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HomeMy Public PortalAbout9143 LA ROSA DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875 (11-84) MISCELLANEOUS APPLICATION ,. CE 875 I hereuo affirm that I have a certificate of consent nc self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec. 3800,Lab.C.). Policy No. Company APPLICANT TO FILL IN I BUILDING - ADDRESS Certified copy is hereby furnished. BUILDING V '"'��5(pr W4V6 LOCALITY ADDRESS 006- Certified copy is filed with the county building inspection >01 LOCALITY �/� NEAREST department. 1. GST l/r` �� CROSS ST. Date Applicant NEARESTZ /A ' DISTR.IICCT NO. GROUP TYPE P CESSED BY CROSS ST. U/v C, /u • LZ CONST- 0 CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY NO. (CIRCLE) STATE MAJOR SECOND LOCAL NO. OF BLDGS. (This section need not be completed if the work involved TRACT NOW ON LOT, USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE OF d I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG. C:) D permit is issued, I shall not employ any person in any manner OWNERFl dl O T7(A) IGAUT `C—' so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP o Date Applicant AD ORE35POk Zo 6 w NOTICE, TO APPLICANT: If, after making this Certificate of CITY V 0AJ6O OCCUPANT LOAD N Exemption, you should become subject to the Workers' z Compensation provisions of the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE: with comply with such provisions or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. deemed revoked. OCCUPANCY INSPECTION ❑ Panic Devices LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) 9 (commencing with Section 7000) of Division 3 of the Busi- NO. OF EXITS ness and Professions Code,and my license is in full force and � /� effect. NAVY6 O� Lt� o/ a PARKING SPACES REQ'D D PROVIDED D License Number Lie. Class w'`��r` ,', r�'^'�� LIMITED TIME USE Contractor Date DATE DATE ElI am exempt from the licensing requirements as I am a FROM: TO: licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE iness and Professions Code). FINAL APPROVAL / Tg Lie.or Reg.No. Date PRESENT USE OF BUILDING ` _/ HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND USE I hereby affirm that 1 am exempt from the Contractor's f License Law for the following reason (Section 7031.5, Busi- /)Il� ID Cell—C+1`1 i f :. .4 ness and Professions Code): NO. PARKING -7 Lt iaf;I SPACES PROVIDED 1'-1'-7 J• �'7�I)•I•-1e-1- I, as owner of the property, will do the work and the structure is not intended or offered for sale (Section 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING I hereby affirm that there is a construction lending agency 67il�/'' OW( 11V,S 6-VVAl 4W for the performance of the work for which this permit is issued(Sec. 3097,Civ.C.). s O Lender's Name PROPOSED MAX. OCC. Lender's Address PERMIT FEE I certify that I have read this application and state that the above information is correct.I agree to comply with all County ISSUANCE FEE ordiillrice's and State laws' relating to building construction, and hereby authorize re resentatives of this County to enter TOTAL FEE upon the above-me t' ed propert r inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of ittee Date WORKERS'COMPENSATION DECLARATION 76M444 M I SC E L LA N EO U.S APPLICATION I hereby a rn that I Have a certificate of consent to self, CE 875 (11-84)COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure,'�or a certificate of Workers'Compensation Insurance,or - a certified copy thereof(Sec. 3800,Lab. C.). y Policy No. Company FOR APPLICANT TO FILL IN BUILDING Ji ADDRESS �-�J' Certified copy is hereby furnished. BUILDING ADDRESS143 LA R , LOCALITY 0 Certified copy is filed with the county building inspection LOCALITY NEAREST department. CROSS ST. Date Applicant NEAREST DISTRICT IJP G OUP TYPE P OCESSED BY CROSS ST. Jam'—D J - w CONST.J/ CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL (� J (/ COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK NO. HIGHWAY E) STATE MAJOR SECOND LOCAL NO. OF BLDGS. (This section need not be completed if the work invoived TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) LLSE OF SIZE OF LOT ©m EXISTING BLDG. _07—/ 7•" I certify that in the performance of the work for which this o permit is issued, I shall not employ any person in any manner OWNER of . r0 e /? so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP /pp/{/A o ' ADDRESS Zf Date Applicant 1C-3 TEL' OCCUPANT LOAD NOTICE TO APPLICANT: If, after making this Certificate of CITY ND. s Exemption,: you' should become subject to the Workers' gppLICATION FOR EXIT HARDWARE. Compensation provisions of the Labor Code, you must forth with comply with such provisions or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ® Panic Devices I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) 9 (commencing with Section 7000) of Division 3 of the Busi- NO.,OF EXITS ness and Professions Code,and my license is in full force and Name of business: U U PARKING effect. SPACES REq'D O PROVIDED License Number Lic. Class LIMITED TIME USE Contractor Date DATE DATE I am exempt from the licensing requirements as I am a FROM: TO: licensed architect or a registered professional engineer SIZE OF A NO. OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. �V� STORIES SI ATURE iness and Professions Code).. PRESENT USE OF BUILDINGG INAL APPROVAL Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS Ogle/ ON LOT AND USE , / I hereby affirm that I am exempt from the Contractor's VX' � License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING I, as owner of the property, 'will do the work and the SPACES PROVIDED C:2 © pr! _��„i` structure is not intended or offered for sale (Section 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued(Sec. 3097,Civ.C.). Lender's Name PROPOSED MAX. OCC. Lender's Address 25 �� I certify that I have read this application and state that the PERMIT FEE ` above information is correct. I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter TOTAL FEE 25.00 upon the above-mentioned property for inspection purposes. I SEE REVERSE FOR EXPLANATORY LANGUAGE X4g&.,� Signature of 'rmittee� Da e N,rORI:LRS' (OMI'f.NSrVION UL( I. 1R,,\Il()N ti . 1„ ll MISCELLANEOUS APPLICATION 11.•,ur ' r I hereb\ affirm that J h.tcc Lcilili-Ic of .,111,;11 1,1 „u ('()(IN'I Y OI I OS ANG1:I.I.S lit III DING AND sM INTI' DIVISION (1 insilre, or a ceitil icate „I' Wot6en (omixiisauon IIIsI;I,IIILC•of ,I certil'led cop) thereof (Sec 3800, Lah C.) Policy No Conlpally FOR APPLICANI TO FILL IN BUILDING BUILDING ADDp�r ESS ADDRESS (L'rlll lL'd cop) 11 Ill'Ieh\' 1111 Ill,hl'll NL� r-p��, LOCALITY ❑ Certified cop) Is I ded wuh the county building in,pCLrinn CITY �����_-��rL� —�1 _ZIP 1 department NEAREST Dale Applicant SI E OF EOT NO OF BLDGS.NOW ON LOT DISTRICT NO GROUP TYPE PROCESSED BY CONST ( Lli ll WAD_ OI' LXLNIP110N I ROM \VORK! R', T---- - BLOCK LOT NO COM11'LNSAIIUN INSIIIZ,ANI I_ ­P HIGH— NO ICIRCLEI STA-E MAJOR SECOND LOCAL (This %cclion need not be completed if the \\oil: 111\111\ed ASSESSOR MAP BOOK PAGE PARCEL 115E ZONE SPECIAL CONDITIONS by the permit is lot- one hundred dollars (~1001 of Ic%%.) - — I certify' thal in the performance of the \\u11�. I,u Mi0i this O/W�NiE(R��� TEL NO Q permit is Issued. I shall not emplu) ,tit) pclum III .m)' n1,uulcl J.�I--.IIIV� � ' ---- so as to become subject to the Woil\ei, (ompen,mion L,n\s 4)RESS — OCCUPANCY GROUP1��E] Applicant CITY ZIP NOTICE TO APPLICANT If. allcl inakine Ih1, t CIIII IL,ttcIf 0 OCCUPANT LOAD oh Exemption. you Should become subICCI to the W01kCI-S APPLICATION FOR Compensation pro\nions of the Labor Code you nni,t Imiliwith - EXIT HARDWARE [ comply Will) 1AICh provisions lir this permit ,ball bC lIL•eillell TRAILERUIELJ GEOLOGY INSPECI[ON O No Spec Knowl ❑ revoked �I LICENSED CONTRACTORS DLCI AR \1I0N OCCUPANCY INSPECTIONPanic Devices ❑ d I herebyaft iris that I aim licensed Under piovlslons of ( hapicl SAFETY PERMIT O (LIST ITEMS BELOW, i 9,(commencing with Section 7000)of Di\Ision )of the BII,IIICss / NO OF EXITS s and Professions Code.and m) liceme I, In lull lolcc and ellcci J��1.J _ __ PARKING I_ICeIISC NLI ltlhl'I I IC ( I,I>, ..r SPACES REQ'D PROVIDED _ I LL��JJ " 1 � CunUaclol Utile - -- - -- -- -- --- - LIMITED TIME USE DATE DATE ❑ I and exempt front the licensing reyuuenicnt, .I, I ,till a FROM TO licensed architect or I reglueicd pro1e„ioral engineer - ' acting In Irl) prolCssional c,lliaciiy (SL ition 70S1 1111,1I1C,1 sI7E OF f G � -NulOFI INSPECTOR'S LXIS INBI-DG SIGNATURE and Piolc„Ion, ('udcl ----- ---- Llc. or Reg. No Ih11C PRESENT USE OF BUILDING CW FINAL APPROVAL �j l IION11- OWNI R-111111 DI It DI l I :\R•�I I(IN N , ,x 1 XIbIING BUILDINGS ---- - - - - ,)N I_UT AND USE hereby alTuin that 1 ,1111 C\Cntpt 110111 IIIC COIIIIJLWI', I'IL•cll,c -- ------ --- v' Law for the following ieason (Sccuon 7031 >. BII,IIIC,s ,Ind _ Profession, (tide) NO PARKING SPACI_S PROVIDED ❑ I, it,, ownel of the plopel l\ \\III ,61 IIIc \1,111. .oil Ib, - ------ -- - - --- -- -- - --- StiuCtulC r, 1101 Intended UI 0IICIC,l 101 ,,dc 11CL11,111 hIII. PRUPUSEDUSE OFBUILDING(,hMdK 1tAe.rLt{a��i�� Business and I lolessions C'odc) 1. -L'�=- oj- CONSTRUCTION l ENDING AG F N( 1 herehy affirm that there t, .I con,nuction Icndnit ,trent\ 1,11 - - — - -- --- ---- ---- the perfurntance of the \\011. lot Much 1111', prinmt r, i„ucd (Sec. 3097, Cil'. (.) PROPOSED MAX OCC [ s” Lenders Name __ ___ - ---- -_ APPLICANT(PRINT TEL Lenders Address A DRESS 1 I certify that I have read this application and ,tmc th,u the 15 rNwri,, 7 above information Is correct. I agree to comply "]Ill all(ounty PERMIT FEE ordinances,End State laws relating to building construction.,Ind hereby authorize representatives of this County to Cntei upon ISSUANCE FEE r• the above-t^entioned property for inspection putpo,c', I TOTAL FEE —W D v '^ /t 2 SEl REVERSE FOR EXPLANATORY LANGUAGE 0 3 S191 ure of flernuree I sur - 1 , f , \MRI LRs CoMPLNbaTION DE(L\RaCIO` 8a CE 7a 7�-aa) WISCELLANEOUS APPLICATION ce a /-' I hereby « lfcertificate rm that I have a nof consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION Insure. or a certificate of nrkers'Comoeoenvnon Insurance or ' a certified copy thereof (Sec. 3800 ab C ) Poll.-% No\a "LC,,imam �T FOR APPLICANT TO FI LL IN BUILDING -03879 -ol9 ADDRESS Certified copy Is hereb} turnlshed BUILDING AC DR ESS LOCALITY 1 a Certified copy is tiled „Itll lie :(l lint, U idlne Inspection LOCALITY `DEAREST depa a Temple City 7 O CROSS ST Date �Dr hunt NEAREST J(STRICT NO GRjjjDDD�f}JJ1P TYPE CESSED BY CROSS ST ,O �/ �'�" CONS I CLRT1 IC\TE Of LSE\IP 10\ FROM 'lC'•RnLRS LEGAL C ()\!PENS \TIOt\ I\SL R \\C L ' DE SCP(PT'ON LOT NO SLCCK I+n.. NiG Hw av STATE MAJOR SECOND LOCAL vcY (CIRCL_1 I NO OF BLDGS (This section need not he completed If the «ori. Involved -RAC- `!O';; ON LOT USE TONE SPECIAL CONDITIONS by the permit Is for one hundred dollar, (S100I or less.) 111111 USE: �F SIZE: OF LOT f I certifs that in :he re-forman.c "t -tie ,nrt: o 'lh1Ch -111s EXISTING BLOB permit )s issue((. I ,hall not cmrio, amam e-w'1 11 111 1manne 0 NER so as to become '11bleet :n the '\orke-c ,`tnrenca[te,r. Lau c- MADIL OCCUPAIs!C" ;ROUP Date \pollcant ADRESS JOTiCL TO aPl'LI(1\T I± .0 n1k:r._ .., _1 ate $] e U0 Nc- 101 7-VOCCUP-N- '_O.0 - E\emnt`n t. ,-ou :i7nnld become abler. -lie \\,),K( (_otnrens tion 7rn•iwil, 'lt :he L.Ih, . ,ou 'nus) io••Il_ i „tib crnnal. ,. h It -u,17 ^ro,7^,I,1, -cr••ut ;hail he _RAILS- JSE I aeenled :'_ ' J _ EC_JG+ N<P= ';Cv _ NO Spon '�;,C,, Lli ENSLD C0\1R\CTORS DECL-\RaTlO` SCC PANC NSPEC-IOti� P=n:C Ce`."C', I hereb, affirm, -,hat I am !lensed undo-r.rc,7,lor.s n:(-barter SAFE— -ER-AIT — (LIS- ITEMS eELO%v) mmn 9 Ic? eLln „ e ith Sec-,inn -000) of Dnucl islon : at the B - — No OF EX17S ness and D-I,1esa0r.1 Cod:. :md •n_, hrense u7 'Lill trrc: .Ind ej'C" RA RES OI 5^AREO'O Llc-en%e \umber _ -- I_:: C.1,. L- -- LIMITED TIME USE N Contractor_ - I),n"—_-- — — --._ onre oast W Z ^ -O �I 11m : emp+ :.om h: 'leen>7nc tea:Ire nen c u I ar.7 s l licensed architect n a regi:terea ---tesslnnat eneine- ;I.E OF v0 -- INSPECTORS SI TURE 2 1�ilr n nt ri�'t•_ �In I7,i1 .'1_.i .. -nil 1;�;, E:15T:v•. S.DG _-'7RE� //1���nnrr itlef't,a[l,l i-nfe,�lUil• C.,d.tl FINAL APOR011AL ._ LIc. or Rei '''RE Eve USE OF BUILDING _ r ` - I -I,L ILDER DI-CL\!: \'tC) NO OF EXISTING BUILDINGS S S _I]'{�4+ I _) ON LOT AND USE ltl VV 11 ail .+• yI•' ^ �.�.:_ I hereb_,' aCuiii that 1 _un e\cmpt t-nin •he Contractor s V License La« for the folio„nm reason Seaton -'til : Bu.l- ness and P-oiesslons Code) NO PARKING 1, as ,saner of the property. ,vitt do he work Ind the SPACES PROVIDED strucnire Is not Intended or otfzrcd int ,Ile ISecnon I 7044 11u.mea and Professions Code) CONSTRUCTIO\ LENDI\G �GENCI X oROPOSED USE OF BUILDING I hereb, iffln[l that there Is a construction lendin? .wencs 1 for the performance Lit the %nrk for ,,filch this rermlt is issued (Ser 30Q7.Ci,. C.) Lender s Name PROPOSED MAX. OCC Lender's -\ddress _ ( PERMIT FEE 25.00 1 certtls that I have read this applil_-atwn and state that the ( dhove Information IS correct I .iuree to cofnply Rith 111 County ISSUANCE FEE ordinances and State la„s relauntr to bulldlnc construLtion. and hereby authorize representatives of this Count), to enter TOTAL. FEE 25.00 ' upon the ibo%e-mentioned property for inspection purposes SEL RCvL-RSL FOR E\PL.aNATORI LxNGU SGL ?nature of`tlermittee Dztel i 1VORKERS'CODIPENSATION DECLARATION CE 875 (11-84) MISCELLANEOUS APPLICATION ' CE 875 1 hereby affirm that I have a-certificate of consent self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers'Compensation Insurance,or if certified copy thereof(Sec. 3800,Lab.C.). CIN BUILDING Policy No.—Company FOR APPLICANTT O IL ADDRESS Certified copy is hereby furnished. XX BUIDLDRESING 9/ IL; LOCALITY - ADS Certified copy is filed with the county building inspection LOCALITY NEAREST department. 3CY. ciiOSS ST. Date —Applicant NEAREST" - DISTRICT NO, GROUP TYPE _ _ ESSED BY CROSS ST. _ /•�"'�� ' CO N_ST:, CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL J16 COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHw Ay No. (CIRCLE) STATE MAJOR SECOND LOCAL _ NO. OF BLDGS. , (Tills Section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars (5100) or less.) USE OF I certify that in the performance of the work SIZE OF LOT EXISTING BLD for which this permit is issued, I shall not employ any person in any manneXX OWNER of bi>alding CAESTE % al as to become suhlect to the Workers' Compensation Laws. MAILOCCUPANCY GROUP - - - ADDRESS � �Q �Z� - - C.] Date— Applicant NOTICE TO APPLICANT- If, after.making'this Certificate of cITYC•-s11E71VZ)0/Q',,J 'TE � OCCUPANT LOAD 0- Exemption, Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE Compensation-provisions of the Labor Code, you must•forth- ❑ HARDWARE- with comply with such provisions or this permit shall -be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. ' deemed revoked. _ Panic Devices LICENSED(:ON-[RACrORS DECLARATION OCCUPANCY INSPECTION ❑ I hereby affirm that 1 am licensed under provisions of Chapter - SAFETY PERMIT ❑ ,LIST ITEMS BELOW' 9 (commencing with Section 7000) of Division 3 of the Busi- No. of EXITS ness and Professions Code,and my license is in full force an effect. XName of businessPARKING _ C SPACES REQ'D PROVIDED License Number Lic. Class I" LIMITED_TIME USE LL��JJ Contractor Date DATE DATE I anf"exempt from the licensing requirements as I am a FROM. TO. licensed architect' or a registered professional engineer- SIZE OF No. OF INSP Tow's acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES S RE iness and Professions Code). FINAL APPROVAL _ - PRESENT USE OF BUILDING Lie. or Reg. No.' " Date HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND USE - r _ •/,I 0_ I 'r"�i i''•r"•'•: hereby affirm that I am exempt from the .Contractor's _ ✓� i�il�tJ�7-f71.1'F.1 i. License Law for the following-reason (Section 7031. 5Busi- ness t-'t•1 i Hess and Professions Code) NO. PARKING - - -• 1, as owner of.the property, will do the work and the SPACES PROVIDED structure is not intended or offered for sale (Section 7044, Business and Professions Code). PROPOSED USE OF BUILDING.–T��r, )� � - - CONS"I RUCTION LENDING AGENCY hereby affirm that there is a construction lending agency ' for -the-,perfonuance of the work- for which this permit is _ issued(Sec. 3097,Civ.C.). Lender's Name PROPOSED MAx*OCC. Lenders Address__ —__ - PERMIT FEE 25 .00 I certify that-l have read this application and state that the above information is correct. I agree to comply with all County ISSUANCE FEE ordinances and State laps relating to building construction, and hereby authorize representatives of this County to enter TOTAL FEE 25 - 00 - 1 _upon the bore mentioned property,for inspection purposes. Q SEE REVERSE FOR EXPLANATORY LANGUAGE } XX XX lwt 11Ili• ..I l : icr 11;i1c -