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HomeMy Public PortalAbout10410 LA ROSA DR_Building__ Yi WORKERS' COMPENSATION DECLARATION 0I`­;r1.beebv affirm that,l have a certificate of consent to self >R_ insure, it o certificate of Workers' Compensation Insurance, ~APPLICATION FOR BUILDING PERMIT _ or o certified'copy'thereof (Sec 3800,'Lab. C.)' •` - — COUNTY OF LOS ANGELES BUILDING AND SAFETY ' Policy No. - 'Company El Certified copy is'hereby furnished-. - _ 3 FOR APPLICANT TO FILL IN ~BUILDING I•G 1 1,4,I�LSA ADDRESS ❑ ' Certified copy is filed with'the'county building'inspec- - BUaDWG nn - ,+� ,( ; tion'depaitnient. ` ! ADDRESS /O' e � F60sA 9? p I' -Date• ApplicantCITY �i��LL� Ur Y"'ZIP Q� LOCALITY' CERTIFICATE OF EXEMPTION FROM WORKERS' ,' - "- NO. OF BOGS. - '- '^ -' NEAREST - ° " COMPENSATION'INSURANCE SIZE OF LOT NOW ON LOT CROSS ST. (This section need nottbe completed if the-permit is for one - - -- -•- ---- - ASSESSOR, hundred dollars ($100)or less.) TRACT BLOCK ,'T LOT NO' p-, MAP BOOK PAGE PARCEL OWNER Pd Z14/A/C tJ:V At1'7ira'�0.57 ..7/G� USE ZONE MAP !'certify that in the performance of the work for which this NO. d a' - SPECIAL permit is,issued, I shall not employ any person in any manner ., ADDRESS,10/// -G� .(�w O so as to become subject'to the Wo rs'Compen ation Laws. CONDITIONS + U d 'y �•L •cwiG� lx�'rL/7Lf1 - CITY. EN�/�'✓�c..n. G •_ zip y/.'7.rid. - - .• cc Date Applicant ARCHITECT OR TEL O NOTICE TO APPLICANT: If, aft r ma king this Certificate of _ ENGINEER NO. DISTRICT GROUP TYPE . IRE ._ PRO ESSED BY.. . F Exemption, you should become subject to the Workers X CONST.. [ ZONE U Compensation provisions of,the Labor Code, you must.forth- ADDRESS with comply with.such 'provisions or this)permit. shall be - - '- TEL; STATISTICAL CLASSIFICATION APT. rONDO. ' Z deemed revoked. .,,- CONTRACTOR , NO. LICENSED CONTRACTORS DECLARATION - - -- - - - LIC, -- CLASS NO. v I DWELL UNITS_ hereby affirm that am licensed under provisions of Chapter 9 ADDRESS NO. SEWER MAP (commencing with Section 70DO).of Division 3 of the Business and - .. . ._ LIC. - - - Professions Cade, and my license is In full force and effect. CITY CLASS - BK "{ - VALIDATION - �, SO. FT . OF _ NO. OF .- CHECK_ I 1 - License Number Lic.Class SIZE STORIES ' FAMILIES ONE t V• NEW ,VALUATION , i - + - DESCRIPTION OF WORK' - 4AI,Contractor Date $ }eI am exempt under Sec. ... .© . _ l . _- - ADDALTER'8.8P.C. for this reasonJ7 � ` .REPAIR. ❑❑Date: EXISTING BLDG. DEMOL Signature - -- _ _ APPLICANT 'T ��.t TEL. p / FINAL'PRINT) " 0. vIEA.G'uivY NO. aOWNER-BUILDER DECLARATION _ -DATE-d hereby offirm that.l om exempt-from the Contractors License ADDRESS �� �'�� �u/� (L. ' CA' y/7PD FINAL +.Law for the fallowing reason (Section 7031 5, Business and 2J8,']A Pr e3sions Code) "' - PRE NT _ rr ,F IByBUILDING �O G,d. 'Q�. # °I, as owner of the property, or my employees with ADDRESS -wages as their sole compensation,will do the work and - - =the structure is notintended or offered for sale(Section LOCALITY L ( °.1 0.6.1 3' 7044,Business and Professions Code). MOVING TEL , OI, as owner of the property, am exclusively contracting CONTRACTOR NO. .- •, ° ° 1 OU 1 3" -with-licensed contractors to construct the project (Sec- tion 7044, Business and Professions Code). ADDRESS _ 0 a 02-85 . LENDING AGENCY REQUIRED SET BACK . YARD HWY' TOTAL SETBACKEXIST.PROP. LINE WIDTH. . . -_. `-'CONSTRUCTION _ I hereby affirm that there is a construction lending agency for FRONT the performance of the work;for which this permit is issued - P,I. - ry (Sec 3097, Civ. C.). SIDE - _ P.L. Lender's Nome \ m Lender's Address -- P.C. Fee$ - - Permit Fee - - V �• I certify..that.I have read this application and.state that the Issuance Fee 0- LDMA P/C# - Q' above information is correct. I agree to comply with all County Investigation Fee S ordinances and State laws relating to building construction, _ - _ Total Fee '� t 0 iDNA Perm. # , - -- t and hereby authorize representatives of this County to enter a upon t above-mned property for inspection purposes. o CZz w- 6� '� -Z a•I SEE REVERSE FOR EXPLANATORY LANGUAGE a - Sig azure-of Applicant or Agent - • ' -Date A� WORKERS'COMPENSATION DECLARATION ` ,y hereby affirm that I haver certificate of consent to =elf insure,br o certificate of Workers' Compensation Insurance, f APPLICATION FOR BUILDING PERMIT or a certified c�oopy'�tthh/ereof (Sec. U LI 3800, Lab C.) Polio ._Company eL_�[G [..�.f/ COUNTY OFAOS ANGELES BNND SAFETY Certified copy is hereby furnBUILDING ished. FOR APPLICANT TO FILL IN ADDRESS Certified copy is filed with the county building inspec- BUILDING , tion department. ADDRE55 Arf LOCALITY Date Z ��/�� Applicct NEAREST / R CITY ZIP' CRO SNEARS Si. CERTIFICATE OF EXEMPTION FRQ WoAve, --o NO. OF BLDGS. ASSESSOR COMPENSATION INSURANCE SIZE OF LOTyr.�JO O NOW ON LOT MAP BOOK PAGE PARCEL (This section need not be completed if the permit is for one TRAC /p GQ O BLOCK LOT NO. USE ZONE NOAP q a hundred dollars ($100)or less.) O� E - � I SPECIAL } T'I certify that in the performance of the work for which this OWNS . CONDITIONS d permit is issued, I shall not employ any person in any manner /� ,� DISTRICT .GROUP TYPE FIRE PR SSED BY O so as to become subject to the Workers'Compensation Laws. ADDRESS 7��i / vv CONST FIR'ZONV �O _ CITY _ ZIP " OLrl �i 3 O Date Applicant STATISTICAL C SSIFICATION A CONDO. V NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL. ENGINEER NO. CLASS NO.�DWELI. UNITS_ W Exemption, you should become subject to the Workers'- _ 6 Compensation provisions of the Labor Code, you must.forth- ADDRESS - SEWER MAP with comply with such provisions or this permit shall be //� z deemed revoked. Cow% t 1R �c"(vfljl/ NO �>✓, BK. PG, VALIDATION LICENSED CONTRACTORS DECLARATION LIC. -7 �-�y I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NOG1eJ 011rVALUATION (commencing with Section 7000)of Division 3 of the Business and LIC p r 5 Professions Code, and my license is in full force and effect. CITY CLASS LJ/ $ ► t—V .7 TL' SQ. FT.+�_,.� SOROS FAMILIES / CONEK �/L icense Number �G Lic Class /5 SIZE L-�T/ I' €p `-2 DESCRIPTION OF NEW � $ �� �( Contractor �4 /J7GDate 6 ���� _ ADD 1 am exempt under Sec. ALTER ❑ FINAL _ C%9flMV-n PEMMIT fiFO,IJ rL'i4A B.BP.C. for this reason REPAIR DATE �" ' 'I'D U D;f! RRPAl P1 3 CP P F'0 Si.[3: < Y USE OF FINAL EXISTING BLDG. V"�'^� . SIT 61�)I4 is.�4:?PIefJ.�{E{a:/1f`''��f� Data: DEMOL By w.. Signature APPLICANTTEL. OWNER-BUILDER DECLARATION (PRINT) RINT NO. I hereby affirm that I am exempt from the Contractor's License �F Law for the following reason (Section 7031.5, Business and ADDRESS .3 2 8 3 5 A Professions Code): PRESENT 7� - t BUILDING I, as owner of the property, or my.employees with ADDRESS fu.—QG o o e o 23 wages as their sole compensation,will do the work and the structure is not intended or offered for sale(Section LOCALITY !�� 2,- 0 9 1:8 0 7044, Business and Professions Code). MOVING TEL. O I,as owmeT of the property, am exclusively contracting CONTRAC70R NO. o e o 9 1 .8 O with licensed contractors to construct the project (Sec- ADDRESS 'tion 7044, Business and Professions Cade). 0 6 1 5-83 REQUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY SET BACK YARD HWV PROP. LINE WIDTH I hereby affirm that there is a construction lending agency for _ FRONT n 28 3.6 A the performance of the work for which this permit is issued P.I. f (Sec. 3097, Civ. C.). SIDE , ego ° a a 1'' P.L. m Lender's Name 2 ° / 1 k 7 5 P.C. Fee'$ ' Permit Fee u , {o o 71 4,7 5 2 Lender's Address �7 I certify that I have read this application and state that the Gr Issuance Fee /�• S C (s 1 5—8 3 above information is correct.i agree to comply with.all County Investigation Fee g ordinances and State laws relating to building construction, 7rd and hereby authorize representatives of this County to enter Total Fee upon thea ave-mentioned property for i pe<tio purposes. � - � - - !y SEE REVERSE FOR EXPLANA70RY LANGUAGE n Signa of Appt or A t Data' ®s li n