HomeMy Public PortalAbout4857 ARDEN DR_Building__ WORKERS"COMP.ENSATiON DECLARATION {
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yoraafce tff cirm 1, a�'e of Worke s' Comipensatoe of nelnsu�an ent to lf APP`'ICAT101 F R l!II.®16�1G PERMIT '
a certified Copy;he'reof (Sac. 3800, lab. C.) COUNTY.OF LOS ANGELES BUILDING AND SAFETY"
Policy No.(,[ .� Company BUILDING / �/� \
❑ Certified copy s hereby furnished. FOR APPLICANT TO FILL IN
ADDRESS uZ�
Certified copy is filed with the county building inspec- BUILDING
tion department. ADDRESS A/�
Dote /A I/I)�/ Applicant fJ/�./�(iI(}��/ CITY �Fj�//�/ l ;/7T ZIP 0117J-_a LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS;f NO. OF BLDGS. r NEAREST
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT fi CROSS ST. > �
(This section need not be completed if the permit.is for one I� ASSESSOR
hundred dollars ($100)or less.) - TRACT MAP BOOK PA
BLOCK LOT NO. GE PARCEL
TEL. C USE ONE MAP J
I certify that in the performance of the work for which this OWNER ,` ,/1�i /lY rrTi4?t7 NO. /�//1rt / NO. 21-7 D
permit is issued, I shall not employ any person in any manner LL// /� y� /� - - I SPECIAL p"
ADDRESS '7r/.5 7/%�11�N�/ CONDITIONS
so as.to become subject to the Workers'Compensation Laws. 7^ / O.
Date Applicant CITY { i -f '/ ?. T!./ ZIP 7 /
NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY O
Exemption, you should become subject to the Workers' ENGINEER /fIlY: NO. > 1 CONST. NE J', 8
/�/i
Compensation provisions of the Labor Code, you must forth- ADDRESS �' �� r
with.comply with such provisions or this permit shall be CL
deemed revoked. > TEVP 1 STATISTICAL CLASSIFICATION APT. 1",ONDO. tq
CONTRACTOR//�U �:�}�7 j NO: fJ 7t5'f(uz
LICENSED,CONTRACTORSDECLARATION > /� LIC. r -, CLASS-NO. DWELL. UNITS '—
T hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS � ry/ �� '!,"!/)J t NOy�lI✓ �.
(commencing with Section 7000)of Division 3 of the Business and / j �j , .i LIC. SEWER MAP
Professions Code, and my license is in full force and effect. CITY ,�1 �/°'7 ! /� CLASS BK PG VALIDATION
SQ. FT. NO. OF J NO.OF CHECK
License Number Lic.Class SIZE STORIES ""FAMILIES l' ONE`
VALU TION
DESCRIPTION OF WORK /7.E!�✓S/, � 7 ✓r - NEW ❑ 9�
Contractor Date _ ADD ❑ $
❑ I am exempt under Sec. -.19160
rF`19/6/ .'� �' ❑
ALTER
B.BP.C. for this reason �// /` _/V /Y%1K �,'i!�7 REPAIR F7 $
Date: USE OF p
EXISTING BLDG. //��iJ L� F//.�. /�L� DEMOL ❑
Signature APPLICANT �j 'TEC
PRINT f ✓ /% jl {1 NO. j, JJ fINAIf—O��!
OWNER-BUILDER DECLARATION DATE_ UA
I hereby affirm that I am.exempt from the Contractor's License7.� z�,�- �l
Law for the following reason (Section 7031.5, Business and ADDRESS 7.n !C'� fyf�rFINAL
Professions Code): PRESENT - - - - BY
❑ BUILDING ;2 7 G.7,�;A
I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the-work and
the structure is not intended or offered for sale(Section LOCALITY 0 0 0 0.�
7044, Business and Professions Code). -MOVING - TEL. _ t -
I, as owner of the property, am exclusively contracting CONTRACTOR NO. ° 1 8,1,•1 3
with licensed contractors to construct the project (Sec- o e 1 =
ADDRESS v
tion 7044, Business and Professions Code). � (] 7,
REQUIRED TOTAL SETBACK FROM
CONSTRUCTION LENDING AGENCY - SETBACK YARD HWY --. PROP. LINE' WIDTH
I hereby affirm that there is a construction lending agency for kFRONT q.
WIDTH-
the performance of the work for which this permit is issued(Sec. 3097, Civ. C.).Lender's NamefLDMA Ref. Nee-$ Permit fee/- t� -
Lender's Address -
3
I certify that I have. read this application and state that the. Issuance Fee, /0 � LDMA P/C k
above information is correct. I agree to comply with all County Investigation Fee
0 ordinances and State laws relating to building construction, Total Fee (moi [• 'I LDMA Perm. #
and hereby authorize representatives of this County to enter
uponahgjabq nnentionedd property for inspection purposes.
!/ !�y/ SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature oicant or 9gent Date
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 BL 0508 0904130026
PHONE: (626) 285-0488 EXT:
ILEGAL ID: I NO. OF CONST I BUILDING ADDRESS: 1
ITR: 11148 LT: 8 BL: A I SQ. FT STORIES TYPE 4857 ARDEN DR 1
I ISTRUCTURE: 600 V-B I TEMP CA 917804051
(ASSESSOR INFORMATION NUMBER: - NEAREST CROSS STREET: I
18585-015-010 I I THOMAS PAGE: 597 GRID: B5 LOCALITY: TEMPLE CITY, Cl
I I I I
(TENANT: (EXIST BLDG USE: GARAG USE ZONE: R-2 (ISSUED ON: PROCESSED BY:
IEXIST OCC GRP: 104/13/09 SR
I I I I
(OWNER: TEL. NO: 1BLDGS. NOW ON LOT: VALUATION: IFI AL DAT FINAL CODE:
IPAGE - I 1,400 1 \ _
14857 ARDEN DR I - 1
ITEMP 917804051 1 FEES PAID JDEIFTION F WORK 1
I I (INSTALL 20 YR COMP SHINGLES OVER EXISTING ON GARAGE ONLY 1
I IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT: ( 1
(APPLICANT: TEL. NO: I I
IDOWD ROOFING (626) 857-1070- IAA BLDG PERMIT ISSUANCE 27.75 1
15405. GLENWOOD IAB STATE GREEN BLDG FEE 1400.00 VAL 1.00 ISPECIAL CONDITIONS: I
IGLENDORA, CA 91741 IAC STRONG MOTION RESID 1400.00 VAL 0.50
ID2 PERMIT W/O EN-HC 1400.00 VAL 82.20
IFR INV WORK W/O PERMIT 257.00 DOL 257.00 I 1
ICONTRACTOR: _ TEL. NO: I TOTAL FEES 368.45 (APPROVALS DATE INSPECTOR SIGNATURE 1
IDOWD ROOFING CO. (626) 857-1070- 1 1 1
1540 S. GLENWOOD AVE. LIC. NO ILOCATION AND SETBACKS I
GLENDORA CA 91741 380611 C39 I1 I 1
I ISOILS ENGINEER APPROVAL 1
I I I I I I
(ARCHITECT OR ENGINEER: TEL. NO: 1 1FOUNDATION/TRENCH FORMS I 1
1 LIC. NO: I (SLAB/UNDER FLOOR I I 1
I I 1
I IRAISED FLOOR FRAMING I I I
I I I I I I
IMAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP:( LUNDERFLOOR INSULATION 1 I
1144H273 3 001 1 1 1
I I IFLOOR SHEATHING
INO. OF FAMILIES: DWELLING UNITS: APT/COND: STAT CLASS: I_ I A I
NO 21 I IROOF SHEATHING 14 1
SCHOOL WITHIN HAZARDOUS I ISHEAR PANELS
(AIR QUALITY: 1000 FEET MATERIALS
1 NO NO NO 1 IFRA,ME INSPECTION I I
I I I I 1 i
IREQUIRED TOTAL SETBACK FROM EXIST 1 (FIRE SPRINKLER HANGERS I I
ISET BACK YARD: HWY: PROP LINE: WIDTH: I I i
IFRONT PL- I - 11NSULATION/WEATHER STRIPI I 1
I SIDE PL- 1 11
1 IINTERIOR LATH/DRYWALL 1 I I
I f I I I I
IEXTERIOR LATH I
1 IRATED FLOOR/CEIL ASSEM. 1 I 1
I 1 IRATED WALL ASSEMBLIES I I 1
IRATED SHAFTS/OPENINGS
I I I I i I
1 IT-BAR CEILINGS I I I
I I ILOT DRAINAGE 1
I I I I I I
IREPORT ID: DPR261 ROUTE TO: BS0508 I I