HomeMy Public PortalAbout5218 FARAGO AVE_SEWER_5/9/2016_ (2)COUNTY OF LOS ANGELES TEMPLE CITY
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL ID: SEWER / SEPTIC: SEWER
TR: 11497 LT: 4 BL: B EXIST OCC GRP:
BLDGS. NOW ON IAT:
ASSESSOR INFORMATION NUMBER: CONNECTION TYPE:
8574-009-025 ORIGINATION:
LENGTH ML TO PL: STATION: DEPTH:
TENANT: IMANHOLE REFERENCE: UPPER/LOWRR:
# 0508
11625 GOLDRING ROAD IRECORD INSTRUMENT NBR: RECORD DATE:
ARCADIA CA 91006 (HIGHWAY/STREET WIDENING:
STATE ENCROACHMENT PERMIT NUMBER:
CONTRACTOR: TEL. NO:
MAPLE BUILDERS, INC. (626) 358-2788-
11625 GOLDRING SO LIC. NO
ARCADIA CA 91006 609931
ITECT OR ENGINEER: TEL. NO:
DAVID (626) 288 -1216 -
SAN GABRIEL BLVD #101 LIC. NO:
MEAD CA 91770 609931
MAP BOOK: PAGE:
PERMIT EXPIRES 180 DAYS IF
L) WORK DOES NOT COtM1ENCE, OR
2) WORK IS SUSPENDED OR ABANDONED, OR
3) FAILS TO OBTAIN CODE REQUIRED INSPECTION
SEWER PERMIT
SE 0508 1605090012
BUILUINU AUDHESS:
5218 FARAGO AV
TEMP CA 917803529
NEAREST CROSS STREET: FREER
THOMAS PAGE: 597 GRID: D4
ISSUED ON: PROCESSED BY:
05/09/16 SR
BY:
LOCALITY: TEMPLE CITY CA
CONNECT DETACHED CONDO TO PUBLIC SEWER
FEE DESCRIPTION:
QUANTITY: UOM:
AMOUNT:INEW
(COUNTY IMPROVEMENT NUMBER:
OWNER:
TEL. NO:
34.40
IPLAN CHECK NUMBER:
CHANG, ANDY
(626) 358-9888-
1.00 CON
(JOB NUMBER:
130 W HUNTINGTON DR.
(BUILDING OR WORK
ITRUNK PERMIT NUMBER:
ARCADIA CA 91007
IROAD PERMIT NUMBER:
NO
IAFFADAVIT:
WAIVER: NO
APPLICANT:
TEL. NO:
(EASEMENT: NO
LI, JAMES
(626) 358-2788-
I
11625 GOLDRING ROAD IRECORD INSTRUMENT NBR: RECORD DATE:
ARCADIA CA 91006 (HIGHWAY/STREET WIDENING:
STATE ENCROACHMENT PERMIT NUMBER:
CONTRACTOR: TEL. NO:
MAPLE BUILDERS, INC. (626) 358-2788-
11625 GOLDRING SO LIC. NO
ARCADIA CA 91006 609931
ITECT OR ENGINEER: TEL. NO:
DAVID (626) 288 -1216 -
SAN GABRIEL BLVD #101 LIC. NO:
MEAD CA 91770 609931
MAP BOOK: PAGE:
PERMIT EXPIRES 180 DAYS IF
L) WORK DOES NOT COtM1ENCE, OR
2) WORK IS SUSPENDED OR ABANDONED, OR
3) FAILS TO OBTAIN CODE REQUIRED INSPECTION
SEWER PERMIT
SE 0508 1605090012
BUILUINU AUDHESS:
5218 FARAGO AV
TEMP CA 917803529
NEAREST CROSS STREET: FREER
THOMAS PAGE: 597 GRID: D4
ISSUED ON: PROCESSED BY:
05/09/16 SR
BY:
LOCALITY: TEMPLE CITY CA
CONNECT DETACHED CONDO TO PUBLIC SEWER
FEE DESCRIPTION:
QUANTITY: UOM:
AMOUNT:INEW
HOUSE SEWER
O1 PERMIT ISSUANCE FEE
34.40
(CONNECT ADDITIONAL
03 CONN TO PUBLIC SEWER
1.00 CON
58.40
(BUILDING OR WORK
TOTAL FEES
92.80
• ADDITIONAL DATA ON FILE
REPORT ID: DPR266 ROUTE TO : BSO508
(SEPTIC TANK, SEEPA
(AND/OR DRAIN FIELD
ALTER, REPAIR, SEWER OR
SEWAGE DISPOSAL SYSTEM I I
HOUSE SEWER
SEEP. PIT _ CESSPOOL
GRAYWATER SYSTEM
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 thatrequiresa permit to construct, alter, 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 U 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 Contr *tor pursuant .to the Contractors' State License
Law).
(_) I am exempt 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 priorl to completion of the improvements covered by
this permit, Icannot 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.leciinfo.m.00v/mlaw.html.
Date:
Signature of Property Owner or Authorized Agent
y
LICENSED CONTRACTOR'S DECLARATION
I 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.
License �C'laasss/-3 License No. Fi QPR 7"
Date �_Contractor Signature /
WORKERS' COMPENSATION DECLARATION
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.
Policy No.
T 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
w rk rs' 6 pe ation nsu ygie and olicypu bei e:
Carrier Policy Number Expiration Date
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' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions
tj—Ci —��6
Signature of Applicant 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 specified on the hazardous materials
information guide?
Yes ❑ N o ❑
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
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 7,20'
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
❑ I 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
Lenders 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.
I 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 property for inspection purposes.
Signature of Properl Ow or Authorized Agent
Date 5--4- IbGo 1