HomeMy Public PortalAbout10465 LA ROSA DR_Building__ WORKERS' COMPENSATION DECLARATION
hereby affirm that I have a certificate of consent to elf APPLICATION FOR UILDING PERMIT
insure, or o certificate of Workers'Compenstion Insurance,, or -
a certifi d oyy t ere Sec b Lab.
tfJ /(ted` O ' COUNTY OF LOS ANGELES BUILDING D SAFETY
Policy / Company r� L'�/
Certified ca is hereby fu fished. BUILDING
copy v �. / f� FOR APPLICANT TO FILL IN ADDRESS `t 4/
Certified copy is filed with the county but ing spec- BUILDING CC
tion department. ADDRESS F--, LOCALITY'
) NEAREST
Date Applicant CITY ZIP 1 O CROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKERS' 1 y 7 NO. OF SLOGS ASSESSOR
COMPENSATION INSURANCE SIZE OF LOT4,;' NOW ON LOT O MAP BOOK PAGE PARCEL
(This section need not be completed if the permit is for one ,G7 USE ON MAP
hundred dollars ($100)or less.) TRACT 75 / BLOCK LOT NO. i/ NO. }
TEL SPECIAL IL
OWNER , NO. CONDITIONS
I certify that in the performance of the work for which this a 0
permit is issued, I shall not employ an person in an manner TRICT GROUP TYPE FIRE PROCE SED By
p P y y y ADDRESS M L n CONST'
so as to become subject to the Workers'Compensation Laws 1�y /� O
Dote Applicant CCTV , ZIP OO STATISTICAL CLAS H;AATIO APT. CONDO. F�J
NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR 'p TEL W
Exemption, you should become subject to the Workers" - ENGINEER NO. CLASS NO. DWELL. UNIT IL
Compensation provisions of the Labor Code, you must forth- ADDRESS h 1 SEWER MAP Z
with comply with such provisions or this permit shall be
deemed revoked. i
CONTRACTOR NO.4,i<— BK. PG, VALIDATION
LICENSED CONTRACTORS DECLARATIONA^ LIC.
I hereby affirm that I am licensed under provisions of Chapter 9 _ ADDRESS /_ & � T NO. r24 VALUATION
(commencing with Section 7000)of Division 3 of the Business andLIC. p
Professions Code, and my'license is in full force and effect. CITY A CLASS $
License Nummber26556{{4 Lic.Class 2 1 SIZEFT.16SOROS I F MILIIES I CHECK
Contract orF f r Lin DPW, Date DESCRIPTION OF WORK 1 NEW S
am exempt from the licensing requirements as I am a T ADD ❑ ;24 9 2 9 A
licensed architect or o registered professional engineer _ ❑ /�_ �/
acting in my professional capacity. (Section 7051, REPAIR ❑ DATE 1— #.o e:e - 23
Business and Professions Code). USE OF DEMOL FINAL ' 2 e <'8 1.60
EXISTING SLOG. ❑ By
Lia or Re No. Date APPUCANT TEL 2
Reg. OWNER-BUILDER DECLARATION PRINT NO. S- /� ° ^,^ 8 1.6 0
1 hereby affirm that I am exempt from the Contractors License Li�,rj Me`•a» e P C Al° � 0 Q,2 4-8 1
Law for the following reason (Section 7031.5, Business and ADDRESS
Professions Code): PRESENT
BUILDING
❑ 1, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and r
the structure is not intended or offered for sale(Section LOCALITY ,��T
7044, Business and Professions Code). MOVING TEL o�(S —�� :2493011 ,
F1I, as owner of the property, am exclusively contracting CONTRACTOR NO.
with licensed contractors to construct the project (Sec- ADDRESS 2•^,5 3050
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY REQUIRED YARD HITOTAL SETBACK FROM EXIST. /)'s se 5 3 0.5 0
SET BACK PROP. LINE WIDTH "
I hereby affirm that there is a construction lending agency for FRONT C (lew
the performance of the work for which this permit is issued P.L. � U.2,.4.-8'�
(Sec. 3097, Civ. C.). SIDE �O
P.L.
Lender's Name
Lender's Address P.C. Fee 53.37aO Permit
I certify that I have read this application and state that the �/ V Issuance Fee ."
a above information information is correct. I agree to comply with all County Investigation Fee .
ordinances and State laws relating to building construction, v Toto] Fee
and hereby authorize representatives of this County to enter '
mupon th bove-mentioned r perry for i pection purposes. -
SEE REVERSE FOR EXPLANATORY LANGUAGE
^ $i ,ore of,, pl or Agent Dote
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 BUILDING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ALTERATION/REPAIR
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91980 BE 0508 0906030030
PHONE: (626) 285-0488 EXT:
(LEGAL ID: NO. OF CONST BUILDING ADDRESS:
ITR: 39579 LT: 11 SQ. FT STORIES TYPE 10465 LA ROSA DR
ISTRUCTURE: 32 V-B TEMP CA 917803481
ASSESSOR INFORMATION NUMBER: I NEAREST CROSS STREET:
18585-018-032 THOMAS PAGE: 597 GRID: C4 LOCALITY: TEMPLE CITY, Cl
(TENANT: IEXIST HIM USE: REBID USE ZONE: R-1 (ISSUED ON: PROCESSED BY:
(EXIST OCC GRP: 106/03/09 SR
(OWNER: TEL. NO: 1BLDG5. NOW ON LOT: VALUATION: II FI/yAL DAT
(E� FINAL BY: CODE: 1
GARCIA ARTURO (626) 448-4497- 6,490 1 `��/ 1
110465 LA ROSA DR 1 ✓l
ITEMP 917803481 FEES PAID IDESCRIPTION OF WORK
IHOUSE ATTACH GARAGE TEAR OFF EXISTING ROOF TO SOLID WOOD, 1
(FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: (INSTALL 7/16" OSB SHEATHING INSTALL 30 YR DIMENSIONAL SHINGL
APPLICANT: TEL N0:
LAKES (562) 688-3483- AA BLDG PERMIT ISSUANCE 27.75 1 1
AB STATE GREEN BLDG FEE 6490.00 VAL 1.00 (SPECIAL CONDITIONS:
JAC STRONG MOTION RESID 6490.00 VAL 0.65
ID2 PERMIT W/O EN-HC 6490.00 VAL 166.20 I
TOTAL FEES 195.60 I I
CONTRACTOR: TEL. NO: (APPROVALS DATE INSPECTOR SIGNATURE
LASES CONSTRUCTION AND ROOFING (562) 861-1278-
IP.O. BOX 2034 LIC. NO 1 (LOCATION AND SETBACKS
IPICO RIVERA,CA 90660 705675
ISOILS ENGINEER APPROVAL 1
(ARCHITECT OR ENGINEER: TEL. NO: FOUITDATION/TRENCH FORMS
LIC. NO: (SLAB/UNDER FLOOR
I I I
(RAISED FLOOR FRAMING I I I
MAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP:III (UNDERFLOOR INSULATION I I I
1147H273 3 001 I I
FLOCR SHEATHING
INO. OF FAMILIES: DWELLING UNITS: APT/COND: STAT CLASS: I
NO 21 1 ]ROOF SHEATHING
SCHOOL WITHIN HAZARDOUS (SHEAR PANELS
(AIR QUALITY: 1000 FEET MATERIALS 1 1 1
NO NO NO iFRAME INSPECTION
IREQUIRED TOTAL SETBACK FROM EXIST 1 IFIRE SPRINKLER HANGERS 1
ISET BACK YARD: HWY: PROP LINE: WIDTH:
FRONT PL-
(INSULATION/WEATHER STRIPI
SIDE PL-
INTERZOR LATH/DRYWALL
I
] i (EXTERIOR LATH I I I
RATED FLOOR/CEIL ASSEM.
(RATED WALL ASSEMBLIES
RATED SHAFTS/OPENINGS
T-BAR CEILINGS
+ ADDITIONAL DATA ON FILE i
LOT DRAINAGE
IREPORT ID: DPR261 ROUTE TO: BS0508
I I