HomeMy Public PortalAbout4843 ARDEN DR_Building__ WORKERS' COMPENSATION DECLARATION
hereby affirm that I have a certificate of consent to self APPLICATION FOR BUILDING 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. 31 6647 35
/mpany TIZAAAkHZ�e-A
[� FOR APPLICANT TO FILL IN BUILDING
I� ,Certified copy is hereby furnished. ADDRESS �-kJ/�•�t
❑ Certified copy is filed with the county building inspec- BUILDING �q _�, �j
tion department. ADDRESS 48 q'3 ��
51 YK 'C�� CITY' �� ZIP ( a LOCALITY _
Date Applicant O. OF BLDGS. NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NOW ON LOT CROSS ST.
COMPENSATION INSURANCE ASSESSOR
(This-section need'not be completed if the permit is for one TRACT BLOCK ,LOT NO. MAP BOOK PAGE PARCEL
hundred dollars ($100) or less.) TEL. PON
USE ZONE MA
OWNER NO. NO. 141 1219
I certify that in the.performance of the work for which this
permit is issued, I shall not employ any person in any manner ADDRESS �, �1 SPECIAL a
d CONDITIONS O
so as to become subject to the Workers' Compensation Laws. U
CITY ZIP
Date Applicant Cie
ARCHITECT ORS-( �r-"f chi TEL. DISTRICT GROUP TYPE FIRE P CESSED BY O
NOTICE TO APPLICANT: If, after makingthis Certificate of ENGINEER Ly C/1 'r N a'7�3'
CONST. Zgj.1E U
Exemption, you should become subject to the. Workers' g _ ,{
Compensation provisions of the Labor Code, you must forth- ADDRESS'Ll� H41Atr1N,*Tv%.J '�1� a�p�. c J
with comply with such provisions,or this permit shall be TEL. STATISTI L SIFC TION APT. CONDO.. to
deemed revoked. CONTRACTOR ►.�,Ul�QsiJ� NO `e.F��i�7lJ Z
LICENSED CONTRACTORS DECLARATION LIC. CLASS DW UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS o . .., G7�t NO.B /63
(commencing with Section 7000)_of Division 3,of the Business
LIC. SEWER MAP
and Professions Code,and my license is in full force and effect. CITY CLASS BK. PG. VALIDATION
SQ. FT. NO. OF NO. OF °. CHECK.
License Number S�/6 3� - Lic.`Closs SIZE 1 STORIES FAMILIES ONE ,
VALUATION
�
Contractor f A� Gere cite��'���" � DESCRIPTION OF WORK NEW $ 01
ADD El polo.ElI am exempt under Sec. / ��` ►.�
ALTER ❑
B.B,P.C. for this reason_ $
USE OF _ 'REPAIR ❑ ,
Date: EXISTING BLDG. DEMO ❑
Signature APPLICANT TEL. FINAL
OWNER-BUILDER DECLARATION. (PRINT). NO. DATE Gb
I hereby affirm thari am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and ADDRESS FINAL _
Professions Code): PRESENT B
BUILDING Y
❑ I, as owner of the property, or-rny employees with ADDRESS
wages as their sole compensation;will do the work andthe structure is not intended or offered for sale(Section LOCALITY --
7044, Business and Professions Code. MOVING TEL.
) CONTRACTOR NO: , � :�'•t!�R
❑ I, as owner of the property, am exclusively contracting -I
with licensed contractors to construct the project (Sec- . ADDRESS '
tion 7044, Business and Professions Code.). #�3 eo s r i y
REQUIRED TOTAL SETBACK FROM EXIST. "EEr
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH
1 hereby affirm that there is a construction lending agency for FRONT, t_i 11sC
the performance of-the work.•for which this'permif is issued P.L.
(Sec. 3097, Civ. C.). SIDE .
P.L. I' Ij it -r-1^: ; q •,}
Lender's Name 77d
/ry LDMA Ref. # ~
P.C.,Fee$ Permit Fee _ i,I _
L'ender's Address
I certify that I have read this application and state that the Issuance Fee LDMA P/C# ,
above information is correct. I agree to comply with all County Investigation Fee p
8 ordinances and State laws relating to building construction, Total Fee CJ LDMA Perm. #
a and hereby authorize representatives of this County to enter
O upon the above-mentioned property for inspection purposes.
a .G
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date
• y
` APPLICATION FOR BUILDING PERMIT �
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN BUILDING ADDRESS
WORKER'S COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self insure, BUILDING ADDRESS
4
or a certificate of Workers'Compensation Insurance,or a certified CITY zIP
copy thereof(Sec.3800,Lab.C.)
r,. -r , t'iS LOCALITY
Policy No.lw�� ��� L!t�ompany 9� 5 ��' SIZE OF LOT NO.OF BLDGS.NOW ON LOT
❑ Certified copy is hereby furnished. •Z }( 2:.�' ..�.4 NEAREST CROSS ST.
❑ Certified copy is filed with the county building inspection TRACT BLOCK LOT NO. d
ol
USE ZONE MAP NO
de ern.;r 'R'�n u ASSESSOR MAP BOOK PAGE PARCEL
Date Applicant ��� "�- /�_ �1 SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' OWNEREL.
P TEL.-1415 NO. e y� YES N 1
COMPENSATION INSURANCE 'Jw CQJt WITHIN 1000 FT.OF SCHOOL?
ADDRESS `I
(This section need not be completed if the permit is for one hundred r��t•�'C/�1� Y f DISTRICT GROUP TYPE CONST.' FIRE ZONE �ESSED BY
Bolla $100)n less.) Pe CITY 5 ZIP ` (i A � � A
I certi that in the' erformance of the work for which this rmit j ,D is issued, I shall not employ any person in any manner so as to ARCHITECT OR ENGINEER TEL.NO.
become subject to the Workers'Compensation Laws. e),-10161,b, STATISTICAL CLASSIFICATION APT CONDO i
Date Applicant ADDRESS CLASS NO. _ L—DWELL UNITSsl W- RutATIA
NOTICE TO APPLICANT. If, after making this Certificate of C NTRACTO `- STK chE7�30 REQUIRED TOTAL SETBACK FROM EXIST
R .nt,' TEL. O.__ (�,'
Exemption, you should become subject to the Workers' ____ rN�V A� SETBACK YARD HWY PROP LINE WIDTH
Compensation provisions of the Labor Code, you must forthwith �_ lCol{S r �•�-C�2$�, FRONT
comply with such provisions or this permit shall be deemed revoked. ADDRESS _ LIC.NO. PL
LICENSED CONTRACTORS DECLARATION CITY - '' LIC.CLASS SIDE a
PL O
I hereby affirm that I am licensed under provisions of Chapter 9 �� ��� EWER MAP v
SQ.FT.SIZE O.OF STO S NO. FAMILIES
(commencing with Section 7000)of Division 3 of the Business and NEW BK ` PG ,t-' � y �
Professions Code,and my license is in full force and effect. d 1',
License Number ` S Lic.Classf-Z DE CRIPTION OF WORK �� ADD ❑ $ I N
`l .,
Contractor�Pla Cr- Date 6 ••� ALTER ❑ z
❑ 1 am exempt under Sec. REPAIR ❑ $ gV®, pee,
B.&P.C.for this reason DEMOL E] LOMA P/C#
Date:
USE OF�EXqgST�ING BLDG. LIRM ❑ -
Signature APPLICANT(PRIN ) TEL.NO.. LDMA Perm#
❑ 1, as owner of the property, or my employees with wages as `' p ACk..`'$
their sole compensation, will do the work and the structure is ADORESEt 3307 619.01
not intended or offered for sale (Section 7044, Business and t O om eA ch dJ FINALC:E) (. C
Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL Lb�-1 j 1 IT.EIM S
❑ 1, as owner of theproperty, am exclusive) contracting with OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN'
Y g
licensed contractors to construct the project.(Section 7044, >THE AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FIN A F I J�!T��- `�19
Business and Professions Code.) YES❑ NO❑ (.1 y� j
WILL THE INTENDED USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING - L•i ii..�.•i: 619.a'jl
^^
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH t�
CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST CHARGE .00
FOR GUIDELINES.
I hereby affirm that there is a construction lending agency for YES❑ NO❑
the.performance of the work for which this permit is issued(Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD Oxy
3097,Civ.C.). PERMITTING CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES (/ /"'" y I^1,0l�'! 11 !0! -' 2 7i!I
eo.
COUNTY CODE,TITLE 2,CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING
�• L—_�_1 :i/.4 -
a Lender's Name HAZARDOUS MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD. i {]-724 A1110:54 1 11•R F'a C4
�{ a.F
Lender's Address rn OWNER OR AGENT �f
o 1 certify that I have red his application and state that the above PC FEE (� PERMIT FEE
information is corr c/ I agree to comply with all county e V /L�
ordinances and Sta ws relating to building construction,and lJ
70
her authorize r esentatives of this County to enter uponn ISSUANCE FEE
the above-mention property for inspection purpose . r/1pt_ �a(
-J -6r. , INVESTIGATION FEE TOTAL FEE
n
ft-W.W APPI a s l'jt`J Ggy t
SEE REVERSE FOR EXPLANATORY NGUAGE ,
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 BUILDING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ALTERATION/REPAIR
BUILDING AND SAFETY % LAND DEVELOPMENT TEMPLE CITY CA 91780 BE, 0508 1309260014
PHONE: (626) 285-0488 EXT:
(LEGAL ID: NO. OF CONST I BUILDING ADDRESS: J
IBK: 244 PG: 87 PC: 1 3 SQ. FT STORIES TYPE 1 4843 ARDEN DR 1
I (STRUCTURE: V-B I TEMP CA 917804054 1
(ASSESSOR INFORMATION NUMBER: 1 NEAREST CROSS STREET: LOWER AZUSA 1
18585-015-075 THOMAS PAGE: 597 GRID: B5 LOCALITY: TEMPLE CITY CAI
(TENANT: (EXIST BLDG USE: RESID USE ZONE: R-1 (ISSUED ON: PROCESSED BY:
(EXIST OCC GRP: 109/26/13 SR
(OWNER: TEL. NO: JBLDGS. NOW ON LOT: VALUATION: IFIN L /A/TJ�E27 FINAL BY: CODE: 1
TU, JOEY (626) 672-8240- i 2,500 I r� l
4843 ARDEN DR
(TEMP 917804054 FEES PAID DE C ION OF WORK
1 1 (REMODEL 2 BATHROOMS I
I IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT: 1 I
(APPLICANT: TEL. NO: I I I
(SAME AS OWNER - IAA BLDG PERMIT ISSUANCE 27.80 1 I
1 JAB STATE GREEN BLDG FEE 2500.00 VAL 1.00 (SPECIAL CONDITIONS:
1 JAC STRONG MOTION RESID 2500.00 VAL 0.50 1 1
1 JB2 PERMIT W/ENERGY 2500.00 VAL 108.90 1 1
1 IFR INV WORK W/O PERMIT 344.00 DOL 344.00 1 I
(CONTRACTOR: TEL. NO: I TOTAL FEES 482.20 1APP OVALS DATE INSPECTOR SIGNATURE
(SAME AS OWNER -
I LIC. NO I (LOCATION AND SETBACKS J
I I i I I I
ISOII,S ENGINEER APPROVAL I J J
(ARCHITECT OR ENGINEER: TEL. NO: FOUNDATION/TRENCH FORMS
I LIC. NO: I ISL .B/UNDER FLOOR I I I
I 1 11 1
I I 1RAISED FLOOR FRAMING J 1 1
IMAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP: ( JUNDERFLOOR INSULATION I I 1
3 001 I _ 11
(FLOOR SHEATHING I
INO. OF FAMILIES: DWELLING UNITS: APT/COND: STAT CLASS: I J J
NO 21 1 (ROOF SHEATHING I 1 J
I SCHOOL WITHIN HAZARDOUS I ISHEBR PANELS
LAIR QUALITY: 1000 FEET MATERIALS I J
NO NO NO (FRAME INSPECTION 1 I 1
J 1 iFIRE SPRINKLER HANGERS 1 1
1 I (INSULATION/WEATHER STRIPI I I
I 1 I
1 _1 \ w cr) (INTERIOR LAT DRYWALI
IQ
1 1 Ccrk ^ &�51EXTERIOR LATH
I I I I I I
1 J IRATED FLOOR/CEIL ASSEM. J J
J 1 JRATED WALL ASSEMBLIES I 1 J
I I I I I I
RATED SHAFTS/OPENINGS I I
I I I I I I
1 J JT-BAR CEILINGS J I J
I I I I I I
1 I ILOT DRAINAGE J J 1
I I I I I I
1 (REPORT ID: DPR261 ROUTE TO: BS0508 I I
I I I I I I