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HomeMy Public PortalAbout9550 LIVE OAK AVE_Building_12/23/2014_BL 0508 1404220015 (2)'LEGA L ID: ON FIL E CO UNT Y OF LOS A NGELES DEPART ME NT OF PUBLIC WO RKS B UILDI NG AND SAFETY / LA ND DE VELOPMENT TE MPLE CI TY 9701 LAS T UNAS TE MPLE CI TY CA 91780 PHONE: (626) 285-0488 EXT: # 0508 B UI LDING PERMIT RESIDE NTIAL ADD/A LT/REP BL 0508 1404220015 'ASSESSOR INFOR MATION NUMBE R: 8588-007-004 TENANT : OWNER: L I, JA SSON 9550 LIVE OAK AV T EMP 917802513 • TEL. NO: (213) 308 -7788 - A PPLICANT: SU SUN NY, SU HW ANG 4833 AGNES AV E rA TEMPLE CITY CA 91780 TEL. NO: (626) 589 -8299 - CONTRACTOR : T A ND J CON STRU CTION 5628 N GLA DYS AVE SAN GABRIEL CA 91776 TEL. NO: (626) 703-6653- LIC. NO 993453 ARCHIT ECT OR EN GINEER : TEL. NO: LIC. NO: MA P N O: SEWER MA P B OOK : PAG E: FIRE ZONE: CMP: 3 00 N O. OF FAM ILIES: DWELLING UN ITS: APT/CON D: STAT CLA SS: 0 NO 21 AIR QUA LITY : NO SCH OOL W ITHIN 1000 FEET NO HA ZAR DOUS MATER IALS NO STRUCTU RE: G ARAGE: O THER: SQ . FT 416 NO. OF STORIES 1 CONS T TYPE V -B NEW OCCUP GR OUP R-3 EXIST BLDG USE: EXIST OCC GRP: USE ZO NE: B LDGS. NOW ON LOT: VAL UA TION: 61,660 FEE DESCRIP TIO N: B1 PLANCHECK W/ENERGY AA B LD G PERMIT ISSUA NCE AB ST ATE G REEN BLDG FEE AC STRONG MOTIO N RESID B2 PE RMIT W/ENE RGY 08 CE RTIF OF OCCUPANCY REPORT ID: D PR261 FEES P AID QUA NTITY: UOM: 61660 .00 VAL 61660 .00 VAL 61660 .00 VAL 61660 .00 VAL TOTAL FEES ROUTE TO: BS0508 AMOU NT: 860 .00 27.80 3.00 6.20 1,011 .70 101 .40 2,010.10 BUIL DI NG ADDRESS: 9550 LIVE OAK AV TE MP CA 917802513 NE AREST CROSS STREET: TE MPLE CI TY THOMAS P AGE: 596 GRID: J3 LOCA LITY: TEMPLE CITY CA ISSUE D ON: 07/09/14 PROCESSE D BY: SR FI NA L DA TE FINAL Y: CODE: ESCRIPTIO N OF ORK ADD M ASTER BEDROO M, B ATHROOM, WAL K IN CL OSET 416 SF AND DE MOLISH AN EXISTING FIRE PL ACE AND & PO RTION OF B RICK VE NER WALL SPECIAL CO NDITIONS: APP RO VALS LOC ATION AND SETB ACKS SOILS ENGINEER APPROVAL FOUND ATION/TRENCH FO SL AB/ UNDER FLOOR R AISED FLOOR FR AMING UNDERFLOOR I NSUL ATIO N 1S T LEV EL FLOO R S HEA TH 2ND LE VEL FLOOR SHEATH ROOF SHEATHI NG FIRE DEPT . FR AME INSPECT BLDG DEP T. FRA ME I NSPECT SHEAR PA NELS I NS ULATION/WEATH ER S TRIP I NTERIO R L ATH/DR YWALL E XTERIO R L ATH LO T DRAINAGE SMOKE DETECTION DE VIC ES FIRE DEPARTMENT APPR OVAL DATE I NSPECTOR SIGN ATURE aerAD4 OWN ER-SUILDER ©:CLA��ATIO M LICENSED CO NTR ACTOR'S DECLARA TION JOB ADDRESS I here by affirm under penalty of pe rjury that I am exe mpt from the Con tractors' 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 re quires a permit to construct, alter, improve, demolish, or repair any structure , prior to its issuance, also require s the a pplicant for the permit to file a signed statement that he or she is licensed pursuant to the provisions of the Co ntra ctors' State Lice nse Law (Cha pter 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 civ il penalty of not more tha n five hundre d dollars ($500). ): U 1, as owner of the pro perty, or my employees with wages as their sole compensation, will do (7) 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 improv es the property, provided that the improvements are not intended or offered for sale. If, howev er, the building or improvement is sold within one year of completion, the Owner - Builder will have the burden of prov ing that it was not built or improved for the purpose of sale.). U I, as owner of the property, am ex clusive ly 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, a nd who contracts for the projects with a licensed Contractor pursuant .to the Contractors' State License Law). U: 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 priori to completion' of the improvements covered by this permit, I cannot legally sell a structure that I have built as an owner -builder if it has not been constructed in its entirety by lice nsed contractors. I understand that a copy of the applicable law, Section 7044 of the Busine ss and Professio ns Code, is av aila ble upo n re quest when this applica tion is submitted or at the following Web site: http://www. leginfo.ca.go v/calaw. html. Date: Signature of Property Owner or Authorized Agent I hereby a ffirm under pena lty of perjury tha t I am licensed under prov isions of Cha pter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Lice nse Class ,(7 Lice nse No. 7g4 -1-5 Date 7 l=4-- Contractor Signature 3 WORKERS' COMPENSATION DECLARA TIO N WARN ING: FAILURE TO SECURE WORKERS' COM PENSATION COVERAGE IS UNLAWFUL, AND SHA LL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES A ND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLA RS ($100,000), IN ADDITION TO THE COST OF COM PENSATION, DAM AGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, A ND 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' compensa tio n, issued by the Director of Industrial Relations as prov ided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. Policy No. I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the wo rk for which this permit is issued. My workers' co mpensation insura nce carrier and policy number are: Carrier Policy Number Expiration Date Name of Agent Phone Numb er I certify that, in the performance of the work for which this permit is issued, I shall not employ any person in any mann er so as to become subject to the workers' compens ation 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 pro visions Signature of Applicant 7/1//LL Date LOBB YIST ORDINANCE CERTIFIC ATION Compl et e thi s secti on f or permit s in Uninc orp orated L os Angeles C ounty only This is to certify that I, as permit applicant, am familiar with the requirements of Los Angeles County Code Ch apter 2.160 et seq., (r elating to th e 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 LOCALITY HAZARDOUS M ATERIAL DECLARATION Will the applicant or future building occupant handle a hazardous material or a mixture containing a hazardous mat erial equal to or greater than the amount specified on the hazardous materials informatio n 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 Qu ality Management District (SCAQMD)? See permitting checklist for guidelines. Yes ❑ No ❑ I hav e 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 SCAQ MD . ASBESTOS NOTIFICATION ❑ Notification letter sent to AQ MD and/or EPA ❑ I d eclare that notification of asbestos removal is not applicable to addressed project. DECL ARATION REG ARDIN G CONSTRUCTION LENDING A GENC Y I hereby affirm under penalty of perjury th at th ere is a Construction lending agency for the perform ance of the work for which this permit is issued (Secti on 3097, Ci vil Code) . Lender's Name Lender's Address By my signature below, I certify to e ach of the following: I am the property owner or authorized to act on the property own er's behalf. I have read this applicati on and the inf ormation I have provided is correct . I agree to comply with all applicable city and county ordinances and st at e law s r elating to building construction . I authorize representatives of this county to enter the above -identified property for inspection purposes . Signature of Prope Owner or Authorized Agent • Date 7/ 7! /C -r CO UNT Y OF LOS A NGELES DEPARTMENT OF PUBLIC' WORKS BUI LDI NG A ND SAFETY / L AN D DEVELOP MENT TEMPLE CITY 9701 L AS TUNAS TE MPLE CIT Y CA 91780 PHONE: (626) 285-0488 EXT: # 0508 BUILDING PERMIT A LTER ATIO N/ REPAI R BL 0508 1409040065 LEGA L ID: ON FILE ASSESSOR IN FORMATION N UMBE R: 8588-007-004 TENANT: OWN ER: LI, JASSON 9550 LIV E OA K AV TEM P 917802513 TEL. NO: (213) 308 -7788 - APPLICAN T: CHANG, JUSTIN 9087 LAS TUNAS DR. TEM PLE CITY CA 91780 TEL. NO: (626) 407 -2076 - CON TRACTOR : T AND J CONSTR UCTION 5628 N G LADY S AVE SA N GA BRIEL CA 91776 TEL. N O: (626) 703-6653- LIC. NO 993453 ARCHITECT OR EN GIN EER: TEL. N O: LIC. N O: MAP NO: SEWER M AP B OOK: PAGE: FIRE ZONE: 3 CM P: 00 NO. OF FAM ILIES: DWEL LING UN IT S: APT /CON D: STAT CLA SS: NO 21 AIR QU ALITY : NO SCHOOL WITHIN 1000 FEET NO HA ZA RDOUS MAT ERIAL S NO ST RUC TURE: NO . OF CO NST SQ. FT S TORIES T YPE V -B EXIST BLDG USE: RESID EXIS T OCC GRP: USE ZONE: R-1 BLDGS . NOW ON L OT: VA LUATION: 1,000 FEE DESCRIPTION: AA BLDG PERMIT ISSUA NCE AB STATE G REEN BLDG FEE AC ST RO NG MOTION RESID B1 PL ANCHEC K W/E NERG Y B2 PE RMIT W/ENE RG Y REPORT ID: DPR261 FEES PAID QUA NTITY: UOM: 1000 .00 V AL 1000.00 VAL 1000.00 VAL 1000 .00 V AL TOTAL FEES ROUTE TO: BS0508 AMOUNT: 27 .80 1 .00 0.50 90.30 71 .90 191.50 BUILDING ADDRESS: 9550 LI VE O AK AV TEMP CA 917802513 NE AREST C ROSS S TREE T: TE MPLE CIT Y THOMAS PAGE: 596 GRID: J3 LOCA LI TY: TE MPLE CIT Y CA ISSUED ON: 09/04/14 P ROCESS ED B Y: SR FINA L DATE FINAL.BY: ff ES�RIPT D O WORK REMOVE / M OVE WALL BET WEE N EXISTI NG LIVI NG ROOM AND HALLW AY CODE: SPECI AL CO NDITIONS: APPROVALS DATE INSPECTOR SIG NATU RE LOCATION AND SETB ACKS SOILS ENGINEE R APP ROVA L FO UNDATIO N/T RE NCH FOR MS SL AB/ UNDER FLOO R R AISED F LOOR F RAMING U NDERFL OOR I NSUL ATIO N FL OOR SHEATHING ROOF SHEATHING SHE AR PA NELS FR AME I NSPECTIO N FI RE SPRI NKLER HANGERS INS ULATIO N/WEA THER S TRIP I NTERIOR LA TH/DR YWALL EXTE RIOR L ATH RATE D FLOOR/CEIL ASSE M. RATE D WAL L ASSEMBLIES RATED SHAF TS/OPE NINGS T -BAR CEILINGS LOT DRAINAGE OWNER -BUILDER DECLA RATION LICENSED CONTR ACTOR'S DECLARA u 9ON JOB ADDRESS I hereby affirm under penalty of perjury that I am exempt from the Contracto rs' State Lice nse 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, 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 lice nsed pursuant to the prov isions of the Contractors' State License Law (Chapter 9 (comme ncing 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). ): L) I, as owner of the property, or my employe es with wage s as their sole compensation, will do (,i) all of or (_) portions of the work, and the structure is not intended or offered for sale (Section 7044, Busine ss and Professions Co de : The Contractors' State License Law does not apply to an owner of property who, through employees' or personal e ffort, builds or improves the property, provided that the improvements are not intended or offered for sale. If, however, the building or improve ment is sold within one yea r of completion, the O wner - Builder will have the burden of proving that it was not built or improved for the purpose of sale. ). L) I, as owner of the property, am exclusively contracting with license d 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 improv es thereon, and who contracts fo r the projects with a licensed Contractor pursuant to the Contracto rs' 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 hav e resided for at least one year prior; to completion; of the improvements covered by this permit, I cannot 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 co py 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. leginfo.ca. aov/calaw. html. Date: Signature of Property Owner or A uthorized Agent I hereby affirm unde r pe nalty of pe rjury that I am licensed under prov isions 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 Class License No. Date 6tiq Contractor Signature qc(34 WORKERS' COMPENSA TION DECLA RA TION WARNING: FAILURE TO SECURE WORKERS' COM PENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EM PLOYER TO CRIMINAL PENALTIES A ND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COM PENSA TIO N, DAM AGES AS PROVIDED FO R IN SECTION 3706 OF THE LA BOR CO DE, INTEREST, A ND 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. 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 workers' compensation insurance ca rrier and policy number are: Carrier Policy Number Expiration Date Name of Agent Phone Number I certify that, in the perfo rmance 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 Co de , I shall forthwith comply with those provisions a14 Cff Signa ture offA pplicant Date LOBBYIST ORDINANCE CERTIFICATION Complete this section f or permits in Uni ncorpor ated L os A ngel es County only This is to certify that I, as permit applicant, am f amiliar with the requirements of Los Angeles County Code Chapter 2 .160 et seq., (relating to the Los Angeles County Lobbyist Ordinance) and th at all persons acting on behalf of myself complied and will continue to comply therewith through the applicati on process. Applicant (Print Name) Applicant Signature Company Name Date LOCALITY HAZARDOUS M ATERIA L DECLARATION Will the applicant or future building occupant handle a hazardous mate rial or a mixture containing a hazardous material equal to or greater than the amount specified on the hazardous materials information guide? Yes ❑ N o El Will the intended use of the building by the applicant or future building occupant require a permit for construction or modification fro m the South Coast Air Quality Management District (SCAQMD)? See permitting checklist for guidelines . Yes El N o El I have read the hazardous materi als information guide and the SCAQMD permitting checklist, I understand my requirements under the Los Angeles County Code Titl e 2, Ch apter 220 Sections 220 .100 through 220 .140 concerning hazardous material reporting and for obtaining a permit from the SCAQMD. ASBESTOS NOTIFICATI ON El Notific ation letter sent to A QMD and/or EPA El I declare that notification of asbestos removal is not applicable to addressed project . DECLAR ATION 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). Lender's N ame Lend er'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 owner's behalf. I ha ve re ad 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 P„r-operty wner or Authorized Agent `ate a COUNTY OF LOS ANGELES DEP AR TMENT OF P UBLIC'WORKS BUILDING AN D SAFE TY / LAND DEVE LOPM ENT TE MPLE CIT Y 9701 L AS TU NAS TEMPLE CITY CA 91780 PHONE: (626) 285-0488 E XT: # 0508 ELECT RIC AL PE RMIT EL 0508 1407090037 L EGAL ID: ON FILE A SSESSOR INFORMATION NUMBER: 8588-007-004 TENA NT: OWN ER: LI, JA SSON 9550 LIVE OAK AV TEMP 917802513 TEL. NO: (213) 308 -7788 - APPLICANT: QIU LIN 9087 LA S T UNAS D RIV E T EMPLE CITY CA 91780 TEL. NO: (626) 589 -8299 - CON TRA CTOR: T AND J CON STRUCTION 5628 N GLA DY S AVE SAN GABR IEL CA 92776 T EL. N O: (626) 703-6653- L IC. NO 993453 AR CHITECT OR ENGINEER: TEL. NO: LIC. N O: FEE DESCRIP TIO N: Al PE RMIT ISSUANCE FEE G1 OU TLETS-LGT,SW,RECP G2 LIG HTING FIXTURES H7 RES EXHAUST FANS JA HEA T PU MPS +3-10 HP LA 100 AMP P ANELS , MCC REPORT ID: D PR265 FEES PAID QUANTITY: UOM: 15 .00 OUT 7.00 LGT 1 .00 EX 1.00 HT 1 .00 P AN TOTAL FEES RO UTE T O: BS0508 AMOUNT: 27 .80 30 .00 14 .00 11 .00 19.70 38 .90 141.40 BUI LDI NG ADDRESS: 9550 LIVE OAK AV TEMP CA 917802513 NE AREST C ROSS ST REET: TE MPLE CIT Y • THOMAS PAGE: 596 GRID: J3 LOCA LI TY: TEMPLE CIT Y CA ISS UED O N: P ROCESSED B Y: PLA N B Y: 07/09/14 SR FI NAL D ATE ;))3.4 D SCRIPTION F WOR K 15 OUTLE TS, 7 LIG HT FI XTURES, E XHAUST F AN, HEAT PU MP A ND REP LACING EXISTING ELECTRICA L PA NEL UPGR ADE TO 100 AMP FIJTALB Y: CODE: SPECIAL CON DITIONS: APPROVALS DATE INSPECTO R SIG NATU RE TE MPOR ARY POWER P OLE UN DE RGROU ND C ON DUI T UFER GROU ND ROUG H CO NDUI T ROUG H WIRING MAIN W ATER LINE PL AS TIC Y/N METAL Y/ N UTILI TY COMPANY NO TIFIE OVIINER-3U LDER DECLA RAT IO NI LICENSED CONTRA CTOR'S DECLARA a GON JO B ADDRESS I hereby affi rm under pe nalty 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 Co de ): Any city or county that requires a permit to construct, alter, improve, demolish, or repair any structure , prior to its issuance, also re quires the a pplicant 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 ba sis for the alleged exemption. Any v iolation of Se ction 7031.5 by any applicant for a permit subjects the applica nt to a civ il penalty of not more than five hundred dollars ($500).): L) I, as owner of the property, or my employees with wages as the ir sole compensation, will do (7) all of or L) 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 inte nded or offered for sale. If, however, the building or improvement is sold within one year of completio n, the Owner - Builder will have the burden of proving tha t it was not built or improved for the purpose of sale. ). L) I, as owner of the property, am exclusively contracting with licensed Contractors to construct the project (Sectio n 7044, Business and Professions Code : The Contractors' Sta te License Law does not apply to an o wner of prope rty who bu ilds or improves thereon, and who contracts for the projects with a licensed Contractor 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 prior; to completion of the improvements covered by this permit, I cannot le gally sell a structure that I have built as an owner -builder if it has not been constructed in its entirety by licensed contractors. I unde rstand that a copy of the applicable law, Section 7044 of the Business and Professions Code, is av ailable upon request when this application is submitted or at the following Web site: htto://www.leginfo.ca.00v/calaw. html. Date: Signature of Pro perty Owner or Authorized Agent I hereby affirm under penalty of perjury tha t 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 Class A, rj License N Date 1 C ontractor Signature L q3 WORKERS' COMPENSATION DECLA RA TION WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERA GE IS UNLAWFUL, AND SHALL SUBJECT AN EM PLOYER TO CRIM INAL PENALTIES A ND CIVIL FINES UP TO ONE HUNDRED THOUSA ND DOLLARS ($100,000), IN ADDITION TO THE COST OF COM PENSA TION, DAMAGES AS PRO VIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. I hereby affirm under penalty of perjury one of the following de cla rations: I have and will maintain a certificate of consent to self - insure for workers' compensation, issue d by the Director of Industrial Relations as prov ided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. Policy No. I hav e 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 workers' co mpe nsation insuranc e carrier and policy number are: Carrier Policy Number Expiration Date Name of Agent Phone Number I certify that, in the perfo rmance 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 pro visions Signa ture of Applicant Date LOBBYIST ORDIN ANCE CERTIFIC ATION C omplete this secti on for permits in U ni nc orp or ated Los Angeles County only This is to certify that I, as permit applicant, am familiar with the requirements of Los Angeles County Code Ch apter 2 .160 et seq ., (relating to the Los Angeles County Lobbyist Ordinance) and that all persons acting on behalf of myself complied and will continu e to comply therewith through the application process . Applicant (Print Nam e) Applicant Signature LOCALITY HAZARDOUS MATERIA L 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 ha zardous 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 ❑ 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 f or obtaining a permit from the SCAQMD. ASBESTOS NOTIFICATION ❑ Notification letter sent to AQMD and/or EPA ❑ I declare that notificati on of asbestos removal is not applicable to addressed project. DECL ARATI ON REGARDING CONSTRUCTION LENDING A GENC Y I hereby affirm under penalty of perjury that there is a Construction l ending agency for the performance of the work for which this permit is issued (Section 3097, Civil Code). Lender's Name Lender's Address By my sign ature below, I certify to,each of the following: I am the property owner or authorized to act on the property own er's b ehalf. I have read this application and the inform ation I have provided is correct. I agree to comply with all applicable city and county ordinanc es and state laws relating to building construction . I authorize representatives of this county to enter the above -identifi ed property for inspection purposes . Signature of Property Owner or Authorized Agent Company Name Date Date COUN TY OF LOS A NGELES DEP ARTMENT OF PUBLIC'WORKS BUILDI NG A ND SAFET Y / LA ND DE VELOPM ENT TEMPLE CI TY 9701 L AS TU NAS TEMPLE CITY CA 91780 PHO NE: (626) 285-0488 E XT: # 0508 ELECTRIC AL PER MIT EL 0508 1408270051 L EGAL ID: ON FILE A SSESSOR INFORM ATION NUMBER: 8588-007-004 TENANT: OW NER: LI, JA SSON 9550 LIVE OAK AV TEMP 917802513 TEL. NO: (213) 308 -7788 - A PPL ICA NT: QIU LIN 9087 LA S TUN AS DRIVE TEM PL E CITY CA 91780 TEL. NO: (626) 269 -2668 - CONT RA CTOR: T A ND J CONSTRUCTION 5628 N GLA DYS AV E SAN GABR IEL CA 91776 TEL. N O: (626) 703-6653- LIC. NO 993453 A RCHITECT OR EN GIN EER: TEL. N O: LIC. N O: FEE DESC RIPTIO N: Al PERMIT ISSU ANCE FEE LB 200 AMP P ANELS, MCC REPO RT ID: D PR 265 FEES PAID QUA NTIT Y: UOM: 1 .00 PAN TOT AL FEES R OUTE TO: BS0508 A MOUNT: 27.80 38 .90 66.70 BUILDI NG ADD RESS: 9550 LI VE OAK AV TE MP CA 917802513 NEA REST C ROSS STREET: TE MPLE CI TY THO MAS P AGE: 596 GRID: J3 LOCALITY: TEMPLE CI TY CA ISSUED ON: PROCESSED BY: PLAN B Y: 08/27/14 SR FI NA L DA TE FINAL B Y• 1>D( L'( Z .)/ ESC RIPTI ON OFWO RK CODE: UPGR ADE 100 AMP TO 200 A MP ELECT RICAL PANEL SPECIAL CONDITIO NS: APPROVALS DATE I NSPECTOR SIGNATURE TE MPO RARY POWER POLE UNDE RG ROU ND CO ND UIT UFER GROUND ROUGH CO NDUI T RO UGH WI RING MAIN WATE R LI NE P LASTIC Y/N METAL Y/ N UTILITY COMP ANY NOTIFIED O WNER -BUILDER DECLARATION I hereby affirm under penalty of perjury that I am exempt from the Contractors' State License Law for the reason(s) indica ted below by the checkmark(s) I ha ve place d ne xt to the applicable item(s) (Section 7031.5, Business and Professions Code): Any city or county that re qu ires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requ ires the applica nt for the permit to file a signed statement that he or she is licensed pursuant to the provisions of the Con trac tors' 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 S ection 7031.5 by any applicant for a permit subje cts the applicant to a civil penalty of not more tha n five hundred dollars ($500).): L I, as owner of the property, or my e mplo yee s with wages as their sole compen sa tio n, will do (V ) all of or L) po rtio ns of the work, and the structu re is no t inte nde d, or offered fo r sale (Section 7044, Business and Professions Code : The Contracto rs' State Lic ense Law does not apply to an own er of property who, thro ugh e mplo yees' or personal effort, builds or improve s the property, provided that the improv ements are not inte nde d or off ered 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 prope rty, am exclusiv ely contra cting with lice nsed Contra cto rs to construct the project (Section 7044, Business and Pro fessions Co de : The Contractors' State License Law do es no t apply to an owner of property who builds or improve s there on, and who contracts for the projects with a licensed Contractor pursuant. to the Contractors' State License Law). L ): I am exempt from licensure under the Contractors' State Lic ense Law for the following reason: By my signature below I ac knowledge that, except for my personal residence in which I must have resided for at least o ne year prior to completions of the improvements covered by this permit, I cannot legally sell a structure that I have built as an owner -builder f it has not been constructed in its e ntirety by licensed co ntractors. I unders ta nd that a co py of the a pplica ble law, Section 7044 of the Business and Professio ns Co de, is available upon request when this application is submitted or at the follo wing Web site: http://www.le ginfo.ca.gov/calaw.html. Date: Signature of Property Owner or Au thorize d Agen t LICENSED CONTRA CTOR'S DECLARA TIO N I he re by affirm under penalty of perjury that I am licensed under provis ions of Chapter 9 (co mmencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. License Class 5 Lice nse No. Date D (21( i'Co ntracto r Signa ture ` - 41-S 3 WORKERS' COMPENSA TION DECLARATIO N WA RNING : FA ILURE TO SECURE WOR KERS' COM PENSATION COV ERAGE IS UNLA WFUL, AND SHALL SUBJECT AN EM PLOY ER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THO USA ND DO LLAR S ($100,000), IN A DDITION TO THE COST OF COM PENSATION, DAMA GES AS PROVIDED FOR IN SECTION 3706 OF T HE LABO R CODE, INTEREST, AND ATTO RNEY'S FEES. I hereby affirm under penalty of perjury one of the following de clarations: I hav e and will maintain a certificate of consent to se lf - insure for workers' compensation, issued by the Directo r of Industrial Relations as provided for by Section 3700 of the Labor Code, for the performance of the work fo r which this permit is issue d. Policy No. I ha ve a nd will maintain workers' compensation insura nce, as required by Section 3700 of the Labor Code, for the pe rformance of the work for which this permit is issued . My workers ' c ompensation insurance carrier and policy number are: Ca rrie r Policy Number Expir ation D ate Name of A gent Phone Numb er I certify that, in the perfo rmance of the work for which this permit is issued, I shall no t e mploy any pers on in any manner so as to become subject to the workers' compensation laws of Ca lifornia , a nd agree tha t, if I should bec om e subject to the wo rkers' compe nsa tio n provisions of Section 3700 of the Labor Co de , I sha ll fo rjhwith comply with those provisions ce(st77(� Signature of Applicant Date LOBBYIST ORDINANCE CE RTIFI CA TION Complete thi s secti on f or permits in Unincorp orated Lo s A ngeles County only This is to c ertify that I, as permit applicant, am familiar with the requirements of Los Angeles County Code Chapter 2 .160 et s eq., (relating to th e Los A ngeles County Lobbyist Ordinance) and that all p ersons acting on behalf of myself complied and will c ontinue to comply therewith through the application pr ocess. Applicant (Print Name) Applicant Signatur e JO B A DDRESS LOCALITY HAZARDOUS MATER IAL 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 spe cified on th e hazardous materials information guide? Yes ❑ N o ❑ Will the intended use of the building by th e applicant or future building occupant require a permit for construction or modification from the South Coast Air Quality Man agement District (SCAQMD)? See permitting checklist for guidelines. Yes ❑ No ❑ I hav e read th e haz ardous materials information guide and the SCAQMD permitting checklist, I understand my requirements under th e Los Angeles County Code Title 2, Chapter 220 ' Sections 220.100 through 220.140 concerning hazardous materi al reporting and for obtaining a permit from the SC AQMD . ASBEST OS NOTIFIC ATION ❑ Notification l ett er sent to AQMD and/or EP A ❑ I declare that notificati on of asbestos remov al is n ot applicable to addressed project . DECL ARATI ON REG ARDING CONSTRUCTION LENDING A GENCY I hereby affirm under penalty of p erjury that there is a Construction lending agency for the perf orma nce of the work for which this permit is issued (S ecti on 3097, Civil Code). Lender's Name Lender's Address By my signatur e bel ow, I certify to,each of the following: I am the property owner or authorized to act on the property owner's behalf . I have r ead this application and the information I ha ve provided is correct. I agree to c omply with all applicable city and county ordin ances and state laws rel ating to building construction. I authorize representati ves of this county to enter the above -identifi ed prop erty for inspection purpos es. Signature Pr Owner or Authori zed Ag ent C ompany Nam e Date Date e (-27((ct- COUNTY OF LOS A NGELES DEP ARTME NT OF PUBLIC WORKS BUILDI NG AND S AFETY / L AND DEVELOP ME NT TE MPLE CI TY 9701 LAS TUNAS TE MPLE CITY CA 91780 PHO NE: (626) 285-0488 E XT: # 0508 MECHANICAL PERMIT ME 0508 1408270023 LEGAL ID : ON FILE A SSESSOR INFORMA TION N UMBE R: 8588-007-004 TENANT: OWNER : LI, JASSON 9550 L IVE OAK AV TEM P 917802513 TEL . NO: (213) 308 -7788 - APPLICANT: QIU LIN 9087 LA S TU NAS DRIVE TEM PLE CITY CA 91780 TEL. NO: (626) 269 -2668 - CON TRACTOR: T AND J CON STRU CTION 5628 N GLAD YS AV E SAN GA BRIEL CA 91776 TEL. NO: (626) 703-6653- LIC. NO 993453 AR CHITECT OR ENG IN EER : TEL. N O: LIC. N O: FE ES P AID F EE DESC RIP TIO N: QUA NTITY: UO M: 01 PERMIT ISSU ANCE FEE 30 AI R I NLE TS/OU TLETS 41 VE NTIL ATIO N F AN 47 AL TE R E XIST DUCT S YS REPORT ID: DPR264 2.00 UNI 1 .00 FA N 1.00 SYS TOTAL FEES R OUTE TO: BS0508 A MO UNT: 27.80 8 .80 15.80 27.00 79.40 BUILDING ADD RESS: 9550 LI VE O AK AV TE MP CA 917802513 NE ARES T CROSS ST REET: TEMPLE CITY T HOMAS PAGE: 596 GRI D: J3 LOCALITY: TE MPLE CIT Y CA ISS UED O N: P ROCESSED B Y: P LAN B Y: 08/27/14 SR FINAL DA TE FI NAL Y: CODE: DESCRIPTION 0g WO RK ALTERATION OF EXIST DUCT SYSTEM, TWO AIR INLETS AND ONE VE NTIL ATION F AN SPECIAL CO NDITIONS: APP RO VALS DATE INSPECTOR SIGNAT URE FAU/ WALL F URNACE COMBUSTION AIR OPE NI NGS DUCT WORK AC/COMPRESSOR THE RMOSTA T FIRE DA MPE RS S MOKE DETEC TION DE VICES COM ME RCI AL HOO D OWNE-BU➢LDER DEOLA SA T➢ON 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 hav e placed next to the applicable item(s) (Section 7031.5, Business and Professions Code): A ny city or county that requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for the pe rmit to file a s igned sta tement that he or she is license d pursuant to the provisions of the Contractors' State License La w (Chapte r 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 applica nt for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500). ): (_) I, as owner of the property, or my employees with wage s as their sole compensation, will do (V) 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 improv ements are not inte nded or offered for sale. If, however, the building or improvement is sold within o ne year of completion, the Owner - Builder will have the burden of proving that it was not built or improve d for the purpose of sale. ). 0 I, as owner of the property, am exclusive ly contracting with licensed Contractors to construct the project (Section 7044, Business a nd 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 Lice nse 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 fo r at least one year prior; to completion: of the improvements covered by this permit, I cannot 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.leginfo.ca.gov/calaw. html. Date: Signature of Property Owner or Authoriz ed Agent L➢LENSED CONT RACTOR'S DECLARA TION I hereby affirm under pe nalty of perjury tha t I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my lice nse is in full force and effect. License Class S. License No. 61g3({ -S 3 Co ntractor Signature WORKERS' CO MIPENSA T➢ON DECLARATION WARNING: FA ILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLA WFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIM INAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COM PENSATION, DAM AGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND A TTORNEY'S FEES. I hereby affirm under penalty of perjury one of the following declara tions: I have and will maintain a certificate of consent to self - insure for workers' co mpe nsation, 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. I have a nd 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 workers' compensation insura nce carrier and policy number are: Carrier Policy Number Expiration Date Name of A ge nt Phone Number V 1 certify that, in the performa nce 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 a gree 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 </2 .1 f 11 - Signature of Applicant Date LOBBYIST ORDIN ANCE CERTIFICATION C omplete this se cti on f or permits in Unin corp orated Los Angele s C ounty o nly This is to certify that I, as permit applicant, am familiar with the requirements of Los Angeles County Code Chapter 2.160 et 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) Applic ant Signature Company Name Date JO B A DDRESS LOCALITY HA ZA RDO US MA T ERIAL DECLARA T ;ION Will the applicant or future building occupant handle a hazard ous material or a mixture containing a hazardous mat eri al equal to or greater than the amount specified on the hazardous materials information guide? Y es ❑ 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 E No ❑ I have read the hazardous materials information guide and the SCAQMD p ermitting checklist, I understand my requirements under the Los Angeles County Code Title 2, Chapt er 220 Sections 220.100 through 220 .140 concerning ha zardous material reporting and for obtaining a permit from the SCAQMD. ASBESTOS NOTIFIC ATION E Notification letter sent to AQMD and/or EP A E I declare that notification of asbestos remo val is not applicable to addressed project. DECLAR ATION REGARDING CONST RUCTI ON LENDING AGENCY I hereby affirm under p enalty of perjury that there is a Constructio n lending agency for the performance of the work f or which this permit is issued (Section 3097, Civil C od e) . Lender's 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 owner's behalf. I have read this application and the information I ha ve provided is correct . I agree to c omply with all applicable city and county ordin ances and state l aws r elating to building construction . I authorize representatives of this county to enter the abov e -identified property for inspection purposes. Signature of Pro erty Owner or Authorized Agent . Date .e 27/(L( COUNTY OF LOS ANGE LES DEP ART ME NT OF PUBLIC WO RKS B UIL DI NG A ND SAFETY / LAND DE VEL OP MEN T TE MP LE CITY 9701 LAS TUNAS TE MP LE CI TY CA 91780 PHO NE: (626) 285-0488 EXT: # 0508 P LUMBI NG PE RMIT PL 0508 1407090017 LEGA L ID: ON FILE ASSESSOR INFOR MATION NU MBER: 8588-007-004 TENANT: OWN ER: LI, JASSON 9550 LIVE OAK AV TEMP 917802513 TE L. NO: (213) 308 -7788 - A PPLICANT: QIU LIN 9087 LA S TUNA S DRIV E T EMPL E CITY CA 91780 TEL. NO: (626) 269 -2668 - CON TR ACTOR : T AND J CON STRUCTION 5628 N GLA DY S AV E SA N GA BRIEL CA 91776 TEL. NO: (626) 703-6653- LIC. NO 993453 ARCHITECT OR ENGINEER: TEL. NO: LIC. NO: FEE DESCRIPTIO N: 01 PE RMIT ISSU ANCE FEE 07 BAT HTU BS/S HOWERS 25 LAV ATORIES/SINKS 29 ROOF DR AIN(S) 45 WATE R CLOSE T/U RI NAL 47 WATE R H EATE R(S) R EPORT ID: DPR263 FEES PAID QUANTIT Y: UO M: 1 .00 FI X 1.00 FI X 1.00 FIX 1.00 FI X 1.00 WTH TOTAL FEES ROUT E TO: BS0508 A MOUNT: 27.80 16.20 16.20 16.20 16 .20 16 .20 108.80 BUILDING ADDRESS: 9550 LI VE OAK AV TEMP CA 917802513 NEAREST C ROSS S TREE T: TE MPLE CITY THO MAS PAGE: -596 GRID: J3 LOC ALITY: TE MPLE CITY CA ISSUED ON: PROCESSE D BY: PL AN BY: 07/09/14 SR FI NAL DATE F�AL Y: CO DE: DESCRIPTIO N OF W ORK BATHTUB/SHOWE R, LAVAT ORIE, ROOF DRAI N, W ATER C LOSET AND WATER HE ATER SPECIAL CONDI TIONS: APP ROVA LS DATE INSPECTOR SIG NAT URE UNDER S LAB WORK WATE R SE RVICE PL ASTIC Y/ N META L Y/ N RO UGH P LUMBI NG GAS PIPING GAS VE NT HOT WATER HE ATE R PL UMBING FIXT URES LAWN SP RIN KLERS GAS TEST UTILI TY CO MPA NY NOTIFIED CW V GRAY WATER SYSTE M *6( A‹ OM E R-BUllLDCR CLA A V DO 1 LICEMSED CON V RAC u OR' S IDECLARAI1O N JOB A DDRESS I hereby affirm under penalty of perjury that I am exempt from the Contractors' State License Law fo r the rea son(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, alter, improv e, demolish, or repair any structure, prior to its issuance, also require s the a pplicant fo r the permit to file a signed statement tha t he or she is lic ensed pursua nt to the pro visions of the Contracto rs' State License Law (Chapter 9 (commencing with Sectio n 7000) of Division 3 of the Business and Profe ssions Code) or that he or she is exempt from lice nsure and the basis for the alleged exe mption. Any violation of Section 7031.5 by any applicant fo r a permit subjects the applicant to a civ il penalty of not more than five hundred dollars ($500). ): L) I, as owner of the property, or my employees with wages as their sole compensation, will do (.7) all of or (_) portions of the work, and the structure is not intended or o ffered for sale (Section 7044, Business and Professions Code: The Contra ctors' Sta te License Law does not apply to an owner of property who, through employees' or personal effort, builds or improves the property, provided that the improv ements 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. ). L) I, as owner of the property, am ex clusiv ely contra cting with license d Contractors to construct the project (Se ction 7044, Business and Professions Code: The Contra ctors' 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 exempt from licensure under the Co ntra ctors' 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 cannot legally sell a structure that I hav e 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, Se ction 7044 of the Business and Professions Code, is availa ble upo n request whe n this application is submitted or at the following Web site: http://www.leginfo. ca. gov /calaw. html. Date: Signature of Property Owner or Authorized Agent I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with Sectio n 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. - ,License Class - .Date1 (4 C ontra ctor Signature License No. (ffi34s3 WORE<CRS' COMPENSA TION DECLA RATION WARN ING: FAILURE TO SECURE WORKERS' COMPENSATIO N COVERAGE IS UNLA WFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIM INA L PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN A DDITION TO THE COST OF COMPENSATION, DAMA GES 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 hav e and will maintain a certificate of co nsent 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. 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 workers' compensation insurance carrier and policy number are: Carrier Policy Number Expiration Date Name of A gent 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 work ers' compensation laws of California , and a gree 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 Sign&of Applicant %/44 - D ate LOBBYIST ORDIN ANCE CERTIFICATION Compl et e this section for permit s in Unincorporated L os Angeles Co unty only This is to certify that I, as permit applicant, am familiar with the requirements of Los Angeles County Code Chapter 2 .160 et seq ., (relating to the Los Angeles County Lobbyist Ordinance) and that all p ersons acting on behalf of myself compli ed and will continue to comply therewith through the application process . Applicant (Print Name) Applicant Signature Company Name Date LOCALITY HAZA RDO US MA TERIA L 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 info rmation guide? Ye s ❑ 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 El No ❑ I have read the hazardous materials information guide and the SCAQMD permitting checklist, I understand my requirements under the Los Ang el es 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 El Notification letter sent to AQ MD and/ or EPA ❑ I declare that notification of asbestos remo val is n ot applicable to address ed project. DECL AR ATI ON REG ARDING CONSTRUCTION LENDING AGENC Y I hereby affirm under penalty of p erjury that there is a Constructi on lending agency for the performance of the work for which this permit is issued (Section 3097, Civil Code). Lender's 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 owner's behalf. I ha ve read this application and the information I ha ve provided is correct. I agr ee to c omply with all applicable city and county ordinances and stat e laws relating to building construction. I authorize r epresentatives of this county to enter the ab ove -identified pr operty for inspection purposes . Signature of Pr operty Owner or Authorized Agent ate % l e(/fC� I CE!.TIFICATE F OCCU '=A CY CITY OF TEMPLE CITY BUILDING AND SAFETY/COMMUNITY DEVELOP MENT This certifies that the building or structures or portion ther eof, as describ ed herein, complies with provision of the Building Code for the following uses(s) and occupancy groups(s). No change shall be made in the character of occup ancy or us e of the building or structur es with out approv al of the Building Official and Community Development . BUILDING ADDRESS: 9550 LIVE O AK AVENUE PERMIT NUMBER: O WNER: ADDRESS: ti PERMITEE: ADDRESS: OCCUPANCY GROUP R-3 ISSUING O FFICE CITY OF TEMPLE CITY 9701 LAS TUNAS DRIVE TEMPLE CITY, CA 91780 BL 0508 1404220015 Li JIAN AND LIN YINGSHI .9 550 LIVE OAK AVENUE, TE MPLE CITY, , CA 91789 T AND J CONSTRUCTION 5628 N. GLADYS AVENUE, S AN GABRIEL, CA 91776 TEMPLE CITY USE OF BUILDING (OR PORTION) ADD MASTER BEDROOM, BATHROOM, WALK IN CLOSET 416 SQ.FT. TO TAL LIVING AREA 1706 SQ.FT. COMM UNITY DEVELOPM ENT DIRECTOR L BUILD G FICIAL DATE ISSUED: DECEMBER 23, 2014