HomeMy Public PortalAbout8766 BURGHARDT RD_Building__ WORKERS'COMPENSATION DECLARATION
I hereby affirm that l have a certificate s f consent to self 1 O �(/,a //E M O �E O ALIS
insure, or a certificate of Workers4ompiisotion Insurance, - APPUU-'l���11V LI ®U�l U���D�I1V`/ PIS U�IO CIU��
or a certifiedcopythereof (Sec 3806,'Lab. ) COUNTY.OF LOS ANGELES BUILDING AND'SAFETY
Policy No.WS;0 Company l'fmo10 TiY)A• 64
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN - BuBUuowc
ILDIN
Certified copy is filed with the county building inspec-.. BUILDING // //�� T
tion department. _ ADDRESS �O SG �rIG-Ir{4AL�A1 LOCALITY. ' IE�NLP��
NEAREST '
Date Applicant CITY.. ErVf PL-1 U,T ZIP cinq L7 CROSS ST. wES; pF NAV-' EL- -
- CERTIFICATE OF EXEMPTION FROM WORKERS' - ( x r1q_1 NO. OF BLDGS. .� ASSESSOR
COMPENSATION INSURANCE - . SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL
y' USE ZONE MAP
(This section need not or completed if the permit is For one TRACT BLOCK LOT NO. NO.
hundred dollars ($100)or less.) - / -
TEL. pp// 7 / SPECIAL
I certify that in the performance of the work for which this OWNER ,ISA S. hpRATv NO.e 10 {{{ CONDITIONS - 1
permit is issued, shall not employ any person in any manner i DISTRICT GROUP TYPE - FIRE PROCESSED BY O
• - ADDRESS S M SCPr1-F�..� Jq I CONST. _ZONE LJO,
so as to become subject to the Workers'Compensation.Laws. '• Fy � �
CITY '7em VLE CG t ZIP 1'Z"OL l7
Date Applicant - .j - STATISTICAL CLASSIFICATION APT. CONDO. !-
ARCHITECT OR TEL.'
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. CLASS NO. 0 DWELL: UNITS / - >y
Exemption, you should become subject to the Workers' d
Compensation.provisionsof the Labor Code, you must forth- SEWER- SEWER MAP -
with comply with such provisions or this permit shall be T�.�� - _ _
deemed revoked. _ - L1=5ROGH tR:S � "L. "V BK.BK. PG, VALIDATION
- CONTRACTOR O'TH NO.
F# LICENSED CONTRACTORS DECLARATION - - - UC '
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS IOL N•OR/i>��jc y2�C� NO. VALUATION
(commencing with Section 7000)of Division 3 of the Business and * LIC. '
Professions Code, and my license is in full force and effect. CITY WEN "V)NA GIS ' CLASS $-rza .
/ '? SQ.FT. NO, OF NO. OF. CHECK' D S 5 8-7,6 A
License Number-4 27S'IL,O 11' Lic.Class rF��. SIZE STORIES FAMILIES. ONE ,
Controctor7[SKSYjJ US.WfIG I!1. Date .} DESCRIPTION OF WORK NEW $ �O r .�e a e•e `Z3
{{��"��� ❑ -� • 4.6.0.92
El am exempt under &U ILi) I.IEYJ '. St-p ADD - -
• �Es+.ilE�.LCt: ALTER C]; FINAL k60,926 ,
B.BP:C. for t ason - O
DATE ! 1
- REPAIR. ❑ •10..1 1 -83
3 '
Dales_ USE OF FINAL -
w` - - EXISTING BLDG. DEMOL ❑ FI /�,_
Signatur APPLICANT TEL.
W ER-BUILDER DE ARA ION.., - PRINT) NO. ✓ ��/�7777_
I hereby affirm th 1 Pam exempt fro Contractor's License
Law for the"following reason (Section 7031.5, Business and I ADDRESS. "Rc••6 5 0,6 A
Professions Code): PRESENT -
❑ I BUILDING. _ # e • ° • 2 3 .
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 ;12'°.1 brQ, 5,7
7044, Busi nese and Professions Code). MOVING TEL.
I,.as owner of the property, am exclusively contracting CONTRACTOR NO: _ ° °� 1 b 0.5 7 6
with licensed contractors to construct the project (Sec- r
tion 7044, Business and'Professions Code). ADDRESS ,
\ REQUIRED TOTAL SETBACK FROM EXIST.
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE - WIDTH '�65 0.7 A
"hereby affirm thot there is a construction Ieriing:agency for "FRONT .O �� 'is ..D - # e • e e s
the performance ofthework for which this Permit is issued P.L. rq
(Sec'3097, Civ. C.). 'SIDE '
- �� -7{+ P:L. 2 . 7.41.75
m Lender's"Name�l"A50.QPXL&:- "St w
q pp� ,r^,^ ° 7;4:1:75
Lender's'Address-OS E,Cin IOfAd'. lasY Aw 6 P.C.Fee$ Permit Fee
, , 1..1 83..
1 certify that I have.read this application and state that the - Q- Issuance Fee �-
a aboveinformation Is correct. I agree to comply wNb:all County In esrrgarmn
g ordinances and State-laws'relating to building construction; total Fee /
b and hereby authorize representatives of this County to a er. -
9 ua the abov - d pprroperty for,inspection put ses. - •" - --
SEE REVERSE.FOR EXPLANATORY LANGUAGE
Signa re of Applicant or Agent Dol r ®a
WORKERS' COMPENSATION DECLARATION ./� r� //,tea /'� y� Lp� p I� IFS
I hereby.affirm that haver certificate'of consent to self /W P Lyr U IA II O O N FOR B IIIA MNG PERM 1T
insusp' or a certificate of Workers' Compensation.Insurance, � � //"V BV- /rkl,llll u V IIYI Ik3t�l�J (� u�'f �C u ,-
.. 'ar a'cerhfied copy thereof (Sec 3800, L bvC�) - COUNTY OF LOS ANGELES - - 'BUILDING AND SAFETY
.Policy Nd. O Y 'Company •
UILDING
ElCertifiedcopy is-hereby furnished. /o� FOR APPLICANT`TO FILL IN ADDRESS
❑ Certified copy is filed with the county bwlding inspec_ ADDRESS .moi ?.. yam- �, C• -
tion department.. : I - - k DDR55
.Date � � Applicant ]].hbLt I C�LD'.n� ' CITY` L� V( ZIP -/ / LOCALITY -
CERTIFICATE OF EXEMPTION.FROM WORKERS' SIZE OF LOT NOW ON NO. OF TOTS NEAREST ,,LL� // -y
COMPENSATION INSURANCE(ThCROSS SL /7.�j '�fL c ' AV
ASSESSOR
hundred ion need not be completed if the perniii ivfor one TRACT- - BLOCK LOT NO. MAP BOOK LP " PAGE.O1� PARCEL D �'
hundred dollars ($100)or less.) - '.' ' /+ p /� v TEL _
OWNER 1. V'E—[A C1I !J NO. USE ZONE_ No
I certify that in the performance of.the work for which this �J�� t ^ SPECIAL . .
permit is issued, I shall not employ,any'person in any manner 'ADDRESS � iLaL! �Y- •- `/ CONDITIONS d
so as to become subject to.the Workers'Compensation4aws. //,/ f,/ (�µJ O .
CITY L�j-`�'f f l ZIP — 0/7 7� .. U
=Date� 1�T Applicant �z+a Lam( ` L W ARCHITECT OR TEL. DISTRICT. GROUP TYPE _ FIRE PROCESSED BY'NOTICE.TO APPLICANT.•If, after making.this.Certificate of ENGINEER. NO. . CONST. - Z NE
Exemption, you should become -subject to the Workers h/ (� iQ{
Compensation provisions of,the Labor Code, you must forth- _ ADDRESS - - >'Q �� �' o< (HCl �+� Lu
s
with comply with such,provatons:or this.permit shall be TEL_ � STATISTICAL CLASSIFICATION APT. CONDO.
N
deemed revoked CONTRACTOR // .�..,/� NO YV'—T�` �.f z
LICENSED CONTRACTORS,DECLARATION ' ADDRE55. 7• >l1c t�7 LIC "T"�"Z CLASS NO.�r... UNITS_
I hereby affirm that I am licensed under provisions of Chapter 9 ' - SEWER MAP
(commencing with Section 7000) of Division 3 o the Business O� LIC
and Professions Code,and my license irin full force and effect. CIT, yn �� CLASS BK x VALIDATION
License Number �'( � YY Lic. Class SIZHECK t4l FIG.
E FT. O TORIIEES AMILOIES CONI,
''ii VALUATION
Contractor/i ,,,I hT+C✓FYote ��";"� DE�SQCyR/I PITION OF'WORK 'NEW f
/ ✓-"M.. �f!.lD .i ADD ' L`k D I1 '�
❑I am exempt under Sec. l oT ` -
- - 'kt./ � ALTER. ❑ 1.
r 8.8P.C. For this reason c`
Ee'TINGBLDG. DEMOL REPAIR El REPAIR
Date: USE OF - _
EXIS ❑
- Signature ' - APPLICANT /� TEL. - FINAL - v 7-
TEL
!.0 V NO.
OWNER-BUILDER DE LARATION t DATE — -. 1
I hereby affirm that I am exempt from the Contractor's License ADDRESS 1 K% p
Law for the following reason (Section 7031.5, Business and C J/ FINAL 1.-113 1 e f 1
Professions Code): " PRESENT eIF _ _
ly
BUILDING t I'1`t.is
El I, as owner of the property, or my employees with ADDRESS -
wages as,their sole compensation,will do the work and - - - - - - py';y4'�,)]F
the structre is not intended or offered for sole(Section - LOCALITY D , _ y
7044; Business'and Professions Code.) MOVING - _ TEL. t.• i
❑ I,.as owner of theproperty, am exclusive) contract in CONTRACTOR NO, J
Y 9 _ _ _ Pt�1i tl Illi 1 -T
with 044, edinessa and
Pro construct the project (Sec-
tion
Seo- ADDRESS
tion 7044, Businessand Professions Code.)
REQUIRED TOTAL SETBACK FROM EXIST.
CONSTRUCTION LENDINGAGENCY _ .SET BACK YARD HWY PROP. LINE
I hereby affirm that there is a construction lending agency for FROND
the performance of the work forwhich this permitisissued P.L" -
(Sea.3097, Civ. C.). - SIDE
Lender's Name
- P.C. Fee S rmit 1 / PeFee / TDMA RI. N
Lenders Address . - `
a I certify that I have read this application and state that the - Issuance Fee' P5 .2 LDMA P/C N D -
8 above information is correct. I agree to comply with all County Investigation Fee ` -
ordinances and State laws relating to building construction, Total Fee i 'LDMA Perm:It
a and hereby authorize representatives-of this Countyto enter _
upon the above-mentioned property for,inspection purposes. - - -
•SEE REVERSE FOR EXPLANATORY LANGUAGE -
Signature of Applicant or Agent Dote - -
COUNTY OF LOS ANGELES TEMPLE CITY 0 0508 BUILDING PERMIT
DEPARTMENT OF PUBLIC WORKS 9901 LAS TUNAS ALTERATION/REPAIR
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 BL 0508 0910140021
PHONE: (626) 285-0488 EXT:
LEGAL ID: NO. OF CONST BUILDING ADDRESS:
BK: 164 PG: 31 PC: 2 SQ. FT STORIES TYPE 8766 BURGHARDT RD
STRUCTURE: - V-B SCAB CA 917752650 j
ASSESSOR INFORMATION NUMBER I NEAREST CROSS STREET:
15386-012-070 THOMAS PAGE: 596 GRID: H3 LOCALITY: TEMPLE CITY, Cl
I
ITENANT: (EXIST BLDG USE: REBID USE ZONE: R-1 (ISSUED ON: PROCESSED BY:
I IEXIST OCC GRP: 110/14/09 SR
I I I
IOWNER: TEL. NO: 1BLDGS. NOW ON IAT: VALUATION: FppppI4AL DAT FINAL BY: CODE:
IYIP, KONG (626) 309-1479- 71000 1 ���
118766 BURGHARDT RD / y A'
FEES PAID
SCAB 917752650
I IDES RIPTIO OF WORK
IKITCHEN REMODEL
I JEER DESCRIPTION: QUANTITY: UOM: AMOUNT: 1
APPLICANT: TEL. NO:
IREN H ZHU (626) 808-2704- IAA BLDG PERMIT ISSUANCE 27.75 1
18631 HERMOSA DR. (AB STATE GREEN BLDG FEE 7000.00 VAL 1.00 ISPECIAL CONDITIONS:
I
ISM GABRIEL CA 91775 AC STRONG MOTION REBID 7000.00 VAL 0.70
B2 PERMIT W/ENERGY 7000.00 VAL 182.82 1
TOTAL FEES 212.27
CONTRACTOR: TEL. NO: JAPPROVALS DATE INSPECTOR SIGNATURE
IJ R TECH CONSTRUCTION (626) 808-2764-
18631 HERMOSA DR LIC. NO (LOCATION AND SETBACKS
SAN GABRIEL CA 91775 750490 B `
ISOILS ENGINEER APPROVAL I I
1ARCHITECT OR ENGINEER TEL. NO: IFOUNDATION/TRENCH FORMS I I
LIC. NO: 1 SLAB/UNDER FLOOR
1 RAISED FLOOR FRAMING
_ 1 I 1
(MAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP: j (UNDERFLOOR INSULATION
150H261 3 001
' 1FLOOR SHEATHING
NO. OF FAMILIES: DWELLING UNITS: APT/GOND: STAT CLASS: ( - '
11
NO 21IROOF SHEATHING
I SCHOOL WITHIN HAZARDOUSSHEAR PANELS 1 1 1
1AIN QUALITY: 1000 FEET MATERIALS _ - • - 4
I NO NO NO - FRAME INSPECTIONff1�
(REQUIRED TOTAL SETBACK FROM EXIST FIRE SPRINKLER HANGERS f1I VV
SET BACK YARD: HWY: PROP LINE: WIDTH:
IFRDNT PL- INSULATION/WEATHER STRIPI�(�jT/3
I SIDE PL-
INTERIOR LATH/DRYWALL 1
IEXTERIOR LATH 11 11
Y
RATED FLOOR/CEIL ABSEM.
1 RATED WALL ASSEMBLIES
I I I
- (RATED SHAFTS/OPENINGS
I I I
IT-BAR CEILINGS I
I I
ILOT DRAINAGE
I
1 - (REPORT ID: DPR261 ROUTE TO: BS0508 1
I I I II I
COUNTY OF LOS ANGELES TEMPLE CITY 4 0508 BUILDING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ALTERATION/REPAIR
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 BL 0508 0910200001
PHONE: (626) 285-0488 EXT:
(LEGAL ID. NO. OF CONST BUILDING ADDRESS: 1
1BK: 164 PG: 31 PC: 2 SQ. FT STORIES TYPE 1 8766 BORCHARDT RD 1
I (STRUCTURE: V-B SCAB CA 917752650 1
(ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET:
15386-012-070 1 1 THOMAS PAGE: 596 GRID: H3 LOCALITY: TEMPLE CITY, Cl
ITENANT: IEXIST BLDG USE: REBID USE ZONE: R-1 (ISSUED ON: PROCESSED BY: 1
IEXIST OCC GRP: 110/20/09 SR
OWNER: TEL. N0: 1BLDG5. NOW ON LOT: VALUATION: 1FINAL DATE FINAL BY: CODE: 1
1YIP, KONG (626) 309-1479- 1 1,000 1
18766 BURGHARDT RD I I f ! - IF'
SGAB 917752650 FEES PAID D CRSS IPTION OF WORK
ICLOSE ONE WINDOW, RELOCATE ONE WINDOW AND SLIDING DOOR AT
IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT:ITHE KITCHEN AREA
APPLICANT: TEL. NO: I I 1
IREN H ZHU (626) 808-2704- 1AA BLDG PERMIT ISSUANCE 27.75 I
18631 HERMOSA DR. IAB STATE GREEN BLDG FEE 1000.00 VAI, 1.00 (SPECIAL CONDITIONS:
SAN GABRIEL CA 91775 IAC STRONG MOTION REBID 1000.00 VAL 0.50
IB2 PERMIT W/ENERGY 1000.00 VAL 71.94
TOTAL FEES 101.19
CONTRACTOR: TEL. NO: (APPROVALS DATE INSPECTOR SIGNATURE
IJ R TECH CONSTRUCTION (626) 808-2764- 1
18631 HERMOSA DR LIC. NO LOCATION AND SETBACKS
15AN GABRIIEL CA 91775 750490 B
ISOILS ENGINEER APPROVAL
ARCHITECT OR ENGINEER: TEL. NO: FOUNDATION/TRENCH FORMS
LIC. NO: (SLAB/UNDER FLOOR
RAISED FLOOR FRAMING
MAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP:1 (UNDERFLOOR INSULATION I
1150H261 3 001 1 1-1-
I
1I (FLOOR SHEATHING
1N0. OF FAMILIES: DWELLING UNITS: APT/COND: STAT CLASS: I
NO 21 1 RODE SHEATHING
SCHOOL WITHIN HAZARDOUS SHEAR PANELS
(AIR QUALITY: 1000 FEET MATERIALS
1 NO NO NO 1FRAME INSPECTION
1REQDIRED TOTAL SETBACK FROM EXIST 1 1FIRE SPRINKLER HANGERS I I I
ISET BACK YARD: HWY: PROP LINE: WIDTH:
FRONT PL- � INSOLATION/WEATHER STRIP(
I SIDE PL-
I INTERIDR LATH/DRYWALL
(EXTERIOR LATH I
RATED FLOOR/CEIL ASSEM.
RATED WALL ASSEMBLIES
IRATED SHAFTS/OPENINGS I
T-BAR CEILINGS
(LOT DRAINAGE j 1
1 (REPORT ID: DPR261 ROUTE TO: BS0508
I I I I I