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Home My Public Portal About10455 LA ROSA DR_Building__ " WDRKERS' COMPENSATION DECLARATION hereby affirm that have a certificate of consent to ,alt -APPLICATION F "I.LDING PERMIT insure, or a certificate of Workers�Lcr mpe tion Insurance, or y }tf% copy thereof Se . 380 k`� COUNTY OF LOS ANGELES, BUILDING AND SAFETY oli o. ompon Certified copy is hereby furnished. / BUILDING ❑ i/f' FOR APPLICANT TO FILL IN ADDRESS �Q P. edified copy is filed with the county wld' g mspec- [ADDRESS DING department. yc j�h E. y LOCALITYDate Applicant e \ ZIPCROSS NEARESTCERTIFICATEOF EXEMPTION FROM WORKERS' OF LOT3I�T NOW ON LOTS. © ASSESSOR COMPENSATION-INSURANCEMAPBOOK PA PARCEL chis section need not be com leted if the ermit is for one 7 '7 US DTE Phundred dollars (5100)or less.)• p T / ! BLOCK LOT NO. NO.1 SPECIAL dI certify that in the performance of the work for which this,- ER yl. N CONDITIONS - O permit is issued, I shall not employ any person in any manner I RICT GROUP TYPE FIRE P O ED BY V CONST so as to become subject to the Workers'Compensation Laws. ADDRESS ACZQNR CITY \ / 1 Date - Applicant 4 ZIP / STATISTICAO APT. CONDO. �/ NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL Exemption, you should become subject to the Workers" ENGINEER O. CLASS NiO. DWELL. UNIT N Compensation provisions of the Labor Code, you must forth-- ADDRESS I SEWER MAP Z with comply with such provisions or this permit shall be - deemed revoked. CONTRACTOR NO. BK. PG, VALIDATION LICENSED CONTRACTORS DECLARATION LIC, I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. � VALUATION (commencing with Section 7000)of Division 3 of the Business andLIC �• Professions Code, and my license is in full force and effect. _ CITY )T 'CLASS S 4 95 5 A SO, FT. NO. OF NO. OF CHECK ' 26SS�4 ' g I SIZE17 Q STORIES FAMILIES ONE License Number Lic.Class Contractor ral rkayen DP Date DESCRIPTION OF WORK 1,no hi NEW Z °.e•g t(a 4 0 ❑ - 1 ) ADD am exempt from the licensing requirements as am a 8 6 4 0 6 licensed architect or a registered professional engineer ALTER � FINAL �p e e e acting in my professional capacity (Section 7051, REPAIR DATE [// - Business and Professions Code). USE OF ✓� 04,24-81 _ EXISTING BLDG. DEMOL FINAL Lic. or Reg. No. Date APPLICANT (OLVTEL By 4 4s OWNER-BUILDER DECLARATION (PRINT) ^ Y7 NO. _ I hereby affirm that I am exempt from the Contractor's License 4 �G Mel n)'� Law for the following reason (Section 7031.5, Business and ADDRESS Professions Code): PRESEN .. F-1 1, - - - - I, as owner of the property, or my employees with ADDRESS _ wages as their sole compensation,will do the work and 7 x � (q.(�� 5.6 A the structure is not intended or offered for sole(Section LOCALITY \ 249 7044, Business and Professions Code). ' MOVING TEL. ❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO, to a o s with licensed contractors to construct the project (Sec- ADDRESS 2 - 5,60.50 tion 7044, Business and Professions Code). - REQUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY n G SET BACK YARD HWY PROP. LINE WIDTH ° ° 5 b 0 5 0 U ' 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. 0 Q 2 4—8 .(Sec. 3097, Civ. C.). SIDE - Lender's Name /�j� P.C. Fee S �/`--�10• /'� Permit Fe • V`� Lender's Address b I certify that I have read this application and state that the Issuance Fee 1 t above information Is correct. I agree to comply with all County Investigmion Fee ,y-- �l ordinances and State laws relating to building construction, Total Fee (� O V,/ and hereby authorize representatives of this County to enter upon the above-me4iione�lrty for in coon purposes. , a SEE REVERSE FOR EXPLANATORY LANGUAGE of Apor Agent Dote or r