Loading...
HomeMy Public PortalAbout10355 LA ROSA DR_Building__ WORKERS'COMPENSATION DECLARATION hereby affirm that I have certificate consent to self APPLICATION FOR BUILDING PERMIT insure, or-a certificate of Workers' Compensation Insurance, or a certif3d copy tliereof.(Sec. 3800, Lab. ' COUNTY OF LOS ANGELES _ BUIL I G A D SAFETY Policy fJo. 7 Company ILDING ®�ertified copy is hereby furnished. Q 75 FOR APPLICANT TO FILL IN ADDRESS _ Certified copy is filed with the county building inspec- BUILDING tion department. // ADDRESS L LOCALITY i/ / NEAREST Date -Z �� lFi 4ppliconr CITY.. I C-/�r' ZIP CROSS ST. CERTIFICATE OF EXEMPTION FROMAWO! ER NO. OF BLDGS. �n 'ASSESSOR COMPENSATION INSURANCE SIZE OF LOT ©o NOW ON LOT r:✓ MAP BOOK PAGE PARCEL (This section need not be completed if the permit.is for oneUSE ZONE MAP hundred dollars ($100)or less.) TRAC BLOCK LOT NO. NO. d TEL. i` SPECIAL y 1 certify that in the performance of the work for.which this OWNER r4-_`Gr`� NO. CONDITIONS 1 permit is issued, I shall not employ any person in any manner �`��%� DISTRICT .GROUP TYPE FIRE PROCESSED BY O. ADDRESS /// - G �� CONST. ZONE U so as to become subject to the Workers'Compensation Laws, G/' I j / -2 ad q iArl sJ Date Applicant CITY A.G / ZIP STATISTICAL CLASSIFICATION 'APT. CONDO. O NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL 'Exemption, you should become subject to the Workers' ENGINEER NO, CLASS NO. DWELL. UNITS_ 1 Compensation provisions of the Labor Code, you must forth- ADDRESS SEWER MAP with comply with such provisions or this permit shall be / ��� • a deemed revoked. CONTRA115 ." M erste ra NO. BK, PG, VALIDATION LICENSED CONTRACTORS DECLARATION LIC. I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NOFe-4— •p� VALUATION (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 $ ► SQ. FT. -O. OF / NO. OF i CHECK License Number Glr.S TJ Lic Class SIZE y STORIES FAMILIES / ONE Jf NEW [� U V Contractor 6�0 /C-a'p ate ( DESCRIPTION OF WORK Cry-'1f ADD u / I am exempt under Sec ° ❑ FINAL / _ VIRA[I?1 PZ"1 7 f 12111 RED ALTER / B.BP.C. for this reason REPAIR ❑ DATE r e`JL4af° io it:l� Ifs ilfI''ri 3t'cF1:C�f 3i USE OF By AL �! _ FiEi.,L Q?A0IiUd APPROVED:Al Date: EXISTING BLDG. DEMOL E] 8-+-'- f Signature APPLICANT TEL OWNER-BUILDER DECLARATION PRINT NO. I hereby affirm that Iam exempt from the Contractor's License ► Id Law for the following reason (Section 7031.5, Business and ADDRESS a 3 Professions Code): PRESENT BUILDING �f— /,? I, as owner of the property, or my employees with ADDRESS 7 J 2'8 2 5 A wages as their sole compensation,will do the work and 9 7 _4 - the structure is not intended or offered for sale(Section LOCALITY �iS - # e o 0 0 '2 3 7044, Business and Professions Code). MOVING TEL. .2 6 -p U ❑ CONTRACTOR NO. I, as owner of the property, am exclusively contracting � 2 o 0817,38 with licensed contractors to construct the project (Sec- ADDRESS 'tion 7044, Business and Professions Code). a e 0 8.7.3 8 5 REQUIRED TOTAL SETBACK FROM EXIST. i U CONSTRUCTION LENDING AGENCY YARD HWY SET BACK PROP. LINE WIDTH , 06. 1 5—8 3 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 P.I. ;92826A m Lender's.Name1 o e.e o 0 Lender's Address P.C. Fee$ / Permit Fee �.� > 0 2 - 5 93 4'5 w I certify that I have read this application and state that the /� Issuance Fee Al r f above information is correct. I agree to comply with,all County Investigation Fee3 f iO ° 5`9.3 2 5 csa' g ordinances and State laws relating to building construction, Total Fee .J. J D and hereby authorize representatives of this County to anter 0•6 1 5-8 3 $ Upon thea ove-menti d propert or inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Si ure pl scant or Agent Date ®s COUNTY OF LOS ANGELES TEMPLE CITY m 0508 BUILDING PERMIT DEPARTMENT OF PUBLIC WORKS 9901 LAS TUNAS ALTERATION/REPAIR BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 BL 0508 1010070057 PHONE: (626) 285-0488 EXT: (LEGAL ID: NO. OF CONST BUILDING ADDRESS: ITR: 37580 LT: 4 { SQ. FT STORIES TYPE 10335 LA ROSA DR I (STRUCTURE: 19 V-B TEMP CA 917803402 (ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET: 18585-018-045 THOMAS PAGE: 597 GRID: B4 LOCALITY: TEMPLE CITY, Cl 1TENANT: (EXIST BLDG USE: REBID USE ZONE: R-1 TISSUED ON: PROCESSED BY I IEXIST OCC GRP: 110/07/10 SR 10WNER: TEL. NO: 1BLDG5. NOW ON LOT: VALUATION: (FINAL DATE FINAL BY: CODE: 1 IMARINERO, ANA (626) 444-8108- 1 2,300 ,O 110335 LA ROSA DR 1I1�1I ITEMP 917803402 FEES PAID D BCRIPTION OF WORK I ROOF REPAIR AND REINSTALL EXISTING ROOF TILES IEEE DESCRIPTION: QUANTITY: UOM: AMOUNT: 1 I 1APPLICANT: TEL. NO: 1GOMEZ, EZEQUIEL (909) 996-0141- IAA BLDG PERMIT ISSUANCE 27.80 1 14287 SHETLAND LN. 1AB STATE GREEN BLDG FEE 2300.00 VAL 1.00 (SPECIAL CONDITIONS: 1 RIVERSIDE CA 92509 1AC STRONG MOTION REBID 2300.00 VAL 0.50 1 ID2 PERMIT W/O EN-HC 2300.00 VAL 99.10 1 I IFR INV WORK W/0 PERMIT 257.00 DOL 257.00 1 (CONTRACTOR: TEL. NO: TOTAL FEES 385.40 (APPROVALS DATE INSPECTOR SIGNATURE IEZ ROOFING (909) 996-0141- 14287 SHETLAND LN LIC. NO (LOCATION AND SETBACKS IRIVERSIDE CA 92509 671055 C39 ISOILS ENGINEER APPROVAL 1ARCHITECT OR ENGINEER: TEL. N0: 1 1FOUNDATION/TRENCH FORMS I I I LIC. NO: (SLAB/UNDER FLOOR . I I (RAISED FLOOR FRAMING 1 I (MAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP:1 (UNDERFLOOR INSULATION I I I 1147H273 3 001 1 IFLQQR SHEATHING I I I INO. OF FAMILIES: DWELLING UNITS: APT/COND: STAT CLASS: I 1 11 1 NO 21 1 IROOF SHEATHING I SCHOOL WITHIN HAZARD005 JSHRkRF PANELS (AIR QUALITY: 1000 FEET MATERIALS NO NO NO FRAME INSPECTION I 1 (FIRE SPRINKLER HANGERS I I I I I I 1 (INSULATION/WEATHER STRIP( 1 I _ (INTERIOR LATH/DRYWALL I (EXTERIOR LATH I 1 (RATED FLOOR/CE IL ASSEM. I I 1 1RATED WALL ASSEMBLIES I I I (RATED SHAFTS/OPENINGS T-BAR CEILINGS II I I 1 1LQT DRAINAGE I 1 1 1REPORT ID: DPR261 ROUTE TO: 850508 I 1 I I I I I I I I