HomeMy Public PortalAbout10430 LA ROSA DR_Building__ WORKERS'COMPENSATION DECLARATION
hereby affirm that I havecertificate of consent to self APPLICATION FOR BUILDING PERMIT LI IS
insure;br a certificate of Workers' Compensation Insurance,
or a certified copy thereof (Sec. 3800, La C.) COUNTY OF LOS ANGELES -�r13�BUILDING AND SAFETY
Policy Nd, �3 7/ Compony ''S- i +'-'d/ BUILDING C
erilfied copy is hereby furnished. FOR`APPLICANT TO FILL IN ADDRESS C td. 3Ar�
Certified copy is filed with the county building inspec- BUILDING
tion deportment. ADDRESS J19044i Zoz Q LOCALITY
NEAREST
Date I�Z_ /6_9fT Applican( 9 �e CITY ZIP CROSS ST.
CERTIFICATE OF.EXEMPTION FR W9 Ir NO. OF BLDGS Q ASSESSOR
COMPENSATION INSURANCP SIZE OF LOT ��O NOW ON LOT MAP BOOK PAGE PARCEL
(This section need not be completed if the permit is for one USE ZONE MAP O/Q
hundred dollars ($100)or less.) TRA a BLOCK LOT NO. NO.
\; TEL. �� SPECIAL ).
I certify that in the performance of the work for which this OWNER '� NO. CONDITIONS 6.
permit is issued, Ishall not employ any person in any manner DISTRICT .GROUP TYPE FIRE PRO ESSED BY O
so as to become subject to the Workers'Compensation Laws. ADDRESS �Z_ �OOc1r CONST. ZONE _ U
Date Applicant ZIP fe04 STATISTICAL CLASSIFICATION APT. CONDO. O
0
ENGINEER NO. CLASS NO. DWELL. UNW
NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL �s
RS
Exemption, you should become subject to the Workers' d
Compensation provisions of the Labor Code, you must forth- ADDRESS SEWER MAP N
with comply with such provisions or this permit shall be _deemed revoked. CON6AAQCLR3 9 �'S/ NEO
.i 2 BK. PG, VALIDATION
LICENSED CONTRACTORS DECLARATION - ���� �/ � LIC
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS N 6L VALUATION
(commencing with Section 7000)of Division 3 of the Business and LIC. y7
Professions Code, and my license is in full force and effect. CITY / CLASS ,p r $'-G�77�>C�U
SIOZE� p- STORIOES FAMILIES / CO ONE ) ,
License Number 2 �6Lia Class r� (/ 0 0 tµ
�/ NEW 2l $ a,/
ConF_Jtr ate DESCRIPTION
ADD ❑
I am e pt u er c.
ALTER ❑ FINAL (�e?;3CI�y8 PERMIT RE[1USAvB /
'B.BP.C. for this reason REPAIR E] DATE x/_30. Lc':UUM CRADWI:I. APFEOVED kill
USE OF
Date: EXISTING BLDG. DEMOL ❑ FINAL <� E{ sdi�.- UI ADHIG R s^.RAVL: SJI�j1<�`3
Signature APPLICAN TEL
g OWNER-BUILDER DECLARATION PRI �f.+ NO.� /J/uj7`/`J r 2 8 Q,3,q
I hereby affirm that I am exempt from the Contractors License /- l� 7 7'tP
Low for the following reason (Section 7031.5, Business and ADDRESS
Professions Code)' 'PRESENT
❑ BUILDING C / / 2 e e.L 3 1 2
I, as owner of the property, or my employees with ADDRESS �O �(O io U
wages as their sole compensation,will do the work and - x
9 P LOCALITY- a e m r6 3. L2
the structure is not intended or offered for sale(Section 7
7044, Business and Professions Code). MOVING TEL. r
'
I, as owner of the property, am exclusively contracting CONTRACTOR NO. 15-83
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code).
REQUIRED TOTAL SETBACK FROM EXIST. 2 H G.4 A
CONSTRUCTION LENDING AGENCY SET BACK YARD HwY PROP. LINE WIDTH.
I hereby affirm that there is a construction lending agency for FRONT , �; o e e o e 1 -
the performance of the work for which this permit is issued P.I. '
(Sec. 3097, Civ. C.). SIDE 2 0•6,6-0,7_5 '
m
P.I.
Lender's Name o 660
P.C. Fee$ ' - ! % V Permit Fee U. 2
0615-83
Lender's Address ! /
I certify that I have read this application and state that the G 3, °Z 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 C) Sr
u and hereby authorize representatives of this County to enter
upon the above-mention e pr perry for i sp coon purposes.
a
.� SEE REVERSE FOR EXPLANATORY LANGUAGE
Sig I reof Ap icon r Agent Date ®s