HomeMy Public PortalAbout5118 ROSEVALE DR_Building__ T�ORKERS COMPENSATION DECLARATION
(�L � 1<- F
s6r@ ae,%cer that 1 have a 8erhhcme of tion Insurance,
to self APPLICATION FOR BUILDING PERMIT
detsBre or gcenifroatq'of Work9n Compensation Insurance,
oor�a(r�pr(t,/lf�`�ycopy thereof (S 3800 � ) � COUNTY OF LOS ANGELES BUILDING AND SAF
0 o O`!SFt mpany BUILDING
❑ Certified copy is hereby furnished FOR LICANT FILL IN ADDRESS
Certified copy s filed with the c budding mspec BUILDING T CI
hon d/partment ADDRESS S LOCALITY
NEAREST /7
Dote��dA pllcont CITY C ZIP CROSS ST 1 L d-5-0
CERTIFICATE OF EXEMPTION FROM WORKERS' n NO OF BLDGS .�• ASSESSOR
COMPENSATION INSURANCE SIZE OF LOT 2 NOW ON LOT MAP BOOK PAGE PAR(IL
(This section need not be completed if the permit is for one TRACT.- BLOCK LOT NO U% I N Iel 2- 7-3
hundred dollars ($100)or less ) TEL SPECIAL >
I candy that in the performance of the work for which this OWNER s NO CONDITIONS d
permit is issued, 1 shall not employ any person in any manner DISTRICT GROUP TYPE FIRE SSm BY U
w as to become subject to the Workers Compensation Laws ADDRESS f n CONST_ ZONE cc
Moo /F ,I1l /n� /I f 15/( i
Date Applicant CITY (�/ V I/r ZIP ORCHITELi ORj` V77cR STATISTICAL CLASSIFICATION An CONDO O
NOTICE TO APPLICANT If, after making this CMifiCate of ENGINEER V NO ( / EJ 6 Q 1 A LV
CLASS No�DWFSL UNR
Exemption, you should become subject to the Worker d
Compensation provisions of the Labor Code, you must forth- ADDRESSa LA SEWER MAP • e • • N
with comply with such provisions or this permit shall be TEL /� 9 Z
deemed revoked CONTRACTOR jJ.�e_ NO 2'^• S �'+ V*�'4 TO JC
LICENSED CONTRACTORS DECLARATION
I hereby off urn that I am licensed under provisions of Chapter 9 ADDRESS LNO VALUATION • - 69a,255
Irr
(commencing with Section 7000)of DmBusinessaon 3 of the Business soLIC (f Sb 1009-86
Professions Code, and my license is in full force and effect CITY CLASS $ J z
.2 SO NO OF NO OF CHECK , t/ A,
License Number. LIrl Classes SIZE STORIES FAMIUES / ONE i� 5t/OdF
ContraqaWl� F 'Date DESCRIPTION OF WORK NEW $
0 1 am exempt under Set ADD ❑
ALTER ❑ FlNA
B 8P C for this reason REPAIR ❑ DATE
Dote
USE OF ❑ FIN
EXISTING BLDG OMtOI By
Signature APPLICM4T TEE
OWNER-BUILDER DECLARATION PRIM O NO
I hereby off um that I am exempt from the Contractor's License �� L✓1 i/.�T7/r ��_tA 10ILaw for the following reason (Section 7031 5, Business and ESS ���/1 r`�/c"'
Professions Code) PFMSENT
❑ BUILDING
I as owner of the property, or my employees with ADDRESS ` 3 6 4 Q 8 A
wages as their sale compensation,will do the work and
the structure s not intended or offered for sale(Section LOCALITY
7044, Business and Professions Code) MOVING TEL
property, am exclusively contracting \ 1
E] I as owner of the o CONTRACTOR NO - t• l`,, -
,
with licensed contractors to construct the project (Sec- ADDRESS \ 11 * 82725
tion 7044, Business and Professions Code) _
REWIREDTOTAL SETBACK FROM EXIST
CONSTRUCTION LENDING AGENCY SEF BACK YARD HWY PROP UK WIDTH • * 827255
hereby affirm that there so construction lending agency for FRONT
the performance of the work for which this permit s issued P L _ 01,27 -87
tSec 3097, Civ C ) SIDE
PL
Lenders Name
B PC Fees C/ / '�� Perms Fee
Lender s Address
t certify that 1 Is r Ls application and state that the Issuance Fee O ll
above Infor ori I agree to comply with all County Investigation Fee
ordinances to I relating to budding construction Total Fee
and here prize esentatives of this County to enix
uPon the v me on property for inspecttii'on)purposes
sa RevetsE FOR EXPLANATORY LANGUAGE
SiprgNro Applicant«Agent Date ms
jL
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