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HomeMy Public PortalAbout10415 LA ROSA DR_Building__ WORKERS' COMPENSATION DECLARATION �F hereby affirm that I havecertificate of consent to self APPLICATION -VOR�� BUILDING PERMIT 11SI insure, or a certificate of Workers' Compensation Insurance, �' or a cerj�fied copy thereof (Sec. 3800, L;?. ..) COUNTY OF LOS ANGELES BUILDING D SAFETY Poficy 0/3�Company Certified copy is hereby furnished. FOR APPLICANT TO FILL IN - BUILDING ADDRESS ❑ Certified copy is filed with the county building inspec- BUILDING // tion department. ADDRESS L LOCALITY Dote it .1! D 7 Appliccm �O'LR i- CITY ZIP CROSSSST. CERTIFICATE OF EXEMPTION FRO OR RS' NO. OF BLDGS. ASSESSOR SIZE OF LOT NOW ON LOT 40 MAP BOOK PAGE PARCEL COMPENSATION INSURANCE (This section need not be completed if the permit is for one �) USE ZONE MAPA D/Q hundred dollars ($100)or less.) TRACT [l BLOCK LOT NO. NO. T ♦ TEL. - ,j SPECIAL y I certify that in the performance of the work for which this OWNEP/- ' NO. CONDITIONS d permit is issued, I shall not employ any person in any manner � .- wA, J _._ DISTRICT GROUP TYPE FIRE PR SED BY O , so as to become subject to the Workers'Compensation Laws. ADDRES A:9,'e u•'G" CONST. ZONE V 5.0 CITY ZIP 0 /d0 — O Date Applicant - STATISTICAL CLASSIFICATION APT. CONDO. V n�T NOTICE TO APPLICANT: If, after makin this Certificate of ARCHITECT OR TEL. / 'Exemption, you should become subject to the Workers' ENGINEER NO. CLASS NO. DWELL. UNITS_ d Compensation provisions of the Labor Code, you must forth- ADDRESS SEWER MAP with comply with such provisions or this permit shall be �i Z deemed revoked. CON ! N07��•�GY.TEL ? BK. PG, VALIDATION LICENSED CONTRACTORS DECLARATION LIS, I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS N VALUATION (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 / E 6 e, 9 SO. FT. STO_FNOOF NO.OF CHECK ► License Nu `7 Lic Class /� SIZE STORIES FAMILIES ONE �� a O d Confryc ot" r%_6�� L Dote �� S� DESCRIPTION OF WO - y�a _ NEW ADD ❑ ❑ I am exe pt un er 5 c. ALTER ❑ FINAI r C-RAIIIAIG PF.PMiT RE(iUMKI B.BP.C. for this reason ❑ DATE % e3 'iAM-110 REPAIR ff�V�. �i Dale: USE OF _ .FINAL f EXISTING BLDG. - DEMOL ❑ By et '�e�` Signature APPLICA TEL. OWNER-BUILDER DECLARATION PR NO. I hereby affirm that I am exempt from the Contractor's License , /� 4 /! �V 0 2 8 U,5 A Low for the following reason (Section 7031.5, Business and ADDRESS , Professions Code):❑ PRESENT ^�/ !' e -.- - 23 BUILDING E /// YV ' I, as owner of the property, or my employees with { ADDRESS 2 e e 6 3 1 2 wages os their sole compensation,will do the work and LOCALITY a ( the structure is not intended or offered for sale Section 7 z 7044, Business and Professions Code). MOVING TEL. o °I°,6 1 2 U I, as owner of the property, am exclusively contracting CONTRACTOR NO. 0,6, 1 5—83 with licensed contractors to construct the project (Sec- ADDRESS ' tion 7044, Business and Professions Code). _ "REQUIRED, CONSTRUCTION LENDING AGENCY $ET BACK YARD HWY TOTAL SETBACK FROM EXIST.PROP. LINE WIDTH Poo. 8 G.6 A I hereby affirm that there is a construction lending agency for FRONT the performance of the work for which this permit is issued -.PL 0 0 0 o e (Sec 3097, Civ. C.). SIDE P.L Lender's.Nome ,2 "6'6 0,7 5 Lender's Address P.C. Fae$ Perrno Fee S0 .2 - e e b 6 0,7 5 i I certify that I have read this application and state that the 3, Z Issuance Fee J 0 6 1 5—83 above information is correct. I agree to comply with all County Investigation Fee I, ordinances and State laws relating to building construction, Total Fee f� G and hereby authorize representatives of this County to enter U0 the aba e-mentioned p op ty for insp ction purposes. - t SEE REVERSE FOR EXPLANATORY LANGUAGE Signal of Appli nt gent - Data ®s r. WORKERS'COMPENSATION DECLARATION v nt to self in��ebo�afcertificatteoYWorkers'tCompensatoneInsurance, APPLICATION FOR BUILDING PERMIT or a certified copy thereof (Sec. 3800, Lob. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company Certified.aopy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING a ADDRESS cL /1 71 Certified copy is filed with the county building insper BUILDING I r J tion department. ADDRESS © 7 L.. 'tJ� )- �L� VO Date Applicant CITY R,L ZIP 191t LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' ( 'y NO OF BLDGS. 1 NEAREST J� / COMPENSATION INSURANCE SIZE OF LOT Z NOW LOT / CROSS ST./'S .i ° CQ ' )Qs, U. (This section need not be completed if the permit-is for one ASSESSOR' hundred dollars ($100)or less.) TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL TEL, fy'`L—Z OS. USE NE MAP OWNER qC f NO. 'N ' I certify that in the performance of the work fo hich t ' NO. - permit is issued, I shall not p any parson' y net ADDRESS���I7 L�+� Q I SPECIAL so as to co a ubje<t to he W rkers' a Q. (� CONDITIONS U Dates Applicant CITY { ZIP 1(l i `v � NOTIC TO PPLICANT: If, aft making this Certificate o ARCHITECT OR /S' TEL. DISTRICWCO'NS FIRE PR OC SED BY O Exemption, you should bec a zubjeci to the' Workari ENGINEER •YAT NO. ^ 'a i. Z9fJE UCompensation provisions of the Labor Code, you must forth- ADDRESS 6 (5 C- $Q SU J�' Ld with comply with such provisions or this permit shall be D.' deemed revoked. TEL. STATISTICAL CLASSIF CATION APT. DO. Z CONTRACTOR ��`` NO. LICENSED CONTRACTORS DECLARATION LIC, CLASS NO. DWELL. UNITS_ 1 hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO.. (commencing with Section 7000)of Division 3 of the Business and LIC SEWER MAP Professions Code, and my license is in full force and effect. CITY CLASS BK 2 PGO VALIDATION SQ. FT. . NO. OF / NO. Of CHECK License Number Lic.Class SIZE STORIES 1 FAMILIES - ONE �f VAL ATION v DESCRIPTION�OF WORK NEWS® Contractor Date lr"l1 N$-SI� ,� ADD ❑ $ , IAP exempt under Sec ALTER ❑ �4 8.8P.C. for this reason REPAIR ❑ $ / .USE Of Date: DEMOI ❑ EXISTING BLDG. Signature APPLICANT TEL '�,�/�3 FINAL PRINT) &C- 1 DATE OWNER-BUILDER DECLARATION � NO. v I hereby affirm that I am exempt from the Contractor's License ( /� Low for the following reason (Section 7031.5, Business and ADDRESS dqf L7 LA Savf FIN Professions Code): PRESENT By El. BUILDING I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and LOCALITY , the structure is not intended or offered for sole(Section 7044, Business and Professions Code). MOVING TEL. s I, as owner of the property, am exclusively contacting CONTRACTOR NO. A9 4 9,'4'A with licensed contractors to construct the project (Sec- ADDRESS " tion 7044, Business and Professions Code). REQUIRED TOTAL SETBACK F CONSTRUCTION O AGENCY SET BACK YARD HWV PROP. LINE WIDTH I e • 4 Q 5 0 ROM EXIST. hereby affirm that there is a coonstrunstru ction lending agency for FRONT - 4Q506 the performance of the work for which this permit is issued P.I. (Sec. 3097, Civ. C.). SIDE P.L. - 05,22"88 Lender's Name t LDMA Reb X •• r ! � v\�� cti Lender's Address - P.C. Fee E Permr Fee 3 I certify that Lhave read this application and state that the . . Issuance Fee LDMA P/C above information is correct. I agree to comply with all County Investigation Fee ordinances and State laws luting to building construction, Total Fee LDMAPerm. R and hereby outhori a rept s ntatives of this County anter on the abov one aper for inspect p peas§s. Q CXJ:. v Q SEE REVERSE FOR EXPLANATORY LANGUAGE J C/ Signature of Applicant or Agent D to31,01T-5 ,0f ('—5 JV-Fft.�rm RKERS'COMPENSATION DECLARATION i ,ce4ica hover certificate of tion Int to Self APPLICATION FOR BUILDING PERMIT l� insure, oro <erlThcotry of NJorkers' Compensation Insurance, or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company Certified c9py, is hereby furnished. FOR APPLICANT TO FILL IN BUBOwG /� / A nS� f�— ❑ ADDRESS V L.f1 Con dep copy is filed with the county building inspec- BUILDING/Q q �r // ig OSA e �� tion department. ADDRESS I 4 /JIB-t p�(`� Date Applicant CITY/t' ke f ZIP �l ! o " LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' �f ^ NO. OF BLDGS. NEAREST COMPENSATION INSURANCE SIZE OF LOT / I� NOW ON LOT I CROSS ST. A rJ%, N L CL K01k (This section need not be completed if the permit is for one TRACT BLOCK LOT NO. ASSESSOR hundred dollars ($100)or less.) MAP BOOK PAGE PARCEL �,L TEL. USE NE AMP OWNER tk 1/r1 G b -En'S No.44L-Zlb I certify that in the performance of the work for whit his {� 'NO. permit is issued, I shall not a loy any person in y on er ADDRESS101f �- 00. Dn I SPECIAL so os to becom s bject to a rkeri Co do Lo s. t CONDUIONS c) q U y Z 25 6 CITY Q w 11 Date Applica t T ZIP M ARCHITECT O TEL. DISTRICT GR P TYPE FIRE PROCESSED BY O NOTICE O APPLICANT: If, of r mubjectt to Certificate of / '4 CONST., Z,1NE U ENGINEER L I NO. �� Exemption, you should bac a subject to the Workers' r-'� r Compensation provisions of the Labor Code, you must forth- ADDRESS ] G t u/ W with comply with such provisions or this permit shall be / deemed revoked. ��* TEL STATISTICAL CLASSIFICATION APT. NDO. N CONTRACTOR NO. �� )) Z LICENSED CONTRACTORS DECLARATION UC CLASS NO._(eL(_DWELL. UNITS_ - I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. SEWER MAP (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 BK. PG. VALIDATION SO. FT. NO. OF / NO. OCHECK _ License Number Lic.Class SIZE I L STORIES I IF M1L1'ES ONE Contractor Date II��r DESCRIPTION OF WORK ! NEW VALUATION IN rlrl.--..-J��1 (f(l I am exempt under Sec. 111( AidQ vtv ADD $ ALTER ❑ �9046A B.BP.C. for this reason REPAIR ❑ $ USE OF # e e s e e tl Dale: EXISTING BLDG. R DEMOL ❑ f e - 59.25 Signature APPLICANT TEL Z.. 0 FINAL Q e s e = OWNER-BUILDER DECLARATION PRINT 0 S C , NO.`fy u 3 DATE 5 9. 2 5 0 1 hereby affirm that Iam exempt from the Contractor's License ��// ^` /' 0 225-88 Law for the following reason (Section 7031.5, Business and ADDRESStc) /! Ln I�elQ r �.4 ��' FINA Professions Code): PRESENT y OBUILDING I, as owner of the property, or my employees with ADDRESS wages their sole compensation,will o the work and the structure for is not intended or offered for sale(Section LOCALITY • ' 7044, Business and Professions Code). MOVING TEL. 's 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). CONSTRUCTION LENDING AGENCY REQUIRED YARD HWY - TOTALPROP.SETBACK LNE WIDTH ' I hereby affirm that there is a construction lending agency for FRONT ' the performance of the work for which this permit is issued P.L. (Sec. 3097, Civ. C.). SIDE j P.I. Lender's Name / LDMA Ref. If m Lender's Address P.C. Fee$ Permit Fee ` -- I certify that I have read this application and state that the Issuance Fee LDMA P/C N '. _ above information is correct. I agree to comply with all County Invesligation Fee ordinances and State laws relating to building construction, Total tae L LDMA Perm. If ' and hereby autho ' re a eftatives of this County to enter upon the aba 'on d .for inspectio pu oses. Z.� SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent to16) - ?.. . s WORKERS' COMPENSATION DECLARATION n hereby affirm That I haver certificate of consent to =elf APPLICATION FOR BUILDING PERMIT insure, or a certificate of Workers' Compensation Insurance, or a certified copy the (Sec. 3800, Lab. C.) - COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company .'Certified copy is.hereby furnished. U LDING FOR APPLICANT TO FILL IN ADDRESS /� Certified copy is filed with the county building inspec- BUILDWG ... lion department. ADDRESS ls# {^ -ve, Date Applicant CITY ZIP CJ LOCALITY ' CERTIFICATE OF EXEMPTION FROM WORKERS' NO. OF BLDGS. NEAREST COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS ST. (This section need not be completed if the permit is for one v ASSESSOR . , hundred dollars ($100)or less.) TEL TRACT BLOCK LOT NO. O MAP BOOK PAGE PARCEL �` NO. USE ZONE MAP I certify that in the performance of the work for Which this NO.�F SPE 7 permit is issued, shalt not employ any person in any manner ADDRESS �� �•� SPECIAL so as to be<ome.subject to the Work rs'Compensation Laws. 0 � #_� CONDITIONS 0 CITY (� ZIP �I/�D 0 Date Applicant NOTICE TO APPLICANT: If, after making thi Certificate of, ARC ITECT ORF TEL. DISTRICT GROUP TYPE FIRE SED By ENGINEER J NO� CONST, ZONE I— Exemption, you should become subject to the Workers' - - �'` V, Compensation provisions of the Labor Code, you must forth- ADDRESS - �./. Up a — LL with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION APT. CONDO. N deemed revoked. CONTRACTOR NO. z LICENSED CONTRACTORS DECLARATION _ LIC. CLASS NO. DWELL. UNITS_ I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. SEWER MAP _ (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 VALIDATION SO. FT. NO.OF NO.OF CHECK BK. PG. License Number Lic.Class SIZE Sao STORIES nFAM_ILIES 'ONE �o vC� .NEW VALUATION , Contractor Date DESCRIPTION OF WORK O $ 3 ADD ' I am exempt under Sec. ALTER Li B.BP.C. for this reason REPAIR $ Date: USE OF • ❑ EXISTING BLDG. DEMOL Signature APPLICANT TEL - FINAL OWNER-BUILDER DECLARATION PRINT NO. DATE I hereby affirm that I am exempt from the Contractor's License Law for the following,reason (Section 7031.5, Business and ADDRESS FIN Profe ions Code): PRESENT - BY as owner of the property, or my employees with BUILDING w ADDRESS wages their sole compensation,will o the work and 'x v the structure for is not intended or offered for sale(Section LOCALITY - , 7044, Business and Professions Code). MOVING TEL ❑ 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). \ - — 7 p q sQp❑P CONSTRUCTION LENDING AGENCY SETT BACK YARD HWY TOTAL ROP.btl LINE WIDTH v - 41Y 1'I` I hereby affirm that there is a construction lending agency for FRONT (iY.• • 7 Q O 0U the performance of the work for which this permit is issued .P.L. - - . - e­ 7a005 (Sec. 3097, Civ. C.). SIDE P.1. O 7.0 2..`$7 Lender's Name LDMA Ref. q . Lender's Address P.C. Fee S Permit Fee. (Q / ✓ v I certify that I have read this application and state that the Issuance Fee 70 LDMA P/C A ' above information is correct. I agree to comply with all Count 9 PY Y Investigation fee. ordinances and State laws relating to building construction, U n and hereby authorize representatives of this County to enter Total Fee LDMA Perm. q $ Qlory the above-mentioned ploperty,for inspection purposes. SEE REVERSE FOR EXPLANATORY.LANGUAGE Signa a of Applicant or Agent - Data -