HomeMy Public PortalAbout9660 LA ROSA DR_Building__ WORKERS' COMPENSATION DECLARATION '�-�e�. ! / ✓i •�
insure, a,acer that haver certificate of tion Inarbpal: ' PLICATION FOR BUILDING PERMIT
insure, or a certificate of Workers' Compensation Insurance,
or�q"_ 11e, gpy COUNTY OF LOS ANGELES BUILDING AND SAFETY
Po Icy No. L Com/ppoony 9
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUDDING
ADDRESS
QCertified copy is filed with the co y building ins c- BUILDING
tion department. ADDRESS LOCALITY
NEARE
Date Q '..c�•' 7 Applicant CITY = ZIP CROSS ST.
CERTIFICATE OF EXEMPTION 46M WORKERS' NO.OF BLDGS. ASSESSOR
COMPENSATION INSURANCE SIZE OF LOT s NOW ON LOT MAP BOOK PAGE PARCEL
(This section need not be completed if the permit is for one POKY/ON O USE ZONE MAP p
hundred dollars ($100)or less.) _ TRACT BLOCK /V' LOTTEL. NO. d,0
. - i ( SPECIAL }
I certify that in the performance of the work for which this OWNER NO a CONDITIONS d
permit is issued, I shall not employ any person in any manner DISTRICT .GROUP TYPE FIRE PR SSED BY 0
so as to become subject to the Workers'Compensation Laws. ADDRESS �,V d CONST. ZONE
a 4 1 -3
Date Applicant CITY 7 �j / ZIP 7177 0STATISTICAL CLASSIFICATION APT. CONDO. Q
NOTICE TO APPLICANT:-If, after making this Certificate Of ARCHITECT OR TEL. 'Y07 • V
Exemption, you should become subject to the Workers ENGINEER C-. NO. CLASS NO.��DWELL. UNITS_
Compensation provisions of the Labor Code, you must forth- ADDRESS - '�(1 N
/
with comply with such provisions or this permit shall be Q SEWER MAP
�
deemed revoked. CONTRACTOR L./ TELEL7'07 '+ BK. PG, VALIDATION
LICENSED CONTRACTORS DECLARATION LIC.
I hereby'off irm that I am licensed under provisions of Chapter 9 ADDRESS Q NO. 0 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 J $0 7 2 2 A
�y [] SO. FT. NO.OF NO.OF CHECK
License Number-S21,970 Lia Cl.. ,RL SIZE STORIES FAMILIES ONE , s re e -'2 3
6AA�1k&WC/.4f/Gh Y_-2V_&5� $
Conbocto ate DESCRIPTION OF WORK NEW ❑ 2 °r3!7 8 0�5
I am exempt under Sac AD ® o 0 3 7 g O Y U
ALTER ❑ FINAL ^�� �Q
B.BP.C. for this ason REPAIR C] DATE Z-`-�/ !/' 0 ( 2 4— 4
USE OF FIN
DEMOL B
' EXISTING BLDG. / ❑ .
...cv - APPLICANT TEL. C)2 Q,.. A
Signature• PRINT NO. 7 p F
OWN R-BUILDER DECL ION
I hereby affirm that I am exempt from the Contractor's License ADDRESS ��b L OSA E LE r s e e
Law for the following reason (Section 7031.5, Business and Ott. , e 23
Professions Code): P EN Q - 2 ° 9 �. a
I, as owner of property, or my employees with ADDRESS
wages as their solele BUILDING compensation,will do the work and o to 1 9 188M
U
the structure is not intended or offered for sale(Section LOCALITY '
7044, Business and Professions Code). MOVING TEL. 0 9.1 9-84
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). 4 2(L b
REQUIRED TOTAL SETBACK FROM EXIST. -- o • e e'e
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE
I hereby affirm that there is a construction lending agency for FRONT _ WIDTH , ('s. 2 - 681.00
the performance of the work for which this Permit is issued P.1. -
(Sec 3097, Civ. C.). SIDE- - ° 0'6
F 1.0 0 E
BA.1/.L✓ wc'AMERICA P.L.
m Lender's Name 0 Q 1 9—8(f,
Lender's Address P.C. Fee E Permit fee
I certify that I have read this application and state that the Issuance Fee
above information is correct. I agree to comply with all County Investlgoti F e \ :\
ordinances and State laws relating to building construction, Total Fee
lY and hereby authorize representatives of this County to enter `J
• up a above-ment' ned proper y for in purposes. -
n Y _ SEE REVERSE FOR EXPLANATORY LANGUAGE
i aNre of plic or Age n Dote