HomeMy Public PortalAbout10335 LA ROSA DR_Building__ WORKERS' COMPENSATION DECLARATION T,
I hereby affirm that I have certificate of consent to self APPLICATION FOR BUILDING PERMIT JISI
insure, or a certificate of Workers' Compensation Insurance,
or gent jed copy thereof (Sec. 3800, Lab C.
u .Y J� Com /` COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. pony:;��-`v/
B--Certified copy is hereby furnished. 3 S FOR APPLICANT TO FILL IN ADDRESS
F1 Certified copy is filed with the county building inspec- BUILDNG
tion departNEAREment, ADDRESS f �,/.S LOCALITY
Dat ' 3 Appl icar 'z�'L� CITY _:CZIP CROSS S
e /7 T. 16
CERTIFICATE OF EXEMPTION FRO VOR S' >> NO. OF BLDGS. - ASSESSOR
COMPENSATION INSU CE SIZE OF LOT 4 e O NOW ON LOT MAP BOOK PAGE PARCEL
(This section need not be completed if the permit is for one USE ZONE MAP
hundred dollars ($110) or less.) - TRAC 7S- � BLOCK LOT NO. NO. QI
/
TEL ,(/`fr/ SPECIAL }
I'certify that in the performance of the work for which this OWNER 27/'� NO. CONDITIONS Il
permit is issued, I shall not employ any person in any manner _ ,rte DISTRICT GROUP TYPE FIRE PRD BV O
so as to become subject to the Workers'Compensation Laws. ADDRESS �Z�r /!/E�/�/�/� �; (� /J CONST. ZONE V
P J-QUO 3 +..L K
Date Applicant ZIP �m(�` STATISTICAL CLASSIFICATION APT, CONDO.
NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL.
ENGINEER NO. CLASS NO. 0/ DWELL. UNITS_ W
'Exemption, you should become subject to the Workers' 1
Compensation provisions of the Labor Code, you must forth- ADDRESS SEWER MAP
with comply with such provisions or this permit shall be //'' I(� Z
deemed revoked. CONTRAQiS _ �/�I7/.0 TEO`��Zd9U_3 BK. PG, VALIDATION
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS N G Y $VALUATIONO
(commencing with Section 7000)of Division 3 of the Business and LIC.
Professions Code, and my license is in full force and effect. CITY CLASS ►
NO.I
F NO
License Number -+«-� � Lic Class/�� S ffFT S
T
ORIIEES Z FAMIOLIES ,/�/ CO EK y
Cont / Date ] DESCRIPTION OF WORK e /moi�/ NEW
ADD ❑
I am e.e7l5.1 and r SW E.s/ ALTER ❑ FINAL
B.&P.C. for this reasonREPAIR ❑ DATES/®��¢ Fi Q!(i C41 ( i�{?Lp(�:; t1PPROltE[3;�/yY'
Date: USE OF DEMOI FINAL . ff'AL 6 01113 APPROVE'Jf�1f�7l
EXISTING BLDG. - ❑ BY
Signature APPLPRW !�
OWNER-BUILDER DECLARATION I�tF J .%✓O Nry. yS�'�-PiGp.J= O n rr 2 8 5 1 A
I herebyaffirm that I am exempt from the Contractors License T C J J
Law for the following reason (Section 7031.5, Business and ADDRESS , - 3 , o a o e 2 3
WEOProfessions Code):' - PRE❑ BUILDING 2 r to 5 7 3 7
I, as owner of the property, or my employees with ADDRESS �j
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section LOCALITY _ o c v 57.3 7 v
7044, Business and Professions Code). MOVING TEL
I, as owner of the property, am exclusively contracting CONTRACTOR NO. �� 0'6 1 57 8 3
with licensed contractors to construct the project (Sec- ADDRESS
'tion 7044, Business and Professions Code).
REQUIRED TOTAL SETBACK FROM EXIST. ^2 8 5 2 A
CONSTRUCTION LENDING AGENCY SET BACK YARD Hwv PROP. LINE WIDTH r
I hereby affirm that there is a construction lending agency for FRONT . e- - -,- 1
the performance of the work for which this permit is issued P.I.
o e o
(Sec. 3097, Civ. C.). SIDE - -
Pt.. 2 66Q75
m Lender's Name
$ P.C. Fee$ T S 3S' Permit Fee - -'G1. 'B2s _ c'c 660755 -
Lender's Address 0 6 1 5-83
D
I certify that I have read this application and state that the 7 3,7 SD Issuance Fee � � -
above information is correct. I agree to comply with.all County Investigation Fee /
ordinances and State laws relating to building construction, Total'Tee Y. Ci wJ�
D and hereby authorize representatives of this County to�enter
upon the a ove-mentioned prope for in spe n purposes. - -
of SEE REVERSE FOR EXPLANATORY LANGUAGE
71rof Appli ty gent Date - Vs
�
COUNTY OF LOS ANGi "S --i t EMPLE VITY # 0508 ` BUILDING PERMIT
DEPARTMENT OF PUBLI(.�RKS 9701 LAS TUNAS RESIDENTIAL ADD/ALT/REP
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 BL 0508 9911290133
PHONE: (626) 285-0488 EXT:
LEGA_ ID: NO. OF CORS? NEW BUILDING ADDRESS:
TR: 37580. LT: 4 SQ. FT STORIES TYPE OCCUP GROUP 10335 LA ROSA DR
STRUCTURE: 196 1 VN R3 TEMP CA 917803402
ASSESSOR INFORMATION NUMBER: GARAGE: NEAREST CROSS STREET: ARDEN
8585-018-045 OTHER: THOMAS PAGE: 597 GRID: B4 LOCALITY: TEMPLE CITY
TENANT: EXIST BLDG USE: USE ZONE: ISSUED ON: PROCESSED BY: EXPIRES.ON:
EXIST OCC GRP: 11/29/99 UT OS/ 700
"' --------- TF' "'0' —� _ . N041 ON LCT.: __-- - VALUATION: IF;NAL DATE FINAL BY: CODE:
1mARINERO BALMORETANA (626) 444-8100- n 1 14,500 [�
10335 LA ROSA DR U _ _ _ (9 �0�
TEMP 9178034'2 -- ----- FEES PAID —_— - �DESCRIPTIORf OF WORK
NEW BEDROOM ADDITION - 196 SQ. FT(._
- 4TH BEDROOM
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT:
APPLICANT: TEL. N0:
SAME AS OWNER - AR BLDG PERMIT ISSUANCE 27.75
AC STRONG MOTION REBID 14500.00 VAL 1.45 SPECIAL CONDITIONS:
AX BUILDDING REVIEW-FEE54.70
B2 PERMiTiW7ENERGY• 14500".GO VAL 330.66
,FEES.
tvTA(!&EE6 414.56
OR: TEL. N0: 05 �/�. .� ROVALS COTE INSPECTOR SIGNATURE
SAME AS OWNER V y
LIC. 'v0 ATICN AND SETBAC
IARCIITTECT DR ENGirvtER: TEL. NU: / Ijr__ A,. -.. TRENCH ORMS
LIC. N. u�lln ,cl JNU LOOK
RAISED FLOOR FRAMING,
-_ - __ _
AAR NO: SEWCR MAF BOOK: -AGE: FikE ZONE: CMP,:' UNDERFLOuR INSULATION —
3 ' 01°�� p UC WA O 1ST- LEVEL FLOOR SHEATH
NO OF FAMILIES: DWELL RdG UN ITB: APT/GOND: STAT CLASS'- R
NU 21 ( U 8 7 2ND LEVEL FLOOR SHEATH
o o
SCHOOL WITHIN HAZARDOUS
^IO 0 ��P`r',f 'it ROOF SHEATHING
R QUALITY: 1006 FEET MATERIALS \ A 0
NO NO NO FIRE DEPT. FRAME INSPECT
REQUIRED TOTAL SETBACK FROM EXIST V6 -,,1p'T� BLDG DEPT. FRAME INSPECT Q
SET BACK
El
FRONT PL- YARD: HWY: PROP LINE: WIDTH: ZC Service 'fha�V`•'' SHEAR PANELS
SIDE PL-
INSULATION/WEATHER STRIP
L
INTERIOR LATH/DRYWALL _ Q
EXTERIOR LATH
LOT DRAINAGE
SMOKE DETECTION DEVICES
FIRE DEPARTMENT APPROVAL
REPORT ID: DPR261 ROUTE TO: BS0508