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Home My Public Portal About9237 LA ROSA DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444 CE-875 (2-80) MISCELLANEOUS, APPLICATION :. I hereby affirm that I have, a certificate ofcoea self COUNTY OF LOS ANGELES BUILDING AND SAFETY. DIVISION insure, or a certificate of Workers'Compensation Insurance, e,or _ - • a certified copy thereof(Sec.3800,Lab.C.) - - Policy No. 'Company FOR APPLICANT TO FILL IN: BUILDING ADDRESS F1`Certified copy is hereby furnished. BUILDINGLocALlrx" ADDRESS _ S/q• �� ❑ Certified copy is filed'with the county;buildmg inspection �� NEAREST department. LocwLlTr cRoss sr: Date Applicant NEAREST. - ,{/`/ DISTRI T.N G OUP TYPE JPROCESS 'BY CROSS ST. Cy J CONST - r CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP NIGH Wwv STATE MAJOR SECOND LOCAL NO. (CIRCLE) _ NO. OF'BLDGS. (This.section need not be completed if the Work Involved TRACT NOW ON'LOT USE ZONE SPEC IAL'COND(TIONS Q by the permit is for -one hundred dollars' ($100) or less.) USE OF SIZE OF LOT - EXISTING BLDG., 1 certify that in-the performance of the work for which this /' Q permit Is Issued, I shall not employ any person In any mariner OWNER �. C9 L L�t-� , so as to become subject to the Workers'-Compensation Laws. MAIL OCCUPANCY GROUP. W Ic ADDRESS tl Date Applicant Cn TEL. .NOTICE 10 APPLICANT: If, after making,this Certificate of CITY NO. 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 USEGEOLOGY INSPECTION 0 ❑. No Spec. Knowl. ❑ deemed revoked. LICENSED CONTRACTORS DECLARATION occuawrvcv INSPECTION Panic Devices ❑ I hereby affirm that I am licensed under provisions of Chapter. 'SAFETY PERMIT q (LIST ITEMS BELOW) NO. OF EXITS 9 (commencing with Section 7000)•of•Division 3 of the Busi- ness and Professions Code, and my license is in full force and GIN RK effect. PA �� REQ'D PROVIDED- SPACES -License Number Lic. Class GCI - - LIMITED TIME .USE Contractor Date DATE . EJ , FRAM'.—�' Q �-�F� I am-exempt from the licerising requirements as- I am aI / s E ro 's licensed architect or a,registered professional engineer• SiZE OF No. OF IG •��„, ,CA GN r acting in my professional capacity 7051, Bus- EXISTING BLDG. STORIES iness and Professions Code)., Y FINAL APPROVAL �p_ �J_ PRESENT-USE OF BUILDING Lic.or Reg.No. Date 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 ❑ 1, as owner of the property, will do the work and the " q 4.63 p structure is- not intended or offered for sale'(Section µ 1 ' 7044, Business and.Professions Code). # ' PROPOSED USE OF BUILDING O O,O'03 0 ' CONSTRUCTION LENDING AGENCY : .2!0 0' 8,Q'5,0 I hereby affirm that there-Is a construction lending agency for the performance "of the work for which this permit is ,o js.o/ b OIv 1 issued(Sec. 3097,Civ.C.). Lender's Name PROPOSED MAX. OCC. -Lender's Address PERMIT FEE O 1: 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,' V C l ordinances and State laws relating to building'construction, V� and hereby authorize representatives of this County to enter ' TOTAL. FEE �o the"aj�ove-mTied property for inspection purposes. SEE REV ERSE-FOR,EXPLANATOAY LANGUAGE 1 L ' ignature of Permittee' Date ~ J WO KERS,'COM$ENSATION DECLARATION 76CE 844(11-84) MISCELLANEOUS APPLICATION I hereby affirm that I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers'Compensation Insurance, e,or a certified•copy thereof(Sec. 3800,Lab.C.). BUILDING 2 �- Policy No. Company FOR APPLICANT TO FILL IN ADDRESS �J 7 i Certified copy is hereby furnished. BUILDING �+. LA ��S� ADDRESS LOCALITY > Certified copy is filed with the county building inspection LOCALITY NEAREST f• department. CROSS ST. Date Applicant NEARESTD O O CONST DISTRICT R UP TYPE CROSS ST. . / IPROC.�Y ,C CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL V V (� COMPENSATION INSURANCE DESCRIPTION Lor NO. BLOCK MAP HIGHWAY No. (CIRCLE) STATE MAJOR SECOND L AL NOOF BLDGS. (This section need not be completed if the work involved TRACT NOW. ON LOT USE Z NE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE OF SIZE OF LOT EXISTING BLDG. r I certify that in the performance of the work foi'which this o permit is issued, I shall not employ any person in_any manner OWNERffh `) so as to become subject to the Workers' Compensation Laws. MAIL ,N Al OCCUPANCY-GROUP_I ` �3 0 ADDRESS • 14 D i. V Date Applicant LI.J NOTICE TO APPLICANT: If, after making this Certificate of CITY 7 l T Noy ��. OCCUPANT LOAD Exemption, you should become subject to the Workers' AP LIGATION FOR EXIT HARDWARE: Compensation provisions of the Labor Code, you must forth- with comply with such provisions Or this permit shall be TRAILER•USEGEOLOGY INSPECTION ❑ ❑ ❑ No Spec. Knowl. deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) 9 (commencing with Section 7000) of Division 3 of the Busi- No. OF Exlrs ness and Professions Code, and my license is in full force and effect. J PARKING REq"D PROVIDED .I I SPACES II !! License Number Lie. Class �lr- LIMITED TIME USE Contractor Date ' I DATE DATE FROM: TO: I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OF NO. OF - INSPECTOR"S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SI ATURE iness and Professions Code). FINAL APPROVAL PRESENT USE OF BUILDING Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION- No.of EXISTING BUILDINGS ON LOT AND USE I hereby affirm that F am exempt from the Contractor's 1 :1 2 7 A License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING # • o'• 0 3 0 0 I, as owner of the property, will do the work and the saAces PROVIDED +� �` �\ structure is not intended or offered for sale (Section ; ( o o.'$Q`cj Q) 7044,Business and Professions Code). PROPOSED USE OF BUILDING �` \ •,10,o .• Q U CONSTRUCTION LENDING AGENCY (•,,1„1 4`i”' LS" 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.Q. Lender's Name PROPOSED MAX. OCC. Lender's Address ti ' I certify that I have read this application and state that the PERMIT FEE '� �,_,-+v 1 '� -• 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 i upon lie above-mentiolied.property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date r / COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MISCELLANEOUS PERMIT DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS MP 0508 1002180001 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 ` PHONE: (626) 285-0488 EXT: ILEGAL ID- - I NO. OF CONST NEW I BUILDING ADDRESS- ITR: 16475 LT: 103 I SQ. FT STORIES TYPE OCCUP GROUPI 9237 LA ROSA DR I ISTRUCTURE: 1 V-B U I TEMP CA 917803732 I (ASSESSOR INFORMATION NUMBER. I I NEAREST CROSS STREET: I 18590-010-003 IEXIST BLDG USE: I THOMAS PAGE 596 GRID: J5 LOCALITY: TEMPLE CITY, Cl IEXIST OCC GRP: USE ZONE I I (TENANT: I (ISSUED ON: PROCESSED BY: EXPIRES ON: I IBLDGS. NOW ON LOT: VALUATION: 102/18/10 SR 08/17/10 I 0 1 I 1OWNER: TEL. NO: I IFI AL DATE FI AL BY: CODE: 1 IWANG, JIE (626) 641-7811- ILIST ITEMS: I 19237 E. LA ROSA DR. ITEMPLE CITY CA 91780 IDE CRIPTION OF WORK 1 IRE-CONVERT THE STRUCTURE TO A STORAGE SHED (NO PLUMBING) IOCCUP LOAD EXIST: I 1 1APPLICANT- TEL. NO: 1OCCUP LOAD NEW: 1 I ISAME AS OWNER - I I IPARKING SPACES REQUIRED: ISPECIAL CONDITIONS: I IPARKING SPACES PROVIDED: 1EXIT HARDWARE: ICONTRACTOR: - TEL NO: I I LIMITED TIME USE 1 ISAME AS OWNER - INBR OF EXITS: - I FROM TO 1 LIC. NO I FEES PAID 1 I (APPROVALS DATE INSPECTOR SIGNATURE- 1 IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT: ( I (ARCHITECT OR ENGINEER: TEL. NO: I ITRAILER USE - IOA PERMIT ISSUANCE 27.75 1 I I 1 - LIC. NO: 101 R/M OCC/USE INSPECT 145.95 ISAFETY PERMIT I I TOTAL FEES 173.70 1 I I I (TEMP. STRUCT. APPROVED I I I I I I I IMAP NO: SEWER MAP BOOK. PAGE: FIRE ZONE: CMP:I (TEMP. STRUCT. REMOVED I 1 I INO. OF FAMILIES: DWELLING UNITS: APNO/COND: STAT CLASS: SCHOOL WITHIN HAZARDOUS I I I I (AIR QUALITY: 1000 FEET MATERIALS NO NO NO I IREQUIRED TOTAL SETBACK FROM EXIST ISET BACK YARD: HWY: PROP LINE: WIDTH: IFRONT PL- I I I I I SIDE PL- I 1 I I I I I I I I I I I 1 I I I 1 I I I I I I I 1 I I I I 1 1REPORT ID: DPR267 ROUTE TO: BSO508 I I I I I I I I