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Home My Public Portal About9102 HERMOSA DR_Building__ WORKERS COMPENSATION DECLARATION _ -�� _.. 840573 LA' s •+t -^_� ....._._, __ „ ' I;hereby affirm that have Ors' ome,of consent to self ~ APPLICATIO.N FOR��U.ILDIN:G': PERMIT: y �� insure or a certificate ofWorkers' Compensation Insufance, or cicertified copy thereof (Sec 3800;•LaE C )'-"i - Polio No.IV84=.225154, COUNTY OF LOS ANGELES ,Y BUILDING AND SAFETY y p y_.'.Fremont. Indem'n.1ty- - - - m an b .•+Certified co is nereb tarnished:. t +•'•f - BUILDING ❑, copy y:,• . FOR APPLICANT TO FILL IN ADDRESS /. Certified copy is f ledwith the county bmlding inspec- - -' BUILDINGET - - - - -` non department ADDRESS 9102 Hermosa Dr. Date .11/2/84 Applicont V 1 rg I IT 'Roof ,Co. CITY Tent e cit ZIP - LOCALITY- CERTIFICATE OF EXEMPTION'FROM WORKERS' ' ' -No. OF BLDGSr- - NEAREST .T ..._ .,,. _ ' �n." COMPENSATION-INSURANCE. ;n 'a SIZE OF LOT NOW ON LOT CROSS ST. ftis,section•need not•be`.completed if'Jhe,permihASSESSOR - is'for one -- - -- - - � -- '- -• •-- - ' + hundred dollars ($100)or less.) „ ., TRACT' BLOCK LOT.NO. ' MAP BOOK PAGE• PARCEL f Y TEL r USE ZONE MAP -' I cernf that in the performance of thework far which this OWNER "M NO. "' "' _ ' NO. ''3' permit is issued, 1 shall not employ any person in.any manner _ - --2lSPECIAL - - ------ . . - - . - ..•. .ADDRESS--aS. above . . _" -__ "' C/ so as to became subject loathe Workers'Compensation laws. 'CONDITIONS - i F U ._ CITY_ _ _. - ' _. ZIP.__ . ..t1"_. t _ K Date Applicant ARCHITECT OR TEL - - NOTICE TO APPLICANT If,`after making this Certificate•of DISTRICT GROUP, TYPE FIRE_ ..PRO ESSED BY H - ENGINEER NO. I, CONST ZONE - U Exemption i you should become subject to the� Workers' /�Xx //(� t W Compensation provisions of the Labor Code you must•form- ADDRESS -s Vl1/V- R75 -. T.3• - N -with comply with.such.provisions ror„this permit shall be ._ . ._ _,. _ - - - .. TEL - - - STATISTICAL CLASSIFICATION APT. COND Z deemed,revoked . r .. CONTRACTOR V 1 r i nR No. - 9 1 _ LICENSED CONTRACTORS DECLARATION - - - - -- -tle, CLASS No. zi _DN/ELL. UNITS'_ I hereby affirm that.I am licensed under,provisions of.Chapter 9 ADDRESS P.O.. BOX J NO. 160650IIIIIIIIIIIIEW (commencing with Section 7000)of Division 3 of the Business and -, _ ._- - .- LIC. --- _ . SEWER P .. S E MA Professions Code, and my license is in full force and effect. CITY San .Gabr 1 el -CLASS C39 - _ '" VALIDATION - s�. rte' 4. 1 , SO. FT. _ NO.OF NO. OF _ CHECK BK. PG' _1606 0 C slzE STORIES AMILIES ONE License Number 5 Lic'{lass 39' ' .. I . VALUATION _ _ 't p Co Nractol+ I rC]1 n ROOF' CO - Dote 1 172784 L DESCRIPTION'OF WORK'Re-rOOf hOl1SE NEW -O $ •2000.00 • #4'• O 4 3 @1DD ' F-1om exempt under sec. - • - garage with Class A comp. shin Aes B.BPC. for this reason - 23 sqs. Flat area hot mop wlih REPAIR. .❑ $ - ' --•L - _ _ .... - -'- - Date -' USE OF EXISTING BL G�0, 15 & 72. 3 sqS.. DEMoL ❑ _...`.. .. ... . .:... .. _. .Signature --"-`.,. __.. _ .__ ' APPLPRINT) Virgin, Roof CO. Np, 287-0507 FINA ,/) OWNER-BUILDER DECLARATION _ _ _ (;Q — -- -- - - --- Ihereby offirm.tho4l am exempt fromthe Contractor's License ADDRESS P.O. BX JF San Gabriel .91778 FIN Low for the following reason.(Seaion 7031 5, Business and - ' 'Professions Code)" . . .• '• '-_ '."",`. . . PRESENT By 0 ' ' BUILDING • ❑ ' I, as owner of the-property, or_my employees with ADDRESS _ _' _ _ •__ _ __ _ - wages as their sole compensation,will do the work and 7 the structure is not intended or offered for sale(Section LOCALITY -`7044 Business and Professions Code). ` " •- MOVING ' ' - 'TELT 1, as owner of the property, am exclusively contracting CONTRACTOR NO. , - •- j with licensed`contractors to construct the project (Sec- -' -- - -' - "- -' --' - • - - -' '-- -' - " "-' tion 7044, Business and Professions Code). ADDRESS. -•.r _ SETT BACK' :. TOTAL PROP. LINE FR WIDTH. CONSTRUCTION LENDING AGENCY -' - YARD - HWY - - I hereby affirm thaP,there is a construction lending agency for- FRONT + -,the'performance-of the work for which this permit is issued - • - PA. • - • -- ' •- - - -+ - - - =- - - (Sec. 3097,-Civ. C.), SIDE , •'7 .o•.. Lenders Name - y LDMA-Ref, # 0 0 _ d Permit Fee.__ .39.38-,- Lender'ss Address . 1 _.I certify that.I haveread this opplication and state,tbat the _.:.., _ ._ _ - .- Issuance Fee- ---10.50. .._. LDMA P/C# _ Q above information is correct. I agree to comply with all County Investigation Fee m ordinan sand:Stole laws relating to building construction, 49 -88' _ '" _ _-_ _ _ _ _ :Total-Fee • +CDMA Pair,,, # .:•^_-. _ - _ I _ � and her by autho a'4 representatives f this County to enter , m upon above-mentioned pr erty f Lawechoo purposes. o ♦ // ^.,;L-iT hC SEE REVERSE FOR EXPLANATORY LANGUAGE -Sig re of Applicant or Agent------ - -- Date - -- - - - ^• "- -'• - WORKERS' COMPENSATION DECLARATION - .I sur, oa certificate that I fiave r certifompens consent to self APPtICAT.ION FOR- BUILDING PERMIT r insure y of certificate of Workers' Compensation Insurance; " , certified copy.thereof (Sec. 3800, Lab C ) t• . - COUNTY OF LOS ANGELES . BUILDING AND SAFETY - ' W0007.146 Beaver .Insurance "Policy No. Company r BUILDING ❑ • Certified copy is hereby furnishedr - APPLICANT TO FILL IN gDORES$ O . - ® Certified copy is filed with the county building inspec- -` F7LOCK -tion department. . Hermosa Dr. Dote 7-1-90 AppLcant Virgin RoofCo. it ZIP 91780_ NO. OF BLDGS. - .. .. NEARESTCERTIFICATE OF EXEMPTION..FROM WORKERS"'_ NOW ON LOT CROSS ST. COMPENSATION INSURANCE - - _ - ASSESSOR(Thissection need not be completed if the permit is For one BLOCK LOT NO. MAP.BOOK. PAGE PARCEL hundred dollars ($100) or less ) _ _ :TEL. _ - - - OWNER Frank WOn 'NO. US ZO E. MAP " `I certify that in the performance of the work for which this . 71 NO. permit is issued,i shall not employ any person in any manner SEE ADDRESS •9.102 E. Hermosa Dr'. 1 CONDITIONS a so as to become subject to the Workers'Compensation.Laws. - O CITY Tem le Cit - 'ZIP 91780' - u Date - - Applicant C- - - ENGINEER OR -TEL DISTRICT GROUP TYPE' "FIRE PROCESSED BY NOTICE TO.APPLICANT: If, after makingthis Certificate of - - ENGINEER-� - —� � -NO. " � - /.y �! '� CONST. ZONE t/J ' U Exemption, you should become subject fo the. Workers' /✓, /v�U( 1V'G.J Compensation;on-pr the Labor Code you must-forth- Com - ADDRESS - 1 d with comply with such provisions or this,permit shall be TEL STATISTICAL CLASSIFICATION APT. CONDO. N deemed revoked. - r CONTRACTOR Ulr 1n Roof Co. NO. 287x0507 _ ? LICENSED CONTRACTORS DECLARATION., UC. CLASS NO. DWELL. ILL I hereby affirm that I am licensed under provisions of.Chopter 9 - _ 'ADDRESS NO._160650 • (commencing.with Section 7000)of Division 3 of the Business 4 LIG. SEWER MAP and Professions Code,and mylicense is in full force and effect. 'CITY ,- CLASS C39 BK PG..61 _ VALIDATION _ License Number 1'60650 SQ. FT. STONO,RIES OF NO. OF CHECK , Lic-Class• C39 SIZE 25 g STORIES '1 FAMILIES ONE 1 VALUATION CohnoctorVir in Roof 'Co. Date 6-30-91 01ESCRIPTIONOFWORK Tear 'off al NEW ❑ $ 10,342.00 ❑I am exempt under Sec. 'TOOfs' then apply Class "Cn ADD ❑ , B.BP.C.,for this reason Medium Shakes ALTER .❑ - " - p i � . .� REPAIR ❑ $ USE OF EXISTIING B TEL. - - ' Dote: � '" EXISTING BLDG Dwellingm.41 ❑ (2S s s. ) n- EXISTING _ _ FINAL p OWNER-BUILDER DECLARATION (PRINT) Vir In Roof Co. NO. 287-0507 +: I hereby affirm that I am exempt from the Contractor's'.License _ _ - DATE .` Law for the following reason (Section 7031.5, Business and ADDRESS P.O. BOX J .Sall Gabriel, 91778 FINAL' ' 1 Professions Code): P ESENT - - - —'By - 1 ` ❑ I, as owner of the property,' or my employees with BUILDING ADDRESS 3�0 134.25 _ - \ V wages as their sale compensation,will do the work and the structure is not intended or offered for sale(Section LOCALITY 1 ITEM 7044, Business and.Professions Code.) MOVING' - - - -TEL. - - ❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO" _ TOTAL 134 . 25 with licensed contractors to construct.the project (Sec- - - - - - ,. c tion 7044, Business and Professions Code.) ADDRESS CHECK ..1.34.25 CONSTRUCTION LENDING AGENCY ySETOBACKD YARD HWY TOTA SETBACK FROM WIDTH- CHANGE �n41 I hereby off irm that there is a cot nstructian.Iendi ng agency for FRONT the performance.of the work for which this'permit i`s issued 'P.L ' _ (Sec. 3097, Civ"C ).- SIDE, L1000-001 ' 10i 91/39 'Lender's Name - T3, 6132 1 FM 4 .I: P.C. Fee$ Permit Fee 123.75UDMA tvo� p� , Lender's Address - _ , r I certify that I have read this opphcaLon and state that the Issuance Fee 10.50 . LDMA P/C N S above information is correct. I agree to comply with all County ordinances,and State laws relating to building construction, - Total Fee �LOMA Perm. N and hereby authorize representatives of this County to enter _ `r upon the above-mentioned'property for inspection purposes. °' ',TAIL/L�l gN',r✓,r✓,rte,`'/',//1I[y ,"[IL� - 11 10-4-89 - SEE REVERSE FOR EXPLANATORY LANGUAGE .. - _„- � •" • � �� Y. ig ture of Applicant or'Agent Date c ' WORKERS' COMPENSATION DECLARATION - + ,Thereby Affirm that I haven certificate of consent to raself APPLICATION' FOR- BUILDING PERMIT - insure, or a certificate he of (Sec. 3 Compensation Insurance,'; - '.or~a certified copy thereof (Sec. 3800,-Lab C.) n .,;L _ S dtic eC COUNTY OF LOS ANGELES ; BUILDING AND SAFETY Policy Na. ?PS� Cam.pariy t.7 Certified copy is hereby furnished.._ - FOR APPLICANT TO FILL IN BUILDING ❑ Certified copy is filed with the county building inspec- ' ' BUILDING �j - ---• " - - - - - - tion department. - - ADDRESS' - 1 I�. L°hry10,54 .Date /!:^z( CITY= T4m -..��._ e ,� ZiF�. - LocAiI7Y" Applicant 'p '� o'� - NO. OF BLDGS. _« -' CERTIFICATE OF EXEMPTION FROM WORKERS'` - SIZE'�OFA6T - NOW ON LOT - NEAREST . - - - ASSES SR - ' COMPENSATION INSURANCE � � ASSESSOR „(This section need not be completed if the permit isforone TRACT ' BLOCK .- LOT NO. MAP BOOK PAGE PARCEL hundred dollars ($100) or less.) r _ TEL ., OWNER . r YA - tc - 'W -h NO. - US OT: MAP .. . i1.certify that in the performance'of the work for'which this I NO permit is issued, I shall not employ,any person in any manner ADDRESS - - - - SPECIAL .. - a so as to become subject to the.Workers'Compensation Laws, CONDITIONS - O - CITV - ZIP' Date Applicant - - ARCHITECT OR TEL, 'DISTRICT GROUPTYPE FIRE PROCESSED BY. O NOTICE TO APPLICANT: If,.after making this CertificateofENGINEER NO. - �i CONST. '�' ZONE �Q' " H- Ezemption, you should,become subject to the Workers' - X , I/ rUTJ ' 'U Compensation provisions of the Labor Code, you must forth- - ADDRESS [r rah- a - with comply with such provisions or this permit shall be - I ' t f - TEL STATISTICAL CLASSIFICATION A. . CONDO. N deemed revoked. _ CONTRACTOR /V b 7."h N E/Y 331•3 W I 1 - z LIC. CLASS NO. - DWELL. UNITS_ t " LICENSED CONcensed n DECLARATION ADDRESS 4? (UwIJ;((� �-6 NO. 4S2 6S6 ' hereby affirm than am licensed under provisions of Chapters LIC SEWER MAP t (commencing with Section 7000)of Division full, of the Business - ` and Professions Code,and myLcenseis in full force and effect. _ CITY .Cp✓,Lta CLASS G"3 S BK PG t VALIDATION - L[! SQ.FT., NO. OF NO: OF CHECK.} - -- - - - License.Numbe+r. I�L ZG5 �+ 'Lia Class �-3'"l SI2E STORIES FAMILIES ONE _ Contractor NO 61 r-, 7 bcS c 'Date' it-21^ � . : - . - %'. -. . VALUATION DESCRIPTION OF WORK NEW ❑ ❑I am exempt under SecADD ❑' _ ' _ .ALTER ❑ -. - - B.BP.C.,for Is re s n - 'REPAIR ❑ $ - ate: .- USE OF.�., _ . .. .. i. EXISTING BLDG. DEMOL ❑ ignature TEC APPLICANT - FINAL S .' -- . . .. _._ . . .. .. OWNER-BUILDER DE LARATION -(PRINT) NO, I hereby affirm that I am exempt fromthe Contractor's License -� _ DATE Law for the following reason (Section-7031.5, Business and ADDRESS FINA - 1 Professions Code): _ PRESENT - - - -- .^• - -- By - /�/ T + El .I„as owner of the property, or my employees.with BUILDING ADDRESS p :O wages as their sole compensation,will do the work and - - s -` ' " - - 3307 87•-Z the structure is not intended or offered for sale(Section LOCALITY' ],,IT ' 7044, Business and Professions Code.) - MOVING • - -TEL. .❑ EM CONTRACTOR NO.I, as owner oftheproperty,am ezclusively,mniracting _ , 7TJsle3�1 with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code..),. - 'CHECK u7..iv REQUIRED -TOTAL'SETBACK FROM EXIST: CONSTRUCTION LENDING AGENCY SETBACK YARD HWV PROP. LINE .WIDTH 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. - (Sec. 3097, Civ. C.), SIDE• - - ' Lender's Name. - i�✓': +� Ref. # -- - + - D (f ,J DGUD=D �i i its P C.Fee B Permit Fee 6934 1 AMl ._t2 - Lender's Address - `I certify shot have read'ih is application and state that the Issuance Fee l.✓ LDMA PVC# above in rmdti is corre agree to comply wish,all County Investigation'Fee, n.K .. ordinan and ate la relatin to ildingconsiructidn,. Total Fee SCJ LDMA Perm. 4' a . n her nut rize re esenta ' es this.County to enter __ _ _ -" _ " u n the enh r 'nspectidn purposes: - - _ 1, `a p , SEE REVERSE�FOR EXPLANATORY_LANGUAGE, - SignaNre of A li<ant or Agent Dole' - -