NO. NO. U
TEL. �� SPECIAL y
I certify that in the performance of the work for which this OWNS NO. CONDITIONS d
permit is issued, I shall not employ an person in an manner // DISTRICT .GROUP TYPE FIRE PROCE ED BY O
p p y y p y ADDRESS Z /� /.6YZ4� `a fY CONST. ZONE V V
so as to become subject to the Workers'Compensation Laws. a
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CITY 6,. / ZIP /Qv.6 S V O
Date Applicant STATISTICAL CLASSIFICATION i APT. CONDO. h
NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL. /
ENGINEER NO. CLASS NO. DWELL. UNITS W
Exemption, you should become subject to the Workers' d
Compensation provisions of the Labor Code, you must forth- ADDRESS SEWER MAP W
with .comply with such provisions or this permit shall be /- Z
deemed revoked. CCgaV5E OD T
-ma y BK. PG, VALIDATION
LICENSED CONTRACTORS DECLARATION LIC.
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. VALUATI, O
(commencing with Section 7000)of Division 3 of the Business and LIC
Professions Code, and my license is in full force and effect. CITY // CLASS $ ,
F JNO. OF
License Numb&'�5+� ( Lic Class SIOZE FT G(1�
STORIES v FAMILIES CONEK
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Contr O Date �j/ DESCRIPTION OF R NEW '-J1r
ADD
I am ex t un/r c. ALTER ❑ FINAL / WIAUPERT REQUIRES
EP
B.BP.C. for this reason ROAR ❑ DATE I MS MI
� '�'r RRU'iiH GRADS('IG QPPRRVEF:14- -Ov.
Date: USE OF DEMOL ❑ 6 NAL �, l „� ¢;"ii:.L GR AMG APPIi.JVEL::�rJj/�/7
EXISTING BLDG. Y
APPLICA TEL
Signature Ny' .l - `
OWNER-BUILDER DECLARATION PRIk 4-+� / G fes` NO. 7 L % 2 85.3 A
I hereby affirm that g r exempt from the Contractor's License ► 7"
Law for the following reason (Section 7031.5, Business and ADDRESS # o e s o 'Z.3
Professions Code): PRESENT /*
F-1
2 0 ° 5 7.3 7
I, as owner of the property, or my employees with Q
wages as their sole compensation,will do the work and AI DDRESS S/3S o e'0 57 37•y
the structure is not intended or offered for sale(Section LOCALITY L.� / �
7044, Business and Professions Code). - MOVING TEL Cj/ 1(, � 2 0'6 1 5-83
❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO.
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code). _ 4 2 8 5 4 A -
REQUIRED TOTAL SETBACK FROM EXIST.
CONSTRUCTION LENDING AGENCY - SET BACK YARD HWY PROP. LINE WIDTH -
I hereby affirm that there is a construction lending agency Tor .FRONT
the performance of the work for which this permit is issued. F.L. , 2 -'6!6 Q 7 5
ZSec. 3097, Civ. C.). SIDE
P.1.
Lender's Name 'O ° 5.60 7.55
Lender's Address Permit Fee S0. .7-Y, 06 1 5_8 3
I certify that I have read this application and state that the 5'7 -7 Issuance Fee
above information is correct. I agree to comply with.all County Investigation Fee _
ordinances and State laws relating to building construction, Total Fee .0 1
u and hereby authorize representatives of this County to enter
upon the above-mentioned prop i f nspecI purposes. -
_ SEE REVERSE FOR EXPLANATORY LANGUAGE
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