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HomeMy Public PortalAbout9469 LA ROSA DR_Building__ WORKERS'COMPENSATION DECLARATION • 'I hereky affirm that I, have a certificate of consent to self q'p p I C qT I O N FOR lJ I L®I N P E 811111 'i'` Insure,•or a certificate of-Wo Cqm ensation Insurance, or'a certified copy'therec f (Sec. 3800, Lab C ) COUNTY OF LOS ANGELES BUILDING AND SAFETY- Policy No. Company ❑• Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING ADDRESS Certified copy is filed with the county building inspec- BUILDING / - hon"department. ADDRESS �� G/�? (` (�7/fl� ©� ,..,A TY- Date. Applicant CITY ' ! L LL U,! . ZIP fl7/�D LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' �� NO OF BLDGS. NEAREST COMPENSATION'INSURANCE SIZE OF LOT / NOW ON LOT CROSS.ST LDVL (.This section.need not be"completed if the permit is for one- ASSESSOR - hundred dollars ($100)or less.) TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL - TEL ,�/ D/ USE NE MAP I certify that in the performance of the work for which this - " OWNER NO. �Jlo O NO permit is issued, I shall riot employ.dny person in any manner. " ADDRESS La I SPECIAL so os to,b'ecome subject to the Workers'-Compensation L ws. CONDITIONS ✓L CITY -¢ (i! ZIP /7 Date �' ' Applicant (� `) �:. 1 -4 TEL ARCHITECT OR . NOTICE TO _APPLICANT: If, after making this Certificate of DISTRICT GROUP TYPE FIRE PROCESSED BY O Exemption, you should become. subject to -the Workers' ENGINEER NO. -. n CONS ZONE U Compensation provisions of the Labor Code„you must.forth- 3 with comply with such provisions or this permit shall be . ADDRESSr / .v CLLL deemed revoked. CONTRACTOR O�J,t1�lz-- TEL' STATISTICAL CLASSIFICATION APTONDO; to LICENSED CONTRACTORS DECLARATION' NOL't LIC, CLASS NO: DWELL. UNITS — I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. (commencing with Sectiom7000)of Division 3 of the Business and LIC SEWER MAP- Professions Code, and,my license is in full force and effect. CITY CLASS 'BK. PG VALIDATION SQ. FT..-a 7 NO.OF NO. OF CHECK License-Number Lic.Class' "SIZE STORIES f FAMILIES I ONE VALUATION Contractor Date DESCRIPTION OFF WORK (3��Li D NEW- ❑ 6 I3 LSU P— A- A- , ADD ❑ I am exempt under Sea ® = • ALTER ❑ B.&P.C. for this reason NG'y✓ %3A1 T REPAIR ❑ _ O J�5 9 A USE OF C GIS Date: EXISTING BLDG. ✓/ DEMOL ❑ # e 0;0 0 e 1 Slgnoture APPLICANT TEL.< FINAL t OWNER-BUILDER DECLARATION PRINT ��/UIV/`� v_ NO.- -���7 DATE '�j� 6 2,3 8 I'hereby affirm that I am-exempt from the Contractor's License._ ¢� G,� / 7�(7 Law for-the following-reason;(Section 7031:5,, Business and L; ADDRESS / FI °';a 1 6 2 3 8 5 Professions Code): ' PRESENT B ❑ BUILDING y , 0 8.�.O, 8 8 I, as owner of the property, or my.employees with ADDRESS wages as their sole compensation,will do the work and t` •..�. the structure isnot Intended or offered for sale(Section LOCALITY r 7044, Business and Professions Code). MOVING TEL. I, as owner.of the property;am exclusively contracting CONTRACTOR NO. with licensed contractors to constructahe project (Sec- r' tion 7044,`Business and Professions Code). ADDRESS ✓`.l t iE.k,, RE UIRED TOTAL T 4V CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP:LINE WIDTH t I hereby affirm that there is a construction lending agency for FRONT the performance of the work for which this permit is issued PL :•� �. t.y t (Sec. 3097, Civ. C.). - SIDE ;' PL. Lender's Name LDMA''Ref. q• \ ' `O P C. Fee$ Permd Fee ,Lender's Address t • , I certify that I have read this application and state that the Issuance Fee. V.V �/ PLD MA`P/C li oabove information is correct. I agree to comply with all County Investigation Fee 9 ordinances and State laws relating to building construction, Total Fee LDMA Perm q $ and hereby authorize representatives of this County to'enter m upo eabove-mentioned o erty for inspection purposes. t �t 2_ SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Dote _ - _ - ,� � - `ti�,� 4+• R ' 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 91780 BL 0508 9909140008 PHONE: (626) 285-0488 EXT: LE N0. OF CONST BUILDING ADDRESS: TR: 13620 LT: 12 SQ. FT STORIES TYPE 9469 LA ROSA DR STRUCTURE: 0 VN TEMP CA 917803840 ASSESSORINFORMATION ° NEAREST CROSS STREET: CLOVERLY 8590-011-012 THOMAS PAGE: 596 GRID: J5 LOCALITY: TEMPLE CITY TENANT: EXIST BLDG USE: RESID USE ZONE: R-1 ISSUED ON: PROCESSED IRES ON: EXIST OCC GRP: 09/14/99 UT 03/12/00 OWNER: TEL. NO: BLDGS. NOW ON LOT: VALUATION: FI AL TE FINAL BY: CODE- KOO CHENYEN;CONNIE (818) 286-1817- 1 4,200 - 9469 LA ROSA DR TEMP 917803840 FEES PAID ns-S0 F WOR TEAR EXISTING ROOF, EW SHEATHING AND RECOVER_ WITH FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: 25 YR. CELOTEX COMP. SHINGLE APPLICANT: TEL. A JA MASTER ROOFING CO (213) 446-9737- AA BLDG PERMIT ISSUANCE 27.75 233 S. HOBART BL 105 AC STRONG MOTION RESID 4200.00 VAL 0.50 SPECIAL CONDITIONS: LOS ANGELES, CA D2 PERMIT W/O EN:HC�4200.00 VAL 132.60 GELESTO`'T®FEES 160.85 CONTRACTOR: TEL. NO: APPROVALS DATE INSPECTOR SIGNATURE , A J MASTER ROOFING CO. (323) 953-9942- 4120 W. MELROSE AVE. LIC. NO LOCATION ADSETBACKS LOS ANGELES, CA 90029 726275C39 SOILS ENGINEER APPROVAL i ARCHITECT OR ENGINEER: TEL. y FOUNDATION/TRENCH FORMS' LIC. N0: SLAB/UNDER FLOOR RAI' - 1111111 - iSED FLOOR FRAMING MAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP,:; n n UNDERFLOOR INSULATION NO. OF ST 3 d i�)U D V V L�C SHEATHING FA G UNITS: C A ' NO 21 VC O 0 OOF'SHEATHING SCHOOL WITHIN HAZARDOUS \ O 0' SHEAR PANELS AIR QUALITY: 1000 FEET MATERIALS NO NO NO d O D ® RAMINSPECTION REQUIRED TO EXIST nn OQ�y HANGERS SET BACK YARD: HWY: PROP LINE: WIDTH: �/ L_i. FRONT PL- 'C ` erviC@ lb6$� INSULATION/ EATHER STRIP SIDE PL- INTERIOR LATH/DR EXTERIOR LATH RATED SSE . RATEI IWALL ASSEMBLES RATED SHAFTS/OPENINGS T-BAR CEILINGS LOT DRAINAGE REPORT ID: DPR261 ROUTE TO: BS0508