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Home My Public Portal About9931 LA ROSA DR_Building__ T"--d WORKERS'.COMPENSATION DECLARATION APPLICATION FOR BUILDING PERMITS F' F �-1 herebyffirm a ;that I have a certificate of consent to self . . ,insure or a certificate of Workers' Compensation Insurance, ' or a certified copy thereof (Sec 3800, Lab. C.) // - COUNTY OF LOS ANGELES BUILDING AND SAFETY - Policy No _ Company' !r/"L fA/,('j., ,�,: - r BUILDING L"T Certlfied copy is,he'.by furnished. - FOR APPLICANT TO FILL IN ADDRESS ❑ Certlfied copy o is filed with the count vi Ing Ins a BUILDING ' e-,4 , - - tion department. Y 9 P '� ADDRESS ! 4- /�'^ / 7T ^Date "Applicant 1 clTr Ec'ifl�L '/T zip %/7,5G. LOCALITY- t s., r - -' NO. OF BLDGS. NEAREST - CERTIFICATE OF EXEMPTION FROMWORKERS' \ SIZE Of1oi Now ON LOT Y CROSS ST - m 'COMPENSATION INSURANCE - : .. ASSESSOR (This section need not be completed if the permit is for one TRACT F�.S L ' �: BLOCK LOT NO. ',MAP,BOOK [...-..a PAGE - PARCEL. " hundred dollars'($100) or,less.) - y - TEL' USE ZONE 'MAP 40 7-7—/ NO. - E NO. z¢-.•• ':'_d C' / , ' •-I.certify that in the performance of The work for which this • ermit is issued, I shall not.em to any person' in an manner ADDRESS T l! SPECIAL t P employ YP Y 1� �% I I"„ t'� //�I. !�'/ CONDITIONS -'so as to become.subject to the.Workers'Compensation Laws. ,. h' r. . } . . _ CIT9 //';SLE ��, '.. zip . 1 /, .G,. O "Date- -' Applicant - ARCHITECT OR TEL QQ % DISTRICT GROUP TYPE FIRE PROCESSED BY. U ! NOTICE TO APPLICANT: If,. after making this Certificate of ENGINEER , -4 di /LAlOG .'+..P$',$�i5'� - �, CONST. ZONEuJ .Exemption, you should become subject •io the Workers'•. :Compensation provisions of the Labor Code, you must forth ADDRESS •{' ¢ ` STATISTICAL. .�' ! ` - �` ,-� ff('•/r /% +'/ a LL deemed complywithsuch provisions or this permit shall be � CONTRACTORS /�lG/%�! //(s'$7•N L. rp er!/ STATISTICALCLASSIFICATION APT. CONDO ❑C. ''• CLASS NO: "�' ! DWELL. UNITS_ < LICENSED CONTRACTORS DECLARATION - `. "C a" 11�4nov. I hereby affirm that I am licensed under provisions of Chapter 9 ••/ ADDRESS / / C', NO' Y��"- SEWER MAP O . (commencing with Section 7000)of Division 3 of the Business S' '�-. LIC' CITY•T�ll:.9i L.G. ./ I! CLASS . s "4 ty i and Professions Code,and my license is in 4u fforc d effect.- BK 'pC, VALIDATIONF �/ SQ. FT.' NO. OF O. OF CHECK License'Number' TVA~ � Class, _ v SIZE C• 5 DRIES FAMILIES ONE T `� / r /•� \ ' ,•ZNC' T,.,, f�'1 VAWATION . .5 . —./ 'F DESCRIPTION OF WORK NEW LJ rJ, clO'PJ. '1 �5� ppt.t 5 Contra C, ADDW.,-1 1 ❑I am exempt under Sec • •Fye/ �s � !L ��--II y -� r .. , rr v ALTER L_I Q�i , -0: r B&P.C. for this reason h'!V G /r"'/��/!x 4 a �� /' REPAIR ❑. 0/ 3 A r Date r USE OF - `'f EXISTING BLDG:. DEMO( ❑ '7k t .Signature �� APPLICANT //J/ ✓� //J� ,IEkf n �-7 FINAL. • -. (PRINT)'--.L%C/ La.C.. Lii•�!/CN6. /t G... OWNER-BUILDER DECLARATION •�; DATE b I�here 'affirm that am exempt from the Contractors License </< Y Contractor's ADDRESS f- I I �h�. . V 'N r / �1 i ' - Law for the following reason (Section 7031.5, Business and FINAL L .Professions Code): - �, PRESENT By*, sT �- BUILDING f,jS,jlr 14*4V it t ❑ I, as owner of the property, or,my employees with �; ADDRESS , }s "3s'tr wages as their sole compensation,.will do the work and the structure is not intend �ed or offered for sale(Section of LOCALITY 7044, Business and Professions,Code.) MOVING TEL. I 1, as owner of the ro ert Y g i I CONTRACTOR. NO, - ❑ p p y;:am exd usivel contracfin - �: with licensed.contractors to construct.the project (Sec. ADDRESS ,C+�i•ti f, Igt°'f f;l Y , tion 7044, Business and Professions Code.). . \y - REQUIRED '-TOTAL SETBACK-FROM EXIST. _ CONSTRUCTION LENDING AGENCY SET BACK YARD HWY: PROP. LINE WIDTH , I hereby affirm that.there is a construction lendingagency for, '•`. FRONT tH6 performance of the work for which this permit is'issued l P.L.- (Sec. 3097,.Civ. C:). - - �' •SIDE - Lender's Name _ f P.I. LDMA Ref N "/ Permit Fee / , . _. Lender's Address " I certify that 1,have read this application and state'that the Issuance Fee �'' LDMA P/C N above information is correct. I agree to comply with all County Investigation Fee - - Rordinances and'State laws relating to'bullding construction, Total Fee �'� ->?•-'`` ! % LDMA Perm. - a an her by authorize representatrvy��'fth is County to enter - I on a abov m hone (Scoper y}6r nsggctn purposes, , , - L^'t��+ r JC i. %'4' / // SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of'Applicanfit or Agent - 'Date 76AB38A C E#809.].S6 APPLICATION FOR BUILDING PE IT 1 BUILDING AND SAFETY DIVISION ADDRES B1UOG RESS 'Department of County Engineer County of Los Angeles LOCALITY JOHN A. LAMBIE, COUNTY ENGINEER NEAREST CASSATT D. GRIFFIN. SUPT OF BUILDING CROSS ST. DISTRICT NO. GROUP I TYPEI SEK MA= G FOR APPLICANT TO FILL IN l Z CONS � BU / ADDRESS �/`�/ �j ��/�ii�Qy/ri��abo 1 Y STATISTICAL .LASSIFICATION LOT NO �r(,Qq V Y BLOCK CLASS. NO. DWELL. UNITS MAP T ASTE YES ER r NUMB ^JCC/ HAT TRACT �Z�NE SPECIAL I NO. OF SLID S. CONDITIONS SIZE OF LOT �V Z gTZ NOW ON LOT / Sove USE OF EXISTING BL G. BUILDING EXIST. YARD HWY STREET NAME OWNER MAIL ` ,/`��f� SETBACK WIDTH ADDRES % /\,�/fC(ate GO•+"�✓• FSIDET -��L-�'--'• TEL. P. L. CITY A R �.[f,. + NG " INSPECTION RECORD OHITECT OR EL. TEL ENGINEER NO. �12 1AF4 r-'I `/. .I Soh-• - - --' J ADDRESSI TEL. CONTRACTOR NO. ADDRESS DESCRIPTION OF WORE NEW ADD ALTER t'/ REPAIR DEMOLISH SO. FT. NO. OF NO. OF SIZE STORIES FAMILIES [F/�STy'R UCTURE % ` I SFTW c APPROVALS SIGNATURE OF APPLICAN j DATE INSPECTOR'S SIGNATURE ADDRESS _ FOUNDATION: LOCATION FORMS. MATERIALS / Q P, C_ S FRAME: FIRE STOPS. FEE BRACING. BOLTS / -D/,_n`7 FURNACE: LOCATION. I FEE �VALUATION S9_ -- GAS VENT,.DUCTS I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS AP- LATH. INT. PLICATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPL WITH ALL COUNTY ORDINANCES AND LATH. EXT. STATE LAWS REG- ULIATING BUILDING CONSTRUCTION'.1 SIGNATURE OF /�..L�G�•�sF�l '9Y�.//�/// ��(//rK//[��//A/] HOUSE NUMBER COR- - PERMITTEE RECT AND POSTED ADDRESS /l FINAL JOHN A. LAK11211E. COUNTY ENGINEER, CLYDE N. DIRLAM, PRINCIPAL STRUCTURAL EGINEE PLAN CHECK VALIDATION CK. N.C. CASH PERMIT VALIDATION CK. M.O. cnsH .ACC 8 9 9 3 JUM 7 1 2.0 0 M D WORKERS' COMPENSATION DECLARATION hereby affirm that I have a certificate of consent to self APPLICATION FO.R. RU •61MG PERMIT insure, or a certificate of Workers' Compensation Insurance, ` or a certified copy thereof (Sec. 3800, lab. C.) - COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. - 'Company ElBUILDING .Q-7/ /� n Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS 1 / C 1n7 'Cl Certified copy is filed,with the county building inspec- BUILDING �n/ /J�.y� /� tion department. ADDRESS �/ff?/J/J /�i TEJ-y/ LE L/7� CITY T �,E L./r ZIP /7 LOCALITY Date Applicant NO.OF BLDG5. CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT,...i NOW ON LOT CROSSSE COMPENSATION INSURANCE �L �• ASSESSOR (This section need not be completed if the permit is for one TRACT / BLOCK LOT NO, p MAP BOOK PAGE PARCEL hundred dollars ($100) or tens.) TEL USE ZONE NO. OWNER / NO / I certify that in the performance of the work for which this /� nr SPECIAL - y permit is issued, I shall not employ any person in any manner ADDRESS /r /( CONDITIONS d so as to become subjecLto,the Workers'Compensation Laws. �jp _/ C1 CITY E L /% ZIP �� /O� U Date Applicant' ARCHITECT OR TEL. NOTICE TO APPLICANT: If, after makingthis Certificate of ENGINEER DISTRICT GROUP TYPE FIRE PROCESSED BY R /�JO. CONST. ZONE 0 Exemption, you should become subject to the Workers' ` ' C w Compensation.provisions of the Labor Code, you must forth ADDRESS �� —� ✓ a STATISTICAL CLASSIFICATION APT. CONDO. with comply with such provisions or this permit shall be TEL. Z deemed revoked. CONTRACT /LLE�J Np.7{5',$— LICENSED CONTRACTORS DECLARATIONp LIC 11ZI CLASS NO. �3 DWELL. UNITS'/_ I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS 17/ �GS17 O. y LIC. p SEWER MAP (commencing with Section 7000)of Division 3 of the Business CITY TE//"/ E Uf— CLASS L7 . and Professions Code,and my license is in full force and effect. BK. PG VALIDATION 50. FT. NO. OFNO. OF 'CHECK License Number `1" �QC�t /� Lic. Class SIZE STORIES FAMILIES ONE a+,pillE�te .S^', SALVATION Contmcto � DESCRIPTION OF WORK NEW ❑ �/!4 O O/ ADD El lc am exempt under Se - ALTER ❑ Boo B.BP.C. for this reason $ USE OF REPAIR ❑ Date: EXISTING BLDG. DEMOL E Signature- APPLICANT T L. 9 -(PRINT) FINAL OWNER-BUILDER DECLARATION - DATE { '�T—li Hs_t•F .v I hereby affirm that 1 am exempt from the Contractor's License gDDREs C�� T� FINAL Law for the following reason (Section 7031.5, Business and Professions Code): PRESENT By - 1 T Ljl_- ❑ I, as owner of the property, or my employees with BUIDING ADDRESS L!I y—y.,,—y wages as their sole compensation,will do the work and LOCALITY - ^ ' - I H� vtF - 00 00 y_. the structure is not intended or offered for sale(Section ,li'_I 7044,.Business and Professions Code.) MOVING - - TEL. ® LiL..n'. __ ElI, as owner of the property, am exclusively contracting CONTRACTOR NO. with licensed contractors to construct a project (Sec- ADDRESS tion 7044, Business and Professions.ons.Code.) REQUIRED TOTAL SETBACK FROM EXIST. - r CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH _ I hereby affirm that there is a construction lending agency for FRONT , the performance of the work for which this permit is issued P.L. - - -nq (Sec. 3097, Civ. C.). SIDE '.4 P.L. . Lender's Name- m LDMA Ref. # � Lender's Address P.C. Fee$ Permit Fee I certify that I have read this application and state that the Issuance Fee ��' LDMA P/C If above information is correct. I agree to comply with all County Investigation Fee d _ O _ordinances and State laws relating to building construction, Total Fee '6 • LOMA Perm. # a and hereby authorize representatives of this County to enter u p h ve- enti ie� erty for inspection purpose ' SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of ApOplicant or Agent Date