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Home My Public Portal About9564 LA ROSA DR_Building__ • - APPLICATION FOR BUILDING PERMIT COUNTY OF LOS ANGELES BUILDING AND SAFETY BUILDIN WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN ' I hereby affirm,that I have a certificate of consent to self Insure, BUILDING ADDRESS or a cerfif cafe of Workers' Compensation Insurance,or a certifieds&Y L A rza,.19 copy thereof,(Sec 3800,Lab C) CITY. ZIPLOCALIT - G T ] Y Policy No Company SIZE OF L T NO OF BLDGS NOW ON LOT ❑ Certified copy is hereby furnished r S-z� K 14!;— - Z, - NEAREST CROSS ST ❑,Certified copy is filed with the county building Inspection TRACT BLOCK LOT NO 1 department - USE ZONE MAP NO ' Date Applicant ASSESSOR MAP BOOK PAGE PARCEL SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' OWER L TEL N COMPENSATION INSURANCE WITHIN 1000 FT OF SCHOOLS YES NO need-not be completed If the permit is,for one hundred ADDRESS---(This-sectionP P DISTRICT GROUP TYP NST FIRE ZONE PROCESSED BY dollars ($100) or less) I certify that In the performance of the work for which this permit CITY ZIP X06Q� Is Issued, I shall not employ any,perso ny manner so as to �C q ARCHITECT OR ENGINEER TEL NO • become subject to the Worker ' peva On Laws STATISTICAL CLA�S}BIFFICATION APT CONDO Date Du l3Tf Applicant �.i___ ADDRESS �- CLASS NO I L DWELL UNITS NOTICE TO APPLICANT If, after,making 'this Certificate of REQUIRED TOTAL SETBACK FROM EXIST Exemption, you Should become subject, to the Workers' CONTRACTOR '^ TEL NO SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code,-you must forthwith i FRONT , comply with,such provisions or this permit shall be deemed revoked ADDRESS LIC NO P L LICENSED CONTRACTORS DECLARATION SIDE CITY LIC CLASS- P L I hereby affirm that I am licensed underprovisions of Chapter 9 SEWER MAP (commencing with Section 7000)of Division 3 of the Business and SQ FT SIZE NO OF STORIES NO OF FAMILIES Professions Code,and my license Is In full force and effect NEW ❑ BK PG d License Number, LIC Class DESCRIPTION OF WORK ADD ❑ VALUATION , O Contractor . Date Se ALTER ❑ $ ��' A-4.51V El am exempt under Sec REPAIR El B&PC for this reason DEMOL ❑ III LDMA P/C# Date USE OF EXISTING B _ URM ❑ a C/)Signature APPLICANT(PRINT) - TEL NO LDMA Perm# i , Z ❑ I, as owner of the property, or my employees with wages as 0 their sole compensation, will do the work and the structure Is ADDRESS not intended or offered for sale (Section 7044, Business and FINAL DATE EL I Professions Code) t WILL THE APPLICANT OR UTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL OR A MIXTURE CONTAI R,," A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE 3• ❑ 1, as owner of the property, am exclusively contracting with AMOUNTS SPECIFIED THE HAZARDOUS MATERIALS INFORMATION GUIDE'S FINAL BY licensed contractors to construct the project (Section 7044, 0 � ii-3 Business and Professions Code) ves❑ No S' WILL THE INTENDED USE F THE BUIDUNG BY THE APPLICANT OR FUTURE BUILDING -�{-t OCCUPANT REQUIRE A MIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH _ �' -'' -• CONSTRUCTION LENDING AGENCY COAST AIR QUALITY M AGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR GUIDELINES I hereby affirm that there Is a construction lending agency for YES 1:1 NO - - a the performance of the work for which this permit Is Issued(Sec WIHAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING _ - N 3097, CIv-C) CHECKLIST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE f-i1'I't� I ''I t TITLE 2 CHAPTER 2 20 SECTIONS 2 20 100 THROUGH 2 20 140 CONCERNING HAZARDOUS --- Lender's --Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD o Lender's Address • OWNER OR AGENT o I certify that I have read this application and state under penalty of perjury that the above Information is correct I agree to comply PC FEE PERMIT FEE �D, N with all c Inances and State laws relating to building (/JI 4 m co Ion, an ereby authorize representatives of this County ISSUANCE FEE M(Denter up - ntioned property for Inspection purposes'lot (/!� INVESTIGATION FEE TOTAL FEE �y Ag- SEE v SEE REVERSE FOR EXPLANATORY LANGUAGE APPLICATION .FO_R-BUILDING PERMIT COUNTY-OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS I hereby affirm that I have a certrflcate of consent to self Insure, BUILG ADDRESS or a certificate�of Workers Compensation Insurance,or a certified copy,thereof(Sec 3800,Lab C) Y ZIP - "T l 7 O LOCALITY Policy NO Company SIZE OF COT NO OF BLDGS NOW ON LOT• f ❑ Certified copy Is hereby furnished NEAREST CROSS ST ❑ Certified copy is filed with the county budding Inspection TRACTBLOCK LOT department USE ZONE MAP NO Date Applicant ASSESSOR MAP BOOK- PAGE PARCEL • O SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER �^ TEL NO COMPENSATION INSURANCE e,,-q ', l! S/$ /7� WITHIN 1000 FT OF SCHOOL? YES NO (This section need not beicompleted if the permit Is for one hundred [ADDRESS Jf�f' dollars ($100) or less) �S 1A DISTRICT GROUP TY CONST FIRE ZONE PROLE Y I certify that m the performance of the work for which this permit CITY ZIP Is Issued, I shall not employ any person In•any'manner so as to become subject t0 the Workers'Compensation Laws ARCHITECT OR ENGINEER TEL NO STATISTICAL CLASSIFICATION APT NDO Date Applicant ADDRESS CLASS NO DWELL UNITS NOTICE 70 APPLICANT If, after making �thls Certificate Of REQUIRED TOTAL SETBACK FROM EXIST Exemption, you Should become subject- ,to the Workers CONTRA R TEL NO SET BACK YARD HWY PROP LINE WIDTH, Compensation provisions•of the Labor,Code,'You must`forthwith FRONT comply with such provisions or this permit shall be deemed revoked ADDR S LIC NO P L '>- LICENSED CONTRACTORS DECLARATION SIDE O CITY - LIC CLASS PL _ V I hereby affirm that I am licensed underprovlslons of Chapter 9 SEWER MAP (commencing with Section 7000)of Division 3 of the Business and SQ FT SIZE NO OF STORIES NO OF FAMILIES Professions Code,and mylicense Is In,full force and effect Q d / NEW' ❑ BK PG O License Number LIC-Class D CRIPTION OF WO' ADD ❑ VALUATION , - V Contractor Date III1-r � !LyLLJ$ a El am exempt under Sec (P9, ��' REPAIR ❑ $ Z B&PC for this reason M) 7G / �L M DEMOL ❑ LDMA P/C# DateFiN�TING LDr,� �C - URM ❑ " t 12 n Signature APPLICANT((PPPoNT) DV TEL NO LDMA Perm# ' /J ❑ I, as owner of the property, or my employees with wages as Z their sole compensation, 6vdl do-,the work and the structure Is ADDRESS O 7 not Intended or offered for sale-(Section 7044, Business and Ff DATE Q Professions Code) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL Z G {� I, as owner of the property am exclusively contracting with OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE A licensed contractors to construct the project (Section 7044, YES❑ No❑ t FINAL BY :Y 1 ti(i T a a r \I Business and Professions,Code) 1'�y(('��t Y64.26 4 n y6 WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING 3530) _ OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH ITEMS CONSTRUCTION LENDING AGENCY COAST AIR UAUTY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKUST FORGUIDE1�GI1J I hereby affirm that there Is a construction lending agency for YES❑ NO❑ TOTAL '64- @ s,. 6 the performance of the work for which this permit is Issued(Sec I HAVE READ THE HAZARDOUS MATERIAL INFORMATION GUIDE AND THE SCAQMD PERMITTING t ��}('£� 3097,CIV C) - CHECKLIST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE l•t HCl r5 264.26 �n TITLE 2 CHAPTER 2 20 SECTIONS 2 20 100 THROUGH 2 20 140 CONCERNING HAZARDOUS Lenders Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD1 c CIO C HANCH7 Lender's Address - • O' ER OR AGENT 3 1 certify that I'have read this application and state under penalty p of perjury that the above information IS correct I agree,to comply PC FEE PERMIT FEE Q' - 0000_0001 5,2 /96 Enwith all,.county ordlnancpand State laws relating to building i rI m constr o , and herebyfaut orize representatives of Ill County ISSUANCE FEE 6552 1 P i $o toe on the abo en n property for Inspect) urpos s 27.30 INVESTIGATION FEE •TOTAL FEE7,6 nv'\ .;y,mw,a a roa<em Aw 6. owe SEE REVERSE FOR EXPLANATORY LANGUAGE