HomeMy Public PortalAbout5612 BALDWIN AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION
CE 875 (11-84) MISCELLANEOUS APPLICATI®N
CE 875
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec.3800,Lab.C.). 13
Policy No. CompanyFOR APPLICANT TO FILL IN BUILDING ref J
ADDRESS 5-6 Z
Certified copy is hereby furnished. BUIL
ADDRDEING (
Sr /� LOCALITY
Certified copy is filed with the county building inspection LOCALITY-7—/ NEAREST
department. L �T`� CROSS ST.
Date Applicant NEAREST DIST�R9-I�CT Ns TYPE PROCES E BY
CROSS ST. �' V C / CON$T,�
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL 111111(((ffJ '1
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY
No. (CIRCLE) STATE MAJOR SE CO LOCAL
NO. OF BLD GS.
(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars (§100) or less.) USE OF
I certify that in the performance of the work for which this SIZE of LOT EXISTING BLDG. 0
permit is issued, I shall not employ any pers 1 n3 manner OWNER
so as to become subject to t sm at' In aws. OCCUPANCY GROUP.. L c�
MAIL O
2Lj/ / )1/Jf
ADDRESS cJ /� W`T7- •.`•. y
Date pplican LUL,
NOTICE TO PLICA _atter aking this Certificate of CITY C Trlo� �S�—�3 �'� OCCUPANT LOAD `L
Exemptio you shoe becom subject to the Workers'
Compen tion prov' • ris abor Code, you must forth- APPLICATION FOR EXIT HARDWARE:
with co Iy such provisions oI this permit shall be TRAILER USE ❑ GEOLOGY NSPECTION ❑ No Spec. Knowl.
deemed revoke
LICE SED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) "
9 (commencing with Section 7000) of Division 3 of the Busi- NO. OF EXITS
ness and Professions Code,and my license is in full force and
effect. T� �1/K��T V� PARKING REQ'D PROVIDED
SPACES
License Number Lic. Class
LIMITED TIME USE
Contractor Date DATE DATE
FROM: TO:
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF NO. OF / INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE
iness and Professions Code).
PRESENT USE OF BUILDING FINAL APPROVAL LzK Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS Z
ON LOT AND USE
I hereby affirm•that I am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING
❑ I, as owner of the property, will do the work and the SPACES PROVIDED Z z 6 3 R
structure is not intended or offered for sale (Section o": ".
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING �j ( �,`,, 8, ;S Q
I hereby affirm that there is a construction lending agency o .'` .8• Jr 06 z3
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.C.). - 0.,� 09 --87
Lender's Name
PROPOSED MAX. OCC. .,0 0 �.
Lender's Address
PERMIT FEE
I certify that I have read this application and state that the l d
above information is correct.I agree to comply with all County ISSUANCE FEE 1 S Cbtb
ordinances and State laws relating to building construction, h oo
and hereby authorize representatives of this County to enter TOTAL FEE s� co C)1C31 \\��
upon thea v - e iord er y for inspection purposes. �l oo O
SEE REVERSE FOR EXPLANATORY LANGUAGE CH
Si at re of fermittee Date
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MISCELLANEOUS PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS MP 0508 0411080001
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL 10: — NO. OF CONST NEW BUILDING ADDRESS:
TR: 16957 LT: 14 SQ. FT STORIES TYPE OCCUP GROUP 5612 BALDWIN AV
_ STRUCTURE: 240 1 VN C TEMP CA 917802628
ASSESSO}2 INf0RLi1iI �IU,'9C'iEl2c �'— NEAREST CROSS STREET: BOGUE
8586-021-001 EXIST BLDG USE: RESID THOMAS PAGE: 597 GRID: B3 LOCALITY: TEMPLE CITY, C�
EXIST OCC GRP: USE ZONE:
ISSUED ON: PROCESSED BY: EXPIRES ON:
BLDGS. NOW ON LOT: VALUATION: 11/08/04 JK 05/07/05
_ _ 0
OWNER: �— �TEL. NO: FINAL DATE ALL BY: CODE:
KOBAYASHI FRANC SCA NATSU:O (626) 571-9160— LIST ITEMS: Q —
5612 BAL.DWIN AV / V
TEMP 917802628 DESCRIPTION OF WOR
ENCLOSED PATIO TO EDROOM 240 SF.
_ OCCUP LOAD EXIST:
APPLICANT: TEL. NO: OCCUP LOAD NEW:
SAME AS OWNER —
PARKING SPACES REQUIRED: SPECIAL CONDITIONS•
PARKING SPACES PROVIDED:
EXIT HARDWARE: _
CONTRACTOR: TEL. NO: _LIMITED TIME USE
SAME AS OWNER - NBR OF EXITS: FROM TO
LIC. NO
FEES PAID
APPROVALS DATE INSPECTOR SIGNATURE
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT:
ARCHITECT OR ENGINEER: TEL. NO: TRAILER USE
— OA PERMIT ISSUANCE 27.75
LIC. N0: 01 R/M OCC/USE INSPECT 145.95 SAFETY PERMIT
TOTAL FEES 173.70
TEMP. STRUCT. APPROVED
MAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP: TEMP. STRUCT. REMOVED
NO. OF FAMILIES: DWELLING UNITS: APT/GOND: STAT CLASS:
NO
SCHOOL WITHIN HAZARDOUS
AIR QUALITY: '1000 FEET MATERIALS
NO NO NO
REQUIRED TOTAL SETBACK FROM EXIST
SET BACK YARD: HWY: PROP LINE: WIDTH:
FRONT PL—
SIDE PL—
REPORT ID: DPR267 ROUTE TO: BS0508