HomeMy Public PortalAbout4908 GOLDEN WEST AVE_SEWER_5/17/2016_COUNTY OF LOS ANGELES. TEMPLE CITY # 0508 SEWER PERMIT
DEPARTMENT OF,PUBLYC WORKS 9701 LAS TUNAS BE 0508 1605170005
BUILDING AND SAFETY / LAND DEVEDOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
I LEGAL ID: ISEWER
/ SEPTIC: SEWER I
BUILDING ADDRESS:
ITR: 13986 IT: 8 IEKIST
OCC GRP: 1
4908 GOLDEN WEST AV
I IBLDGS.
NOW ON LOT:
TYPE:
ML TO PL: STATION: DEPTH:
REFERENCE: UPPER/LOWER: TISSUED
TEMP CA 917803937
NEAREST CROSS STREET:
THOMAS PAGE: 597 GRID: AS LOCALITY: TEMPLE CITY CA
(ASSESSOR INFORMATION NUMBER: ICONNECTION
18589-020-008 (ORIGINATION:
I ILENGTH
TTENANT: 1MANHOLE
ON: PROCESSED BY:
05/17/16 SR
I 1COUNTY
IMPROVEMENT NUMBER:
CHECK NUMBER: IFINALTE
I_ T
(OWNER: TEL. NO: IPLAN
FI Y: CODE:
14908 GOLDEN WEST LLC - IJOB
HUNTINGTON DR ITRUNK
NUMBER: I
PERMIT NUMBER:
��
I2275
SAN MARINO CA 91108 (ROAD
PERMIT NUMBER:
DESCR PT1 N OF WORK
1 1AFFADAVIT:
NO
CONNECT NEW SINGLE FAMILY DWELLING TO PUBLIC SEWER
IWAIVER:
NO
NO
(APPLICANT: TEL. NO: (EASEMENT:
IDIRIM, ANNA (626) 279-1800-
SPECIAL CONDITIONS:
I
19324 E GARVEY AVENUE T
MONTE CA 91733 (HIGHWAY/STREET
RECORD INSTRUMENT NBR: RECORD DATE:
WIDENING:
TEL
]STATE
ENCROACHMENT PERMIT NUMBER:
ICONTRACTOR: TEL. NO:
I FEES PAID
]APPROVALS
DATE
INSPE RJIGNATORE
ISD DESIGN CONSTRUCTION CORPORATION (626) 279-1800-
HOUSE SEWBA3z
/� rJ/'
GARVEY AVENUE LIC. NO
IFEE DESCRIPTION: QUANTITY: DOM: AMOUNT:INEW
I9324
EL MONTE CA 91733 930443
1
]CONNECT ADDITIONAL
]
I
]
101 PERMIT ISSUANCE FEE 34.40
103 CONN TO PUBLIC SEWER 1.00 CON 58.40
I TOTAL FEES 92.80
I
]BUILDING OR WORK ]
I
I
IARCHITECT OR ENGINEER: TEL. NO:
CTMAX DEVELOPMENT INC. (626) 285-3408-
(SEPTIC TANK, SEEPAGE PITI
]
112 N. EARLE ST. LIC. NO:
I
(AND/OR DRAIN FIELD
I
1SAN GABRIEL, CA 91775 930764
1
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1
1DRYWELL
SEWER MAP BOOK: PAGE:
ALTER, REPAIR, SEWER OR
ISEWAGE DISPOSAL SYSTEM
T
IDISCONNECT PLUG AND
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(ABANDON HOUSE SEWER
IBACKFILL SEPTIC TANKS _I
TISEEP.
PIT _ CESSPOOL _I
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1GRAYWATER SYSTEM
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PERMIT EXPIRES 180 DAYS IF
T
1
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1) WORK DOES NOT COMMENCE, OR
2) WORK IS SUSPENDED OR ABANDONED, OR
3) FAILS TO OBTAIN CODE REQUIRED INSPECTION
T
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TT"PORT
ID: DPR266 ROUTE TO BS0508
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OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from
the Contractors' State License Law for the reason(s) indicated
below by the checkmark(s) I have placed next to the applicable
item(s) (Section 7031.5, Business and Professions Code): Any
city or county that requires a permit to construct, atter, improve,
demolish, or repair any structure, prior to its issuance, also
requires the applicant for the permit to file a signed statement
that he or she is licensed pursuant to the provisions of the
Contractors' State License Law (Chapter 9 (commencing with
Section 7000) of Division 3 of the Business and Professions
Code) or that he or she is exempt from licensure and the basis
for the alleged exemption. Any violation of Section 7031.5 by
any applicant for a permit subjects the applicant to a civil
penalty of not more than five hundred dollars ($500).):
U I, as owner of the property, or my employees with wages as
their sole compensation, will do (✓) all of or (_) portions of the
work, and the structure is not intended or offered for sale
(Section 7044, Business and Professions Code: The
Contractors' State License Law does not apply to an owner of
property who, through employees' or personal effort, builds or
improves the property, provided that the improvements are not
intended or offered for sale. If, however, the building or
improvement is sold within one year of completion, the Owner -
Builder will have the burden of proving that it was not built or
improved for the purpose of sale.).
U I, as owner of the property, am exclusively contracting with
licensed Contractors to construct the project (Section 7044,
Business and Professions Code: The Contractors' State License
Law does not apply to an owner of property who builds or
improves thereon, and who contracts for the projects with a
licensed Contractor pursuant to the Contractors' State License
Law).
(_): I am exemdt from licensure under the Contractors' State
License Law for the following reason:
By my signature below I acknowledge that, except for my
personal residence in which I must have resided for at least
one year prior) to completion of the improvements covered by
this permit, I c4nnot legally sell a structure that I have built as an
owner -builder If it has not been constructed in its entirety by
licensed contractors. I understand that a copy of the applicable
law. Section 7044 of the Business and Professions Code, is
available upon request when this application is submitted or at
the following Web site: http�//www.1aginfo.ca.gov/calaw.htmi.
Date:
Signature of Property Owner or Authorized Agent
y
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm under penalty of perjury that I am licensed under
provisions of Chapter 9 (commencing with Section 7000) of
Division 3 of the Business and Professions Code, and my
license is in full force and effect. (�
Licensee Class /� License No. tD
�Bate 0 ///Bpntractor Signature
W/O'R77K77E"RS' COMPENSATION ECION
WARNING: FAILURE TO SECURE WORKERS COMPENSATION
COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN
EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO
ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION
TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED
FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND
ATTORNEY'S FEES.
I hereby affirm under penalty of perjury one of the following
declarations:
I have and will maintain a certificate of consent to self -
insure for workers' compensation, issued by the Director of
Industrial Relations as provided for by Section 3700 of the
Labor Code, for the performance of the work for which this permit
is issued.
4 lNo.
/P` I have and will maintain workers' compensation
insurance, as required by Section 3700 of the Labor Code, for
the performance of the work for which this permit is issued. My
we c don d licy number are:
r er Policy Number
Exp do Da e
Name of Agent Phone Number
I certify that, in the performance of the work for which this
permit is issued, I shall not employ any person in any manner
so as to become subject to the workers' compensation laws of
California, and agree that, if I should become subject to the
workers' compegsation provisions of Section 3700 of the Labor
Code, I shall with c mply with those provisions
X--� /
40>4 of AWnt Date
LOBBYIST ORDINANCE CERTIFICATION
Complete this section for permits in
Unincorporated Los Angeles County only
This is to certify that I, as permit applicant, am familiar with the
requirements of Los Angeles County Code Chapter 2.160 at seq.,
(relating to the Los Angeles County Lobbyist Ordinance) and that
all persons acting on behalf of myself complied and will continue
to comply therewith through the application process.
Applicant (Print Name) Applicant Signature
Company Name Date
JOB ADDRESS
LOCALITY
HAZARDOUS MATERIAL DECLARATION
Will the applicant or future building occupant handle a hazardous
material or a mixture containing a hazardous material equal to or
greater than the amount specked on the hazardous materials
information guide?
Yes ❑ No ❑
Will the intended use of the building by the applicant or future
building occupant require a permit for construction or
modification from the South Coast Air Quality Management
District (SCAQMD)? See permitting checklist for guidelines.
Yes ❑ N o ❑
I have read the hazardous materials information guide and the
SCAQMD permitting checklist, I understand my requirements
under the Los Angeles County Code Title 2, Chapter 220
Sections 220.100 through 220.140 concerning hazardous
material reporting and for obtaining a permit from the SCAQMD.
ASBESTOS NOTIFICATION
❑ Notification letter sent to AQMD and/or EPA
❑ 1 declare that notification of asbestos removal is not
applicable to addressed project.
DECLARATION REGARDING CONSTRUCTION LENDING
AGENCY
I hereby affirm under penalty of perjury that there is a
Construction lending agency for the performance of the work for
which this permit is issued (Section 3097, Civil Code).
Lenders Name
Lender's Address
By my signature below, I certify to'•each of the following:
I am the property owner or authorized to act on the
property owners behalf.
1 have read this application and the information I have
provided is correct.
I agree to comply with all applicable city and county
ordinances and state laws relating to building
construction.
I authorize representatives of this county to enter the
above -identified properjy for inspection purposes.
Agent