HomeMy Public PortalAbout5431 BALDWIN AVE_Building__ WORKERS"COMPENSATION DECLARATION
-hereby affirm that I have certificate of consent to Self APPLICATION FOR BUILDING PERMIT
insure, or a certificate of Workers' Compensation Insurance,
or a certified copy thereof (S 800, L�bb.. C..c)_
� =Go� COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy.Not G+® 73Company f
BUILDING
•Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS 7 '�/ •
BUILDING q/J
❑ Certified copy is filed with the county building inspec- ADDRESS 7� W /U /7✓�. �r� �' 3 137 j C
tion department. ✓ j
Date
CITY ZIP LOCALITY 1
Applicant NO. OF BLDGS. NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT a°V NOW ON LOT D CROSS ST. �j� �j Fi�'CT°s
COMPENSATION INSURANCE ��I
(This section need not be completed if the permit is for one TRACT BLOCK LOT NCL ASSESSOR ,('� � °7J
MAP BOOK PAGE .rU PARCEL
hundred dollars ($100) or less.) �^ TEL. yip+
OWNER ®/zo NO. (lt' USE ZONE OP ,.r
I certify that in the performance of the work for which this n (t �
permit is issued, I shall not employ any person in any manner ADDRESS 1 /�� — CONDITIONS )I I s ° "
so as to become subject to the Workers' Compensation Laws.
XDatCITY l/7ZIPe Applicant ARCHITECT O /�E TEL.OTICE TO APPLICANT: If, after makingthis Certificate of ENGINEER /� g5/<,G' NO. 6 DISTRICT OUP TYPE FI 1%i IALIGE PROCESSED BY
J CONST. ZONE �
Exemption, you should become subject to the Workers' ` _ J�Ww
Compensation provisions of the Labor Code, you must forth- ADDRESS J ,O 3 J
with comply with such provisions or this permit shall be n fl TEL d STATISTICAL CLASSIFICATION —t—AP ONDO.
deemed revoked. CONTRACTOR ICJ/ NO. ! C �� 1 AM :•_ku
LICENSED CONTRACTORS DECLARATION IC. CLASS NO. DWELL. UNITS
I her affirm that I am licensed under provisions of Chapter 9 ADDRESS � O.
(commencing with Section 7000)of Division 3 of The Business LIC. SEWER P
and Professions Code,and my license is in full force and e ect. CITY ,/5 CLASS BK PG VALIDATION
�j t 4
SQ. FT zas9' NO. OF NO. OF ` CHECK
License Number :1777 �� Lic. Class SIZE { "Iv°� STORIES � FAMILIES / ONE
VALUATI N
Contractor Loin Date A,4 •2' DESCRIPTION OF WORK NEW S ®�
❑ ❑ ►I am exempt under Sec. ADDALTER ❑ ,J
B.&P.C. for this reason REPAIR ❑ $
Date: USE OF
EXISTING BLDG. �jDEMMOrLL El
Signature APP(RNN)��tlJ S .NO. g- /a FINAL ,
OWNER-BUILDER DECLARATION +W ��e� p DATE
I hereby affirm that I am exempt from the Contractor's License (J��{l��i!
Law for the following reason (Section 7031.5, Business and ADDRESS ��� / FINAL t;
Professions Code): PRESENT By "�
❑ 1, as owner of the property, or my employees with DDRESS ��' I it
wages as their sole compensation,will do the work and °
the structure is not intended or offered for sale(Section LOCALITY , 13,;x07 812.82
7044, Business and Professions Code.) MOVING TEL. ITEMS
❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO. T 1 ITEMS
with licensed contractors to construct the project (Sec- ADDRESS TOTAL o 12 +-32
tion 7044, Business and Professions.Code.). �°
REQUIRED YARD HWY TOTAL SETBACK FROM EXIST. ; � 01`T 0'?
CONSTRUCTION LENDING AGENCY SET BACK _.- PROP. LINE ._ WIDTH
I hereby affirm that there is a construction lending agency for FRONT _ t}�A �E .I�IJ
the performance of the .work for which this permit is issued P.I.
(Sec. 3097, Civ. C.). SIDE
P.L.
Lender's Name d —0001 6�.2`_7/v9
675 LDMA Ref. #
P.C. Fee$ Permit Fee D 4202 1 ASA 9:0
42
Lender's Address (�� F'!1 i 7 JY
a 1 certify that I have read this application and state that the O' Issuance Fee In 1 LDMA P/C#
8 abo nformation is correct. I agree to comply with all County Investigation Fee
ord no es and State la s relating to building construction, Total Fee lo6o. O LDMA Perm. #
a an her by author re esentatives of this County to enter
u th bove- i d property for inspect'
SEE REVERSE FOR EXPLANATORY LANGUAGE
` Signature of Applican or Agent Date
r.�--rOUNTli 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 1009160047
PHONE: (626) 285-0488 EXT:
ILEGAL ID: I NO. OF CONST I BUILDING ADDRESS: I
IBK: 219 PG: 72 PC: 2 I SQ. FT STORIES TYPE 5431 BALDWIN AV
I (STRUCTURE: V-B TEMP CA 917802625
ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET: I
18588-019-032 I I THOMAS PAGE: 597 GRID: B4 LOCALITY: TEMPLE CITY, Cl
(TENANT: - IEXIST BLDG USE: RESID USE ZONE: R-1 (ISSUED ON: PROCESSED BY: I
1 IEXIST OCC GRP: 109/16/10 SR I
(OWNER: TEL. NO: 1BLDGS. NOW ON LOT: VALUATION: IFINAL DATE FINAL BY: CODE: 1
IGIMEREZ, MANUEL (626) 614-9199- 1 3,800 1 I
15431 BALDWIN AV 1 I I
ITEMP 917802625 I FEES PAID IDESCRIPTION OF WORK I
I I IREPLACE 3 WINDOWS 1
IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT: (
1APPLICANT: TEL. NO: 1 1
IRANDY COLE (626) 402-0828- IAA BLDG PERMIT ISSUANCE 27.80 1 I
IPO BOX 711564 IAB STATE GREEN BLDG FEE 3800.00 VAL 1.00 ISPECIAL CONDITIONS: I.
ISANTEE, CA 92072 IAC STRONG MOTION RESID 3800.00 VAL 0.50 1
ID2 PERMIT W/O EN-HC 3800.00 VAL 116.00 I I
TOTAL .FEES 145.30 1 I
ICONTRACTOR: TEL. NO: I (APPROVALS DATE INSPECTOR SIGNATURE 1
ISEARS HOME IDfPROVEMENT (800) 807-9889- 1 I I
110395 SLUSHER DR LIC. NO I ILOCATION AND SETBACKS
ISANTA FE SPRINGS, CA 90670 721379
ISOILS ENGINEER APPROVAL
I I
(ARCHITECT OR ENGINEER: TEL. NO: IFOUNDATION/TRENCH FORMS I'
LIC. NO: (SLAB/UNDER FLOOR
I I I
IRAISED FLOOR FRAMING
IMAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP: ( (UNDERFLOOR INSULATION I
1144H264 3 001 EXPIRED
1 I
I I I FLOOR SHEATHING
INO. OF FAMILIES: DWELLING UNITS: APT/GOND: STAT CLASS: I I
NO 21 1 IROOF SHEATHING
SCHOOL WITHIN HAZARDOUS ✓/ ..// (SHEAR PANELS 1
1AIR QUALITY: 1000 FEET MATERIALS
NO NO NO (FRAME INSPECTION 1
I IFIRE SPRINKLER HANGERS I I
I I 11NSULATION/WEATHER STRIPI I I
I I (INTERIOR LATH/DRYWALL
1 1EXTERIOR LATH I I I
IRATED FLOOR/CEIL ASSEM. I, I
IRATED WALL ASSEMBLIES I I I
I IRATED SHAFTS/OPENINGS I I I
I IT-EAR CEILINGS 1
I I ILOT DRAINAGE I I
I IREPORT ID: DPR261 ROUTE TO: BS0508 I I I I
I 1 I I I I