HomeMy Public PortalAbout10325 LA ROSA DR_Building__ WORKERS'COMPENSATION DECLARATION
hereby affirm that I have certificate of consent to self - APPLICATION FOR BUILDING PERMIT PI'S
insure, or a certificate of Workers' CompensationionInsurance,
or a certified copy thereof (Sec. 3800, Lo
/ COUNTY OF LOS ANGELES BUILDING AND SAFETY
Po4F4o.��Compony
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS
Certified copy is filed with the county building inspec- BUILDINGQ LOCALITY�� QS J
lion department. ADDRESS
,9 NEAREST
Date C 1115�6 Applican '� CITY L i ZIP CROSS ST.
CERTIFICATE OF EXEMPTION FRO ORK S' NO.OF LOT ASSESSOR
COMPENSATION INSU NCE SIZE OF LOT 00 NOW ON LOT MAP BOOK PAGE PARCEL
(This section need not be completed if the permit is for one USE ZONE MAP
hundred dollars ($100)or less.) TRACT BLOCK LOT NO. NO. 1416
TEL. SPECIAL
I certify that in the performance of the work for which this OWN % V✓ NO. CONDITIONS 1
permit is issued, Isha not employ any person in any manner _ DISTRICT .GROUP TYPE FIRE PR ESSED BY O
so as to become subject to the Workers'Compensation Laws. ADDRES /� CONST. ZONE V
CITY C/� ZIP i(,�a� O
O.
Date Applicant STATISTICAL CLASSIFICATION APT. CONDF
ARCHITECT OR TEL
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. V
Exemption, you should become subject to the Workers' CLA55 NO. DWELL. UNITS lua
Compensation provisions of the Labor Code, you must forth- ADDRESS SEWER MAP N
with comply with such provisions or this permit shall be _ �J Z
deemed revoked. CONTR �O (///C Gi//�� �p. j BK. PG, VALIDATION
LICENSED CONTRACTORS DECLARATION LIC.
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS N�r✓'.�86 L/ VAL TION
(commencing with Section 7000)of Division 3 of the Business and LIC f.
Professions Code, and my license is in full force and effect. CITY J CLASS $ azV
Pool License Num b4r�5�96 Lt Lic.Class 5 SalE� /fJ 5 ORIIEES FAMILLIIES CO EK c)
Contr "C Date
DESCRIPTION OF WORK /C / NEW
ADD ❑
❑ I am ex,41 un r a ALTER ❑ FINAL �1 !ii".iau;fiy P�,RiN?7 RL•2UliiED
B.BP.C. for this reason REPAIR ❑ DATE " ( "' ¢ f?uL:G li.i'irSL•:;)£t fIPP�;t78ED; /
Date: USE
OEXISTINGBLDG. DEMOL ❑ FINAL Fi ;.'!L G5kDli:9 faPPRDVED:li/6�'rj
Signature APPLICA T 4 7 P
OWNER-BUILDER DECLARATIONEL.t/ By �� ?PR CLs LG Nc�/S/�Z 'E- 'j
I hereby affirm that I am exempt from the Contractor's License ► �7 S�v o o - 23
Law for the following reason (Section 7031.5, Business and ADDRESS
Professions Code): E EN --2 m 6 3 i
❑ BUILDING
I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section LOCALITY / rc_ -x -
7044, Business and Professions Code), MOVING TEL. 8`�
I, as owner of the property, am exclusively contracting CONTRACTOR NO. ` .3
with licensed contractors to construct the project (Sec- ADDRESS
'tion 7044, Business and Professions Code).' 1 C 8 n
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH
REQUIRED TOTAL SETBACK FROM EXIST.
,
I hereby affirm that there is a construction lending agency for FRONT _ 0 0
the performance of the work for which this permit is issued P.I. O 7 F
(Sec. 3097, Civ. C.). SIDE " ,
P.L.
Lender's Name / ,t S
$ P.C. Fee$ 49C 0 Permit Fee elle 5 0-
Lender's Address
I certify that I have read this application and slate that the J 9 Issuance Fee S-0
above information is correct. I agree to comply with all County Investigation Fee r
ordinances and State laws relating to building construction, 0 7
17 and hereby authorize representatives of this County to enter Total Fee
upon the above-mentio -on purposes.
ned open ff specs
SEE REVERSE FOR EXPLANATORY LANGUAGE
57
e of A 0 cant o/!, Dale ®s
COUNTY OF LOS ANGELES TEMPLE CITY K 0508 BUILDING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ALTERATION/REPAIR
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 BL 0508 1205220115
PHONE: (626) 285-0488 EXT:
ILEGAL ID: NO. OF CONST BUILDING ADDRESS: 1
ITR: 37580 LT: 3 SQ. FT STORIES TYPE 1 10325 LA ROSA DR 1
_(STRUCTURE: 2000 V-B TEMP CA 917803402
(ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET: ARDEN
18585-018-078 THOMAS PAGE: 597 GRID: B4 LOCALITY: TEMPLE CITY, C
TENANT: (EXIST BLDG USE: REBID USE ZONE: R-1 TISSUED ON: PROCESSED BY:
IEXIST OCC GRP: 105/22/12 SR 1
IOWNER: TEL. N0: IBLDGS- NOW ON LOT: VALUATION. IFINAL DATE FINAL BY: CODE: 1
CHU TONY C;NGAN S (626) 202-8986- 2,980
110325 LA ROSA DR
I
ITEMP 917803402 FEES PAID IDESCRIPTION OF WORK
(REMOVE EXISTING CONCRETE TILE AND RE-DO UNDERLAYMENT AND
IEEE DESCRIPTION: QUANTITY: SUM: AMOUNT: ICOVER BACK WITH SAME TILE
IAPPLTCANT: TEL. NO: I I
(SAME AS OWNER - JAA BLDG PERMIT ISSUANCE 27.80 1
AB STATE GREEN BLDG FEE 2980.00 VAL 1.00 SPECIAL CONDITIONS:
QAC STRONG MOTION RESID 2980.00 VAL 0.50
D2 PERMIT W/O EN-HC 2980.00 VAL 99.00
_I FR INV WORK W/O PERMIT 342.20 DOL 342.20
CONTRACTOR: TEL. NO: TOTAL FEES 470.50 JAPPROVALS DATE INSPECTOR SIGNATURE
(SAME AS OWNER -
LIC. NO ILOCA^.ION AND SETBACKS
SOS L3 ENGINEER APPROVAL
ARCHITECT OR ENGINEER: TEL. NO: iFOUNDATION/TRENCH FORKS
LIC. NO: iSLAB/UNDER FLOOR 111
RAISED FLOOR FRAMING
MAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP: ( UNDERFLOOR INSULATION
1147H273 3 001
I IFLOOR SHEATHING
NO. OF FAMILIES: DWELLING UNITS: APT/COND: STAT CLASS:
0 NO 21 IROOF SHEATHING
SCHOOL WITHIN HAZARDOUS SHEAR PANELS
(AIR QUALITY: 1000 FEET MATERIALS
NO NO NO (FRAME INSPECTION
_ I
(FIRE SPRINKLER HANGERS
I I I
I 1 (INSOLATION/WEATHER STRIPII I
INTERIOR LATH/DRYWALL
I
'PIPE® EXTERIOR EACH
ry
I ` (RATED FLOOR/CEIL ASSEM. I I I
J �� (RATED WALL ASSEMBLIES
I 1RATED'SHAFTS/OPENINGS I I I
T-BAR CEILINGS
I � I
LOT DRAINAGE
I I I
(REPORT ID: DPR261 ROUTE T0: BS0508
I I 11 I I