HomeMy Public PortalAbout10440 LA ROSA DR_Building__ WORKERS' COMPENSATION DECLARATION / rr •�
insure, afirm certifcatte of Workes' Compensatioe of n ent to Insurane, APPLICATION FOR BUILDING PERMIT
or a certified copy thereof(Sec. 3800, Lob,./C�..)� --7�
rPolicy o- _ ` ! Company .1 d - COUNTY OF LOS ANGELES 0'�/ o BUIL ING AND SAFETY
tr , Certified copy is hereby furnished. FOR APPLICANT TO FILL IN - ' BUILDING ' t
ADDRESS
Certified copy is filed with the county building inspeo- BUILDING
tion department. ADDRESS
� //� ��.•/ LOCALITY
NEAREST
CROSS ST
.�Date �S/ ✓ Applicant, CIT ZP
CERTIFICATE OF EXEMPTION FRO ORR /yNO.OFBLDGS. .
-
ASSESSOR
COMPENSATION INSURANCE 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
hundred dollars d not or less.) TRACL37-4 d BLOCK LOT NO. 1✓ NO. r� a
SPECIAL y
.I certify that in the performance of the work for which this NO. CONDITIONS d
/� GRTYPE Y
FIRE PR CESSED BO
permit is issued, shall not employ any person iISTRICT OUP n any manner X6DRESS // �� E LG.`� CONST. ZONE V
so as to become subject to the Workers'Compensation Lows. // 4/ ,.�
Date - Applicant CITY 10ICe, STATISTICAL CLASSIFICATON APT. CONDO. V
NOTICE TO APPLICANT: If, after making 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 Z
with comply with such provisions or this permit shall be —
deemed revokedTEL
- CONTRACTo /� /yfJ NO. a 8A BK. PG, VALIDATION
LICENSED CONTRACTORS DECLARATIONtic.C.
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS3/ � NO. 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 S. ►
NO. OE NO. OF CHECK
r License Number 5���� T�Lic.-Clos/ SIZE' �/y STORIES / FAMILIES ONE $ a i.y
Contrcctor�� �X Z7;tDate [o /S �� DESCRIPTION Of WORK /G= NEW ❑ I CJ
ADD r
I am exempt under Sec. ALTER ❑ FINAL 131=31111 PERM 11' REM90
❑ DATE l��Z�`C7 LR000'}f G f L;ii<.€i APPI10VED/Okoo
B.BP.C. for this reason - REPAIR
USE OF
Data: DEMOL FINAL (' Ylitirid. @SFa OEPdb APP9G VC.'il:�
EXISTING BLDG. ❑ BY _ }
Signature APP(LPRI CAN — TEL pp �•/
OWNER-BUILDER DECLARATION /C"G NO { (/
I hereby affirm that I am exempt from the Contractor's License Y(► P(� / 7
Law for the following reason (Section 7031.5, Business and ADDRESS
Professions Code): -
BUILDING . �- ;92821 A
I, as owner of the property, or my employees with ADDRESS ��� -
wages as their sole compensation,will do the work and �� # ee e e 2 3
the structure is not intended or offered for sale(Section LOCALITY
7044, Business and Professions Code). MOVING TEL 'l y CG� 2 o - 87.38
I, as owner of the property, am exclusively contracting - CONTRACTOR NO. 11 C
with licensed contractors to construct the project (Sec- ADDRESS .o a o'8 7,3 8=
tion 7044, Business and Professions Code). 'M ,
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH G 6 1 �5• 8 3
REQUIRED TOTAL SETBACK FROM EXIST.
—
I hereby affirm 2 82.2 A that there is a construction lending agency for FRONT tD
the performance of the work for which this permit is issued P.L,
(Sec. 3097, Civ. C.). SIDE
P.L.
//T/ T 1 e
Lender's Name } 712'- 59325'
$
Lender's Address P.C. Fee 8 J Permit FeeJ �/ 'e e 5 9 3. 2.5 6
I certify that I have read this application and state that the P Ja Issuance Fee d < �J
above information is correct. I agree to comply with all County Investigation Fee 0615-83
,
ordinances and State laws relating to building construction, Total Fee
b and hereby authorize representatives of this County to enter
upon/the/p bove-mentioned r perry for ins ection.purposes.
O /Gp�i fi SEE REVERSE FOR EXPLANATORY LANGUAGE
!!rSign ) a of Appli an gent Date - ®s