HomeMy Public PortalAbout10721 DANBURY ST_Building__ ♦.\ A11 11 U CAMON Il O Y ISf U L M V `CN 11 E YNT ' 1
COUNTY OF LOS ANGELES BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS
I hereby affirm that 1 have a certificate of consent to self insure,
BUILDING ADDRESS
or a certificate of WorkersCompensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.) CITY -1 ZIP
LOCALITY -v
Policy No. Company SIZE F L T ^ NO OF LDGS.NOW ON LOT
El Certified copy is hereby furnished. lOn I NEAREST CROSS BY
❑ Certified copy is filed with the county building inspection TRACT BLOCK LOT NO.
department. 11.3&13 1 417 USE ZONE MAP N0.
Daft Applicant ASSESSOR MAP BOOK PAGE PARCE
7 io SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' 0 NER TEL No.
COMPENSATION INSURANCE 109— -S WITHIN 1000 FT.OF SCHOOL? YES I NO
(This section need not be completed if the permit is for one hundred AD SS
dollars($700)or less.) R.
all DISTRICT GROUP TYPE CONST FIRE ZONE PROCESSED BY
Ill BE-191Z CITY ZIP II
A CJ %2�LG '
I certify that in the performance of the work for which this permit 9z /✓S
i5 Issued, ( Shall not employ any person in any manner so as 10 ARCHITECTENGINEER TEL NO.
become subject to the Workers'Compensation Laws. STATISTICAL CLA IFICATION APT CONDO
Date /11/9- 1
Applicant ADDRESS CLASS NO DWELL UNITS
NOTICE TO APPLICANT It, after making this Certificate of RECUIRED TOTAL SETBACK FROM EXIST
Exemption, you should become subject t0 the Workers' CONTRACTOR TEL NO. SET BACK YARD HWY PROP LINE WIDTH
Compensation provisions of the Labor Code, you must forthwith
FROM
comply with such provisions or this permitshall be deemed revoked. ADDRES LIC.N0. PL
LICENSED CONTRACTORS DECLARATION SIDE
CITY LIC.CLASS PL - }
I hereby affirm that I am licensed underprovisions of Chapter 9 SEWER MAP d
(commencing with Section 7000)of Division 3 of the Business and SO.FT SIZE N0.OF STORIES NO.OF FAMILIES O
Professions Code,and my license is in full force and effect. NEW ❑ BK PG D 0
License Number LID.Class DES IPTION OF WORK• ADD ❑ VALUATION
Contractor Date ALTER C1 $ 16 • �� Q
O
❑ I am exempt under Sec. REPAIR $ U
134P.C.for this reason DEMOL bW
CDMA P/C x _ tl
Date: USE OF XISTING BLDG. URM ❑ -- H
Signature 12 •r- s Z
g F APPLICANT(FEINT) TEL NO LDMA Perm x
1, as owner of the property, mF RFw /Yl/q/l. I ZO cIj
-1;eireek-eern9eaeat u will d0 the work and the structure is ADDRESS -'�I�= 7
Get intended or offered for Sale (Section 7044, Business and1.105-baFINAL 9TE < i
Professions Code.) WILL THE APFUCANT OR FUTURE BLUONG OCCUPANT HANDLE A HAZARDOUS MATERIAL
❑ 1, as Owner of the property, am exclusively contracting with OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EOIML TO OR GREATER THAN THE J - 8
AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FI L
licensed contractors to construct the protect (Section 7044, �?fiv
Business and Professions Code.) YES El No� 1{1?,-Tt
WILL THE INTENDED USE OF THE BUIDIING BY THE APPLICANT OR FUTURE BUILDING .f
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH _ 1 -
CONSTRUCTION LENDING AGENCY GUI COAST
AIR CUAUTY MANAGEMENT DISTRICT ISCAOI SEE PERMITTING CHECKUST FOR
I hereby affirm that there is a construction lending agency for YES❑ NOV, WW ,•- TOTAL 15:3 - 40
N the performance of the work for which this permit is issued(Sec. {c-�
q IHAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING / \'• CHEt_K - v.71)
3097,Civ.Ci.) CHECKUST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE. L.
Lender's Name TITLE 2 CHAPTER 220 SECTIONS 2,20 100 THROUGH 2.20.100 CONCERNING HAZARDOUS CHANGE
MATERIALS REPORG NG AND FOR OBTAINING A PERMIT FROM THE SCAOMDL. fT ,9 L
Lender's Address
Q 0ANm OP eLENI
o I certify that I have read this application and state under penalty
O of perjury that the above information is correct.I agree to comply PC.FEE �r PERMIT FEE 1jIl1J�l-I1Q1)i 111 1!
with all county Ordinances and State laws relating to building D•so • n7L, Ahi +
m construction, and hereby authorize representatives of this County ISSUANCE FEE
tcleI the bo -mentioned er q for inspection rpo S
(� 3 INVESTIGATION FEE TOTAL FEE /D-I-s O
�F• u N ypav w 04Fl� DYa
SEE REVERSE FOR EXPLANATORY LANGUAGE
COUNTY OF LOS ANGELES TEMPLE CITY $ 0508 BUILDING PERMIT
DEPARTMENT OF PUBLIC WORKS 9901 LAS TUNAS ALTERATION/REPAIR
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 BE 0508 1205170046
PHONE: (626) 285-0468 EXT:
ILEGAL ID: NO. OF CONST 1 BUILDING ADDRESS: 1
ITR: 13613 LT: 147 SQ. FT STORIES TYPE 10721 DANBURY ST
(STRUCTURE: 2300 V-B TEMP CA 917802826
(ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET:
18573-002-010 - THOMAS PAGE: 597 GRID: C3 LOCALITY: TEMPLE CITY CAI
I I
I TENANT: (EXIST BLDG USE: REBID USE ZONE: R=1 (ISSUED ON: PROCESSED BY:
I IEXIST OCC GRP: _ 105/17/12 SR I
I I I
IOWNER: TEL NO: IBLDGS. NOW ON LOT: VALUATION: F AL TE FIN CODE:
(GREATER SAN GABRIEL VALLEY PROPERTY (626) 443-2993- 1 8,000
4333 N PECK RD
JEL MONTE CA 91732 FEES PAID DESCRIPTION OF WORK
REMOVE EXISTING ROOF DOWN TO DECK THEN INSTALL NEW ONE LAYER(
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: 130 YR CLASS "A" FIRE RATED COMPOSITION SHINGLES
APPLICANT: TEL. NO:
I CARMAN, ANTHONY (310) 527-0504- AA BLDG PERMIT ISSUANCE 27.80 1
12161 18TH 4104 1A STATE GREEN BLDG FEE 8000.00 VAL 1.00 (SPECIAL CONDITIONS: 1
TORRANCE CA 90504 IAC STRONG MOTION REBID 8000.00 VAL 0.80
�D2 PERMIT W/0 EN-HC 8000.00 VAL 183.00
I IFR INV WORK W/0 PERMIT 342.20 DOL 342.20
CONTRACTOR: TEL. NO: TOTAL FEES 554.80 APPROVALS DATE INSPECTOR SIGNATURE
CAL TOP ROOFING INC. (310) 527-0504-
12161 W 182ND ST LIC. NO LOCATION AND SETBACKS
14104 77244-C39
TORRANCE CA 90504 (SOILS ENGINEER APPROVAL
I
ARCHITECT OR ENGINEER TEL. NO: (FOUNDATION/TRENCH FORMS
LIC. NO: SLAB/UNDER FLOOR
RAISED FLOOR FRAMING
1 I I
MAP N0: SEWER NAP BOOK: PAGE: FIRE ZONE: CMP: I UNDERFLOOR INSOLATION
115OH273 3 001 1-1-
I I (FLOOR SHEATHING 1
ANO. OF FAMILIES: DWELLING UNITS: APT/COND: STAT CLASS: I -I-
0 NO 21 1 ," ROOP SHEATHING
SCHOOL WITHIN HAZARDOUS SHEAR PANELS
1AIR QUALITY: 1000 FEET MATERIALS _
NO NO NO FRAME INSPECTION
(FIRE SPRINKLER HANGERS
I I I
JINB ULATION/WEATHER STRIP(
11 I
IINTERIOR LATH/DRYWALL
I
EXTER IOR LATH
11 I 11 I I
RATED FLOOR/CEIL ASSEM.
RATED WALL ASSENBLIEB
I I 1RATED SHAFTS/OPENINGS I I I
I
I I 1T-BAR CEILINGS I I I
* ADDITIONAL DATA ON FILE I 1--i
ILOT DRAINAGE
IREPORT ID: DPR261 ROUTE TO: BS0508
t.