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Home My Public Portal About9151 LA ROSA DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444 CE 875 (11-84) M ISCELLANEOUS APPLICATION I hereby a'um that I have a certificate of consent to self insure, or, rtificate-of Workers'Compensation Insurance,or COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION a cert-ffied copy thereof(Sec. 3800,Lab.Q. Policy No. Company- FOR APPLICANT TO FILL IN ABUILDING C:)J DDRESS Certified copy is hereby furnished. ` esUILDING n 1 ' n / ,^ LOCALITY ADDRESS `1 V7 �F'+- ECertified copy is filed with the county building inspection LOCALITY (�-� NEAREST department. 'r 0J CROSS ST. Date Applicant NEAREST � o.h DIS RICT NCCC��' ]C:31TYPE: C CROSS ST. A-IZZ �% CONST, CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL J a COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP H G WAV NO. F BLDGS. NO. (CIRCLE) STATE MAJOR SECOND LOCAL (This'section need not be completed if the work involved TRACT NOWOON LOT USE ZONESPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE OF - } I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG. � permit is issued, I shall hot employ any person in any manner OWNER (! so as to become subject to the Workers' Compensation Laws. OCCUPANCY GROUP o MAIL Date Applicant ADDRESS' pp t w NOTICE TO APPLICANT: If, after making this Certificate of CITY NO. 1 OCCUPANT LOAD D_ 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 oI this permit shall be TRAILER USE ❑, GEOLOGY INSPECTION ❑ No Spec. Knowl. deemed revoked. El LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT 9 (commencing with Section 7000) of Division 3.,of the Busi ❑ (LIST ITEMS BELOW) NO OF EXITS ness and Professions Code, and my license is in full force and ''C �.Y effect. WAX34 PARKINGEO'D SPACES RO PROVIDED License Number Lie. Class �n ��'✓l) J LIMITED TIME USE Contractor Date DATE DATE 0 I am exempt from the licensing requirements as I am a PROM• TO: licensed architect or a registered professional engineer SIZE OF NO. OF sPECTOR'S acting in my professional capacity (Section 7051, Bus EXISTING BLDG. STORIES G.NATUlff iness and Professions Code). FINAL APPROVAL u Lie.or Reg.No. Date PRESENT USE OF BUILDING - id IK1FE 10C-14C, fL C —_9 HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND USE I hereby affirm that I am exempt from the Contractor's License Law for the following.reason (Section 7031.5,,Busi- �f11-011—I i/ 9190 ness and Professions Code): NO. PARKING I,, as owner of the property, will do the work and the SPACES PROVIDED L i-1 7 r7 1 AM110"s structure is not intended or offered for sale (Section 7044,Business and Professions Code). • `1 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 �� V issued(Sec. 3097,Civ.Q. Lender's Name PROPOSED MAX, OCC. Lender's Address 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, O and hereby authorize representatives of this County to enter TOTAL FEE u o the aM-DAAD oned property for Inspect' n purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE . SPermittee Date WORKERS'COMPENSATION DECLARATION 76M444 CE875 (2-80) MISCELLANEOUS APPLICAtION I hereby affirm that I have a certificate of consent to self - COUNTY OF LOS ANGELES . BUILDING AND SAFETY DIVISION insure, or a certificate of Workers'Compensation Insurance,or a certified copy tliereof.(Sec. 3800,Lab.C.)• - Policy No. Company FOR APPLICANT TO FILL IN BUILDING', / ADDRESS 1 ❑' Certified copy Is hereby furnished LOCALITY ADDRESS 51- La Rsa ❑ Certified copy is filed with the county b-uilding inspection r NEAREST department. LOCALITY Temple Cit CA91780 CROSS ST. Date Applicant 6,10 NEAREST DISTR CT G UP TYPE PRO SSE11 BY - CROSS ST.. �/ CONST. CERTIFICATE OF EXEMPTION FROM•WORKERS'. LEGAL COMPENSATION LNSURANCE 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 - V SIZE OF LOT •-- EXISTING BLDG.- �� - cc I certify that in the 'performance-of the work for which-this Q permit is issued, I shall not,employ any-person in any manner OWNER Richard'-D. Betzler' so as to become subject to'the Workers' Compensation Laws. Lu OCCUPANCY GROUP_ . r� V MAIL SSpOBox •4458 ADDR - iL Date Applicant E1 Monte ,917:32 91732 TEL• 443-8861 OCCUPANT LOAD NOTICE TO APPLICANT:.If; after making this,Certificate of CITY NO. Exemption, you should become subject to the Workers' 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. `' • LICENSED CONTRACTORS DECLARATION occuPwNcv INSPEcr1oN� Panic,DevicesL ❑ I hereby affirm that I am licensed under provisions of Chapter- SAFETY PERMIT L 1 (LIST ITEMS BELOW) ` 9 (comrrlencing with Section 7000)-of Division 3 of the Busi- NO. OF EXITS ness and Professions.Code, and my license is in full force and PARKING effect, - * SPACES REO'D' PROVIDED Li'Liense Number Lic. Class' LIMITED .TIME USE r Contractor Date DATE DATE • FROM'• TO: ' ❑ I am exempt from the licensing requirements as.1 am a licensed architect or a registered professional.engineer SIZE OF NO. OF (N CTR acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE iness and Professions Code). g FINAL APPROVAL ' /1 , PRESENT USE OF BUILDING;. Printin ,�'�7—� �-�—•. Lic.or Reg.No. Date' C HOME OWNER-BUILDER DECLARATION NO:-OF EXISTING BUILDINGS ON LOT AND USE I hereby affirm -that- I •am exempt from the, Contractor's License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING SPACES PROVIDED ' ❑ I,'as owner of'the property, will do the work and the i-,7,'8,'A structure is not intended or offered for sale (Section 7044;.Business and Professions Code). PROPOSED9USE OF BUILDING • ,Machine Shop. ., g g Y CONSTRUCTION LENDING AGENCY oro 0 0-o e o z I hereby affirm that there-is a construction lending agency for the performance of the work for which this)permit is Q .� 87-8.,3 issued(Sec. 3097,Civ C.). Lender's Name -_- PROPOSED MAX. OCC. - - - Lender's Address PERMIT FEE'' I certify that I hav read this'application and state that the- ' above info 0 orr t. agree to comply with all County' ISSUANCE FEE ordinance n a e I to building construction•, and ' a t r entatives of this County to enter. TOTAL.FEE upon b v ent' property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE (13181 2fiMaT&of Per a Date WORKERS (ONIPI-NSAI-ION DF_( L:)R;�IION " MISCELLANEOUS APPLICATION .�U uUl,.;nl vl t bll fly \ 'I hereh) al'hrm that I h;r\e a celtlllc;lle of Loll-IllIosc11 ( OIIN IN OI I OS ANGI I:S BVI\ DING AND SAFETY DIVISION nlsttre, Ill a celtll lcatc of Wo[hcls"(ompcn,.m nl Inlnl,ulLc. III .1 celfil'ied cols) theicol' (Sec 38(1(1 [,if) ( 1 Rertif'ied No ("ontpally FOR APPLICANT FO FILL IN i BUILDING BUILDING ADDRESS � r ADDRESS cup)' I1 belch) lulnl111rd �,�� -��-/l_per-- - -- - LOCAurY f ❑ Certll led c(lp) IS I tied will) [lie Cl Rllll) hulllhni' Irl'•l,LI,Illlll CIrY ZIP / C_ CROSS ST �� 4 C J,� /• / ��O NEAREST department Date applicant SIZE OF LOT NO OF BLDGS NOW ON LOT I DISTRICT NO GROUP TYPE PROCESSED BY 1 1 ERI 11 K All" OF EXEMPTION I ROM \\,ORkI RS TBLOCK LOT NO I COMI'LNSAI ION INSIIRAN( E 4 MAF' HIGHWAY l ..� No ICIRCLEi STATE MAJOR SECOND LOCAL (This seclion need Ilol he compleled II the v%oilk llit )l\ed ASSESSOR MAP BOOK PAGE PARCEL IISE ZONE SPECIAL CONDITIONS by the permit i% lol one hdddred dullvti (~100) of Ic%s.) 777 - 1 OWNER TEL NO t - I cerllly 111,1\ in the pcllolnuulce of the \%olh II,I \011,11 [III,, --- - -- - -------- ( -- - �_--_ — _- --- --- ' pClllll( 11 ISSIICd. I 511,111 not L'i1111I11) ;111) prl 11,11 III _ I• so a1 to become stihlect to the Woikeis ( onlpen.auon I,It('s ADDRESS OCCUPANCY GROUP I Date----_ - Applicant CITY zIP NOTICI- lO APPI R ANI It ,IIIc[ nl,llnu 1111s ( rulln,llc OCCUPANTLOAD of I \cntption \oil should betonlc suhfcki I„ the \voll,cls APPLIGAIION[ OI - -_--- ---_- -- Conlpensation pm\Islonsol the L,Ihol ( odc )ou dnlsl 1"Illn\dl1 FXII IIAl1DWAliE comply N'fill such plmislU11s 111 [III, I)CIllllt 111,111 hr IIL'CIIICl 1RAILERLISCLI GEOLOGY INSPECIION I_� No Spec Kllowl ❑ revoked - — OCCUPANCY INSPECTIONK Panic Devices ❑ 1( I-.NSI_D ( ON I RA( IORS DI CI AR \I InN _ -- ---.---------- - I hereby all mill (11,11 1 :Inl IICCIISCLI IIIILICI l)1l1VIs1O111 01 ( 11,11)ICI SAFETY PERMII 1_ISr ITEMS BELOW. I 9(commencing\%'fill Section 7000)of Dl\111(111 I of tilt' 11t11111css NO OF EXITS El s and Professions Code and ill) license Is fn lull lolce amt ellecf c i,' ItITS i PARKING• REQ'D J� PROVIDED License Nunlhel ►.lc ( 1,1,1 SPACES 1 I Ctmtlactol Date LIMITED TIME USE - DATE DATE I ❑ I all( exempt Iron( the licCn mig re Ll1Il cmenls d1 I ,111) I FROM TO licensed alchilect or a reglsteled piol'C6101lal rnenlccl actin Ill Ill lolessiollill ca)aclt) (Sccnon 7(1 1 lfllsllh'15 SIZF OI- ��y�----7777 ��++,� NO Or INSPECTOR'S 1 g ) p 1 E%ISIING dl_lIG D ,�IORICS SIGNATURE and Plofcsslons (Ude) -- DC -- - -IRIS --- -- n LIC. or Reg. No 1),Ile PRESENT USE OF BUILDING FINAL APPROVAL 1 -- --"---- --------------- ---II-III --- --- IIONIL OWNI.R-Ill Ill DI R DI ( I ARAI ION pit) Or_%ISIING BUILDINGS ON LOT AND USE hereby it*fll 111 111x1 I ,lilt mnipi llolll file Coll[I'lC111 ) Itclise -- — ---- Law for the fullu\tnlg leason (SCcllon 7031 5 Busmcls .Ind ' Professions Code) NO PARKING ❑ SPACES PROVIDED L as owner of lite p[opclt\ will LII' Thr „1111. .rid Thr --- ------- ------- ----"--- - -- ------ 1lltic Idle I> riot IIll ended of of(Car(1 11 If s,l le (')Cil wit /0 11 PROPOSED USE OF BUILDING Business and Ptofess[ons ('ode) — " CRP S2�d S �L�P CONSTRUCTION LENDING AGI N( 1 hereby all'irm that there is ,1 commictlon Icndnle awcnc\ Io1 - - - ----- -- --the perlornlance of (he t%olh tot Mitch Ihrs lic[nut I, Issued (SCL 3097, CIV ( ) PROPOSED MAX OCC6.2,6 T ,r I Lenders Name _-_ _ _ APPLICANT IPItI,'JI i' n // TE%NO Lender's Addlcls ADDRESS certify that I nave read [III,, appllc,lllon and ,I,Ilc [ILII the above InIUYllIaIIUII iscorrect I ,1glc'C tocomply \%1111 J11( Ulllll\• PERMIT FEE ordinances and State Lilt's lel.lting to building const[uLtinn ,Ind hereby authorize lepresentati\es of till,, Comm to enter apoll ISSUANCE FEE the above-mentioned propel[) for nnpcction pulposcl �. \Drill_rrE X SEF REVERSE FOR LXPLANAIORY LANGUAGE 'i Signature of Pernnnee DJIC WORKERS'COMPENSATION DECLARATION CE 875 (11-84) MISCELLANEOUS APPLICATION CE 875 � `• I hereby affirm that I have a certificate of consent to 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.). Polic No. Company FOR APPLICANT TO FILL IN BUILDING ADDRESS Certified copy is hereby furnished. BUILDING / /J�I /� LOCALITY XX ADDRESS / ,G L/J �S/J Z, Certified copy is filed with county buil g insp ction LOCALITY NEAREST101, department. XX EM L ,i 7 CROSS ST. Date Applicant NEAREST •-� DI TRICOT NO. GROu� TYPE CESSED BY CROSS ST. N� �� / CONST. CERTIFICATE OF EXEMPTION OM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION I 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 SIZE OF LOT EXISTING BLDG. / I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manneX OWNER of building /VT�R RlS�S so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP ADDRESS 2066 Date Applicant � � ' �`��' CC TO APPLICANT: If, after making this Certificate of CITY Vo A/ ce O OCCUPANT LOAD � Exemption, you should become subject to the Workers' APPLICATION 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. El deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION EJ 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 anix effect. Name of business PARKING SPACES REO'D PROVIDED �o License Number Lic. Class / (� r� T//V LIMITED TIME USE Contractor Date DATE DATE FROM: TO: El I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTORS acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. p2p0 B.f STORIES SIG ATURE iness and Professions Code). _� �� FINAL APPROVAL / PRESENT USE OF BUILDING � Lic.or Reg. No. Date �f HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS D ON LOT AND USE I hereby affirm that 1 am exempt from the Contractor's �L License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING El1, as owner of the property, will do the work and the SPACES PROVIDED 2 0 structure is not intended or offered for sale (Section 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED USE OR BUILDING I hereby affirm that there is a construction lending agency /"I rr k 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 Q.Q `.4' o. I certify that I have read this application and state that the PERMIT FEE f�-' above information is correct. I agree to comply with all CountyISSUANCE FEE ordinances and State laws relating to building construction, 2ty and eby authorizer sentatives of this County to enter TOTAL FEE 25 . 00 :' r upo th above4n, tio e prope 'y for inspection purposes. XX XX SEE REVERSE FOR EXPLANATORY LANGUAGE � 1 1 Si 'ennittee Date J