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Home My Public Portal About9128 HERMOSA DR_Building__ WORKERS' COMPENSATION DECLARATION hereby affirm fica have certificate of consent to self APPLICATION FOR' BUILDING PERMIT insure, or a certificate of Workers' Compensation Insurance, or a certified copy.thereof (Sec. 381 Lab. C.) ' W0007146 Beaver 'Iri`s. COUNTY OF LOS ANGELES BUILDING*AND SAFETY Policy No.• Company - ' Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDADDRESSING 7 G 'O Certified copy is filed with the county building inspec- - BUILDING lion deportment. ADDRESS 9128 Hermosa Date 7-1-89 Applicant Virgin Roof Co. CITY Temple-City, CA . zip 91780 ]LOCALITYCERTIFICATE OF EXEMPTION FROM WORKERS' - NO. OF BLDGS. NEAREST'• COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS ST. (This section need notbe completed if the permit is for one TRACT BLOCK LOT NO. ASSESSOR - _ hundred dollars ($100)or less.) - _ • _ MAP BOOK PAGE I PARCEL OWNER Mrs. Miller NOi USEPNE MAP 'certify that in the performance of the work for which this NO, permit is issued, I shall not employ any person in any mariner / SPECIAL ' 'so as to become subject to the Workers'_Compensation Laws. ADDRESS 9128 Hermosa CONDITIONS O CITY Temple City - .ZIP Date Applicant 0.' ARCHITECT OR TEL NOTICE TO APPLICANT: If, offer making this Certificate.04 DISTRICT G OUP TYPE CONST. FIRE PROCESSED BY Exemption, you should become subject to the Workers' - ENGINEER NO {�(� jCompensation provisions of the.Labor Code, you must forth- �.1� J W l ADDRESS with comply with such provisions or this permit shall be _ ELI "deemed.revoked. - TELSTATISTICAL CLASSIFICATION APT. C COz CONTRACTOR Virgin ROOF CO. NO507 , ;�/ Z j - LICENSED CONTRACTORS DECLARATION LIC0.A55 NO. l DWELL UNITS_ - hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS P.O. BOX' J NO0 (commencing with Section 7000)of Division 3 of the Business and LIC SEWER MAP ' Professions Code,.and my Ilcense is in full force and effect. CITY San Gabriel' CLAVALIDATION 50. FT. NO.OF No IFHECK BK. PG. License Number 160650 Lic.Class C39 SIZE STORIES l FAMILIES ONE • - VALUATION Contractor Virgin Roof Co.Daie 6-30-89 DESCRIPTION.OF WORK Slopes T/O apply W ❑❑ $.3862.00VALUATION , Q 1 am exempt under Sec. - 1130, Class. A Fiber lass ShiADD � .❑ TER B.BP.C. for this reason Flat Apply 1128 #11 and ca 9&7AIR ❑ $ •� � ' � 1 3IL 9'A Date: USE OF EXISTING BLDG. 'DwellingMOL ❑ -_# ��:1 Signature APPLICANT TELFINAL OWNER-BUILDER DECLARATION PRINT Vlrgln Roof CO. NO507 DATE I_ZZ� ;I ° .' 68.63 •1 hereby affirm that I am exempt from the Contractor's License ' Low for the following reason"(Section 7031.5, Business and ADDRESS P.O. BO FINAL - t • • 6 8 6 3,= Professions Code): - - PRESENT - - _-- - BT • _ ❑ BUILDING 1, as owner of the property, or my employees with ADDRESS 12,1 6�88 wages as their sale compensation,will do the work and - the structure is not intended.or offered for sale(Section LOCALITY 7044, Business and Professions Code). '- ' - 'MOVING TEL. l OI, 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). - CONSTRUCTION LENDING AGENCY" SETT BACK YARD HWY TOTAL ROP SETBACK I Thereby affirm that there is aconstruction lending agency for FRONT - the performance of the work for which'this permit is issued PL. (Sec. 3097, Civ. C.). SIDE. _ P.L. Lender's.Name LDMA Ref. R m Lender's Address P.C. Fee S - Permit Fee• 58. 13 ® - 1 certify that I have readthisapplication and state that the Issaonce Fee 10.SOiDNA P/C N - above information is correct.'I agree to comply with,oll County Investigation Fee ordinances and State laws relating to building construction, Total Fee 68.63LDMA Parm. X and hereby authorize representatives of this County to enter _ m upon the above-mentioned( .�'prroyp�erty for inspection purposes, - y0L J I I�.k��F.LY'(/'II 10-27-88 SEE REVERSE FOR EXPLANATORY LANGUAGE 5n.tvre of Applicant or Agent = Dot. - - APPLICATION FOR BUILDING PERMIT FOR APPLICANT TO FILL IN (Prior or (YOB colt) BUILDING - COUNTY OF LOS ANGELES ADDRESS ' ' DEPARTMENT OF COUNTY ENGINEER CITY. ZIP' ]0 — ADDRESS BUILDING ANI,SAFETY DIVISION NO.OF BLDGBUILDING SIZE OF LOT NOW ON LOTADDRESS TRACT / BLOCK LOTLOCALITY TENEAREST OWNER•. NOCROSS ST. ASSESSOR ADDRESS MAP BOOK PAGE PARCEL DISTRICT GROUP TYPE FIRE PROCESSED BY CITY ZIP — CONST, ZONE ARCHITECT OR TE - '- ENGINEER NO STATISTICAL CLASSIFICATION SEWER MAP CLASS NO. � DWELL,UNITS SK PG CONTRACTOR NOUSE ZONE MAP LIC. .� NO. ADDRESS NO. 1, - j SPECIAL LIC. / CONDITIONS CITY -' CLASS ROAD DEPARTMENT APPROVAL REQUIRED YES❑ NO ❑ CONSTRUCTION LENDER a NAME AND BRANCH BLDG.SETBACKPROP. FROM O FRONT PROP.LINE OF (STREET(. U ADDRESS CITY TOTAL SETBACK FROM TYPE OF EXISTING =SII HIGHWAY + YARD 50. FT. NO. OF NO. OF CHECK FRONT PROP. LINE HIGHWAY WIDTH ly. SIZE STORIES FAMILIES ONE Y ❑ + = C DESCRIPTION OF WORK NEW 2 ADD BLDG.SETBACK FROM C:- SIDE SIDE PROP. LINECE _ _ - (STREET) G. ALTERT QL STBACK FROM TYPE OF EXISTING W REPAIR HIGHWAY + YARD — SIDE PROP. LINE HIGHWAY WIDTH ~ USE OFDEMOL ❑ + EXISTING BLDG. APPLICANT TEL CORNER CUTOFF YES ❑ NO ❑ IPPINT) J_.j/ ND'. BY (SIGNATURE) IN OPEN SPACE YES ❑ NO ❑ IN COASTAL ZONE YES ❑ NO ❑ VALUATION CATE GOPICAL EXEMPTION YE$❑ NO ❑ 1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION ENVIRONMENTAL ANO STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY IMPACT EXEMPTION DECLARATION SIGNED (DATE( WITH ALL ORDINANCES AND LAWS REGULATING BUILDING CON- STRUCTION. I CERTIFY THAT IN DOING THE WORK AUTHORIZED IMPACT REPORT PROCESSED GATE) HEREBY IWILL NOT EMPLOY ANY PERSON IN VIOLATION OF THE LABOR CODE OFTHE STATE OF CALIFORNIA IN RELATING TO WORKMEN'S COMPENSATION INSURANCE. - SIGNATURE OF PERMITTEE ADDRESS FINAL BY TELDATE CITY NO. 11.1FE CH6LFS P.11.-181.1- TOr P.C. $ PMT.$ FEE FEE YY HARVEY T. BRANOT, COUNTY ENGINEER ,r PLAN CHECK VALIDATION NO CASH PERMIT VALIDATION CK M.o. 'CASH 76A638A CE4803 12/72 FOR APPLICANA �PPLICATIONDFOR BUILDING PERMIT FILL IN p ING COUNTY OF LOS ANGELES SS DEPARTMENT OF COUNTY ENGINEER ZIP BUILDING AND SAFETY DIVISION NO.OF BLOGS. BUILDING F LOT C NOW ON LOT ADDRESS i'er'''.osix .' VC ) ,-\ BLOCK LOT NO LOCALITYTELNEAREST- - NO; CROSS ST. ASSESSORSS C ' MAP BOOK PAGE - PARCEL015TRICT E PROCESSED BYC,ZIP _ CONST, ZONEECT OR TER NO. STATISTICAL CLASSIFICATION SEWER MAP SS CLASS NO.'YY' i .DWELL.UN ITS BK/ Pg/`ACTOR NOL USE ZONE MAP LIC. NO. ADDRESS NO. + SPECIA L LIC A� CONDITIONS CITY CLASS ROAD DEPARTMENT APPROVAL REQUIRED YES ❑ NO ❑ CONSTRUCTION LENDER d NAME AND BRANCH BLDG.SETBACK FROM CD FRONT PROP.LINEOF (STREET', U ADDRESS CITY w HIGHWAY } YARD - TOTAL SETBACK FROM TYPE OF EXISTING .3 5CZ FT. NO. OF NO. OF CHECK FRONT PROP. LINE HIGHWAY WIDTH L� SIZE STORIES FAMILIES ONE Y DESCRIPTION OF WORK NEW ❑ + ADD BLDG.SETBACK FROM (STREET) nom. _ SIDE PROP. LINE OF ALTER ❑ HIGHWAY i YARD = TOTAL SETBACK FROM TYPE OF JI EXISTING W E PAIR❑ SIDE PROP. LINE HIGHWAY WIDTH USE OF } _ EXISTING BLDG, DEMOL El APPLICANT TEL CORNER CUTOFF YES ❑ NO ❑ (PRINT) NO. . BY (SIGNATURE) IN OPEN SPACE YES ❑ NO ❑ IN COASTAL ZONE YES ❑ NO ❑ VALUATIONS - CATEGORICAL EXEMPTION YES[] NO ❑ I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION ENVIRONMENTAL AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY IMPACT EXEMPTION DECLARATION SIGNED (GATE) WITH ALL ORDINANCES AND LAWS REGULATING BUILDING CON- STRUCTION. I CERTIFY THAT IN DOING THE WORK AUTHORIZED IMPACT REPORT PROCESSED (DATE) HEREBY I WILL NOT EMPLOY ANY PERSON IN VIOLATION OF THE LABORCODE OF THE STATE OF CALIFORNIA IN RELATING TO WORKMEN'S COMPENSATION INSURANCE, SIGNATURE OF PERMITTEE ADDRESS "11. FINALBY l TEL. r CITY yi _ NO. DATE 111h1 t Hf � h� 1' I1-.-I(SIJ- IUr P,C, PMT. HARVEY T. BRANDY. COUNTY ENGINEER EE FEE ✓' i PLAN CHECK VALIDATION 1� s" _ PERMIT VALIDATION C. M CASH y J 76A838A CE»80312/72