HomeMy Public PortalAbout9850 LA ROSA DR_Building__ WORKERS' COMPENSATION'DECLARATION • =
hereby affirm that I have a certificate of coosenlito self APPLICATION FOR
BUILDING PERMIT �
insure, or a certificate.of Workers'Compensation insurance,
or a certified copy thereof (Sec 3800,•Lob. C.) - ( - - "
State Com"Ins+ COUNTY OF`LOS ANGELES ' BUILDING.AND SAFETY
sty Policy No 2307J0 Company P
',{ O Cerrfied copy is hereby furnished. ., p FOR APPLICANT TO FILL IN nDDREss s ✓ `S�!
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"T Certified copy is filed witZthe. unity building inspec- BUILDING - ' - - - -
tion:department. .ADDRESS 9850 E, La Rosa
Dote - 1/1/89 i gppucon .Pres.; CITY Tem le City ZIP .91780 LOCALITY
CERTIFICATE OF EXEMPTION FROM' S'• - - - NO. OF BLDGS. '._ NEAREST
COMPENSATION INSURAN SIZE OF LOT NOW,ON LOT CROSS ST -
(This+section need not be;complefed if the.permit is for-one. BLOCK LOT NO.
, - - .. ASSESSOR -
hundred dollars ($100)orrv'less.) TRACT' - - MqP BOOK PAGE PARCEL
TEL: USE ZONE MAP
" certify that.in the,performance of the work for which°this OWNER - Grunwald' - 818 NO.-287-9841 N0.
permit is-issued,'I'shall not employ any parson in any manner ✓� SPECIAL
so as to become subject to the Workers'Compensation Laws. " ADDRESS. 9HSO E. La Rosa • CONDITIONS U
CITY Temple CitZIP 91780
Dote Applicant - - " -
ARCHITECT OR' TEL DISTRICT GR UP TYPE FIRE PROCESSED BY:
NOTICE TO APPLICANT: If, after making this Certificate of O
Exemption, ENGINEER NO. CONST./ ZONE ' V
p you should become subject Jo the.Workers' f V
Compensation provisions of the Labor Code, you mush forth- ADDRESS
with comply with,suchprovisions or,this permit shall be _ �'
deemed revoked: coNTRgcTORMontebello Rf TENo.I. -722-6975 STATISTICAL CLASST1 ATION APT, CONDO.
Z
LICENSED CONTRACTORS DECLARATION _ - LIC, -CLASS NO. v _ DWELL. UNITS_ -
I.hereby affirm that I am licensed under provisions of Chapter 9 T ADDRESS 868 Truck WayNO. 248852 _
(commencing with Section 7000)of Division 3 of the Business and _ LIC - SEWER
Professions Code, and my license is in full force and effect. CITY Montebello CLASS. C-39BK .-% VALIDATION
248852 C"39 SQ. FT. NO.Of NO.OF CHECK
License Nu er Lia Class SIZE . STORIES FAMILIES ONE
_ VALUATION t -
� Controc PTeSpote 5/31/,89 DESCRIPTION OF WORK 2 existin "roofs. NEW ❑ 6 2195.00
❑ I am exempt d ec. eroof w/ 23 sq Class "A" ADD ❑ ,
_ 1 erg ass shingles. Slope LTER
B.BP.C.for this reoson REPAIR
Data: USE OF .DEMOL ❑ ;29 0 7.4 A
EXISTING BLDG, dwelling # e'•IssY•)�
Signature - APPLICANT - - - TEL.
g Montebello Rf 722-6975 FINAL . 2& I •• 5 9,2 5
OWNER-BUILDER DECLARATION PRIN7 g NO.. DATE O -
I hereby affirm thahl.am exempt from the Contractor's License
Law for..the following reason (Section 7031.5, Business and ADDRESS 8688 Truck Way FIN ••• • 5 4.'2.5 x
v
Professions Code): - -' 9 - 2 2 9 f'
I, as owner of the property, or m}' employees with BUILDING
- - 6229.-88
wages as their sole compensation,will do the work and - Poo
-
the structure 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"contractorsto construct the project (Sec- ADDRESS ~ -
tion 7044, Business and Professions Code). ,
FROVW _ -
CONSTRUCTION LENDING AGENCY - REQUIRED SET BACK `YARD -HWV TOTAL SETBACK PROP.TINE WIDTH - -
hereby affirm that 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
_
P.I.
Lender's Name '
Lpermit Fee
48'.7S
Lender's Address LDMA Ref. If
I certifythat I have read this application and state that the 10.50
PP Issuance Fee LDMA P/C# ..
above information is correct. I agree to comply,with all County Investigation Fee - -
ordinances and State laws relating to building construction, Toml Fee S9.2S LDMA Perm. fl• . .
and hereb authorize representatives of this County to enter
upon-the ove-mentioned property for inspection purposes.
Pres 2/15/88 SEE REVERSE FOR EXPLANATORY LANGUAGE -
-Signature of pli n or Agent Data