HomeMy Public PortalAbout6032 AGNES AVE_Building__ � WORKERS COMPENSATION DECLARATION
T, .
r
I hereby affirm that I have a certificate of-consent to self
insure or a certificate of Workers Compenstion Insurance or APPLICATION FOR BUILDING PERMIT
a certified copy thereof (Sec 3800 Lab
��C��) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No/dd � ,o r
h '
any *e1'Wr--R-6BUILDING
<
Certified copy is hereby furnished FOR-APPLICANT TO FILL IN ADDRESS
cF Certified copy is filed with the county building mspec BUILDING 6032 N. AGNE3-AVEo
tion department 3 ADDRESS LOCALITY
Date -7` pp a Applicant A ���iUhJ�is^�L ^ CITY TEMPLE CITY ZIP 91780 NEAREST
CROSS ST +
CERTIFICATE OF EXEMPTION FROM WORKERSCQ X !2�� NO OF BLDGS 2 ASSESSOR
' 'COMPENSATION INSURANCE SIZE OF LOT J NOW ON LOT MAP BOOK J PAGE PARCEL
(This+section need not be`completed if the permit is for one USE ZONE MAP '
TRACT BLOCK LOT NO NO
hundred dollars ($100)or less ) - s Y
THOS o JABWNSKY TEL ZH5-ti240 — / SPECIAL M 0
I certify that in the performance of the work for which this OWNER NO CONDITIONS
permit is issued I shall not employ any person in any mannerDISTRICT I GROUP TYPE- FIRE PROCE ED BY U
so as to become subject to the Workers Compensation Laws ADDRESS,6030 No AGNES AVE,, CONST ZONE _ Ilm
e TEMPLE CITY 917$0 �i0 /-1 O
Date - Applicant CITY ZIP STATISTICAL CLASSIFICATION APT CONDO U
NOTICE TO APPLICANT If after making this Certificate of ARCHITECT OR TEL W
Exemption you 'should become subject to the Workers ENGINEER NO
CLASS NO DWELL UNITS H
iCompensation provisions of the Labor Code you must forth ADDRESS SEWER MAP r Z
with comply with such provisions or this permit shall be /
deemed revokedOWNER TEL BK �PG �-3v VALIDATION
CONTRACTOR NO
1 !LICENSED CONTRACTORS DECLARATION LIC
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO VALUATION
(commencing with Section 7000)of Division 3 of the Business and LIC
Profession's Code and my license is in full-force and effect CITYCLASS $ 'n, d
SQ FT 200^ NO OF 1 NO OF .,0 CHECK
License Number Lic Class SIZE STORIES FAMILIES " ONE
h
^
Contractor Date° i DESCRIPTION OF WORK NEW ® $
I am exempt from the licensing requirements as I am a ADD
licensed architect or a registered professional engineerALTER FINAL
acting in r' y professional capacity (Section 7051 REPAIR 67 DATE
Business and Professions Code) USE OF ' y
EXISTING BLDG DEMOL BY
NAL
Lic or Reg No _Date APPLICANT _ TEL IN�1Vn
t' OWNER BUILDER DECLARATION (PRINT) NO
I hereby affirm that I am exempt from the Contractor s License f _ +
Law for the following reason (Section 7031 5 Business and ADDRESS
Professions Code) PRE EN
BUILDING + K -
LIEN I as owner of the property or'my employees with ADDRESS 0 2 8 A
wages as their sole compensation will do the work and
the structure is not intended or offered for sale(Section LOCALITY
7044 Business and Professions Code) MOVING TEL 1 # o e o e o
CONTRACTOR f NO
I'as owner of the property am exclusively contracting 2 0`0 3[��Q �
with licensed contractors to construct the project (Sec ADDRESS e
tion 7044 Business and Professions Code)
REQUIRED TOTAL SETBACK FROM EXIST r 0,0 m
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP LINE I WIDTH r y r `3A 0 0 v
I hereby affirm that there is a construction lending agency for FRONT r
the performance of the work for which this permit is issued F L Q d 7 8'—8 1
(Sec 3097 Civ C )- SIDE '
PL j t
Lender s Name
+
m P C Fee$ Perrno Fee +
Lender s,,Address
> I certify That I have read this application and state that theIssuance Fee
Qabove information is correct I agree to comply with all County Investigation Fee
0 ordinances and State jaws relating to building construction 00 �
and hereby authorize representatives of this County to enter Total Fee 1
a v upon the above mentioned property for inspection purposes
ayy (� SEE REVERSE FOR EXPLANATORY LANGUAGE
Signa e of Applicant or Agent D ) Os
G032-- N Ave z8?-2-e.2.3
DEPARTMENT OF BUILDING AND SAFETY APPLICATION FOR PERMIT
" �'COUNTY OF LOS ANGELES ISA N 5 l
r WM J FOX CHIEF ENGINEER I "Blum ' ' mnkm GA
FOR APPLICANT TO FILL IN FOR OFFICE USE ONLY
DISTRICT NO PLANCK NO ^ PERMIT NO
BUILDING '44Al b A, P—* 5 // �� Jr
h
ADDRESS / yy,t �y am✓
LOCALITY dyp pv �'� RECEIVED BY DATE OFAPPL /i 13A�TjE ISSUED
NEAREBT ✓S e / — /-/--
C BB T
i
OWNER 1 I ��r ADDRESS
f"BUILDING T"
/`,/ �o A C7 MAIL J
ADDRESS /'! P,..? LOCALITY (n 2 �L C/ 7
yH NEAREST
CITY P� I t NO i J s TEL CR0559T
ARCHITECT OR TEL ZONE fJ / PLANS 7Z_
TYPE / GROUP
ENGINEER NO Yv f
BLDG `� / ,f ORD NO
ADDRESS /
SETBACK LINE P.�
APPROVED
CONTRACTORSE A NOL BY DATE' „1
USE y �, APPROVED
ADORES ZONE BY DATE
LEGAL CORRECTIONS
DEHCRIPTION PLOT NO BLOCKS/�-��/y
TRACT
�\ NO OF BLDG9 '
1
SIZE OF LOT �/ L1 NOW ON LOT C;),
USE OF 1NO OF NO OF
EXISTING BLDG wC FAMILIES ROOMS
DESCRIPTION OF WORK }�
NEW X ALTERATION ADDITION - �! D /� i -.L�G/ /'�r 19;
O (Z
REPAIR MOVING DEMOLISH (/ �C,/. G �1/G//~ G
SO FT w NO OF f ; �
SIZE �ry a 4J ROOMS STORIES / � JJ /�� r
COVERING bX/(� I COVERING W(9/) J> Rn s7wI�°
USE OF NEW
BUILDING t �'► a G //p,Q r 0E y
�r C� (1-0�/
f)4
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS �('�\„ Q �` APPROVALS $ ppp
APPLICATION AND STATE THAT THE ABOVE IS CORRECT FOUNDATION LOCATION
'
` //'p/INSP TOR ��Ef
AND AGREE TO COMPLY WITH ALL CO NTY ORDINANCES �'
AND STATE LAWS REGULATING BUILDING CONSTRUCTION FORMS MATERIALS '
.t
FRAME FIREBTOPS
SIGNATURE OF BRACING BOLTS
PERMITTEE
LATH INT
AUTHORIZED AOT
LATH, EXT
7SA632A 3 7 49 $ P C s1 Q PLASTER INT
Ji, FEE I°�,/� PLASTER EXT
VALUATION IDI�Q� — �..+ FINAL
FEE
t
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 BUILDING PERMIT
DJEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS RESIDENTIAL ADD/ALT/REP
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 SL 0508 9904220095
PHONE (626) 235-0488. EXT
LEGAL D NO OF CONST EW BU DING ADDRESS
TR 6561 LT 52 SQ FT STORIES TYPE OCCUP GROUP 6030 AGNES AV
STRUCTURE 866 1 VN R3 TEMP CA 917801707
ASSESSOR INFORMATION NUMBER GARAGE NEAREST CROSS STREET GARIBALDI/LAS TUNAS
5385 028 031 OTHER THOMAS PAGE 597 GRID A2 LOCALITY TEMPLE CITY
TENANT EXISTLD S ZONE PROCESSED BY EXPIRWON
EXIST OCC GRP 07/08/99 UT !1/X/0 0
OWNER TEL NO BLDG—S WOWUNLOT VALUATION FINAL DATE FINAL BY CODE
LIU DON,PHUNG KIN M 2 64,100 ��
6030 AGNES AV
TEMP 917801707 FE R N
EXTEND LIVING ROOM AND ADD NEW MA R BEDROOM/BATHROOM
FEE DESCRIPTION QUANTITY UOM AMOUNT
APPLICANT TEL NO
SAME AS OWNER B1 PLANCHECK W/ENERGY 64100 00 VAL 885 52
AA BLDG PERMIT ISSUANCE 27 75 SPECIAL CONDITIONS
AC STRONG MOTION'RESI— D' 64100 00 VAL 6 41
82 PERMIT W/ENER`GYY�E 1 048 74
6A100EES VAL 1,968 42
CONTRACTOR TEL NO �j v/�/ APPROVALS DATE INSPECTOR SIGNATURE
SAME AS OWNER
LIC NO LOCATIONACKS
Sn!�,EMEUP ROVAL
ARCHITECT OR GI EER ETO FO T N/TRENC FOR?TS� /
LIC NO 1111111 SLAB/UNDER FLOOR
rRAISED FLOOR FRAMING
MAP NO SEWER MAP BOOK PAGE FIRE ZONE C PNDERFLOOR INSULATION� Q
z0 '�U � 1ST- LEVEL ATH 17
NO OF FAMI LASS NO 21 op ND LEI EL FLOOR SHEATH
HAZARDOUS
AIR QUALITY 1000 FEET MATERIALS 'o �s ROOF SI° NG
NO NO NO nI ® ®y FIRE DEPT FRAME INSPECT /
R 0 A E !I (- 4 t� BLDG DEPT—FFAME INSPECT
SET BACK YARD HWY PROP LINE WIDTH �0
FRONT PL C ` ervice'T'hOt SHEAR PANELS
SIDE PL
INSULATION/INSULATION/WEATH IP
INTERIOR LAI!!/DRYWA
EXTRIO
LOT DRAINAGE
SMOKE DETECTION-DEVICES
FIRE DEPARTMENT APPROVAL
REPORT ID DPR261 R ROUTE TO BS0508