HomeMy Public PortalAbout8833 ELM AVE_Building__ WORKERS'COMPENSATION DECLARATION `®
I-hereby, affirm that I have a certificate.of consent to self O D M O D D
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insure, or a certificate of Wor rs' Compensation Insurance, LJ V O R v D Lod
U M V�. �LI V LI D
or a certified copy they 16c.1 ,.L.Lab.'C.)
Policy No. Company
�� _t_M0A)T_ COUNTY OF LOS•AWGELES BUILDINGANDSAFETY
BUILDINGCertified copy is hereby furnished. t FOR APPLICANT TO FILL'IN g
ADDRESS
Certified copy is filed with the county building inspec- BUILDING
Tion department. 'ADDRESS �"l •LOCALITY
_,,r,�!/ NEAREST`
Date i l_30 "applicant) 10 -.t=om` � CITY • t[�n�4 . y ZIP ii CROSS ST S"ate. \h
CERTIFICATE OF EXEMPTION FROM WORKERS', ASSESSOR SIZE OF LOT - '`TIOW ON LOT 1 MAP BOOK PAGE PARCEL
COMPENSATION INSURANCE •
(This section need,not be completed if.the permit is forone �7 ,y y/` USE ZONE. MA?
hundred dollars ($1,00)or less.) .' I TRACT: L� BLOCK '. L T NO. C/v .. NO..
I certify that in the performance of the work-for which thi's OWNER E. f�Ge �3i .� DISTRICT,E SPECIAL 9-
CONDfT10NS t3.
ermit is issued,;l shall not em to an erson in an manner �//�� Y //--yy q� GROUP TYPE" FIRE PROCESSED BY
so as to become subject to the Workers,Compensation Laws. _ ADDRESS (�/ /-'.i `j'1 CONST ZONE U
77� 0
Date Applicant CITY ZIP STATISTICAL CLASSIFICATION APT. CONDO.
NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL.
ENGINEER NO. CLASS NO.�=DWELL. UNITS_L.J_ LU
Exemption, .you should become subject to the Workers' d
Compensation provisions of the Labor Code, you must forth- ADDRESS. SEWER MAP N
with comply with,such provisions or.this permit shall• be z
deemed revoked. TEL. /l� BK-.,, PG - VALIDATION .
CONTRACTOR 9v D f PE <_SC7 - NO.��(G n®L7
LICENSED CONTRACTORS DECLARATION `i/ LIC.
I hereby'affirm'that I am licensed under provisions of Chapter 9 ADDRESS 94(D. M U� N0.3 7i VALUATION
(commencing with Section 7000)of Division 3 of the Business and LIC. j
Professions Code, and my license is in full force and effect. CITY' `SL CLASS 1 $
SQ. FT. NO."OF NO. OF CHECK
License Number 32 I -3 . rLic.Class t_ SIZE ; toO STORIES FAMILIES ONE
t� � V EAT SOrV 'f� T�i' NEW $
Contractor i r Date Z
DESCRIPTION OF WORK
ADD
am exempt under Sec. L( � e :�"e f�Z1DiP
ALTER E] FINAL,
B.&P.C. for this reason REPAIR DATE � •'
Date: .` USE OF DEMOC FINAL"
EXISTING.BLDG. By
Si, 10 APPLICANT hh TEL. / _
O ER-BUILDER DECLARAT_190N ��c' PRINT S'��J NO. eb L `
I hereby affirm that I am exempt from the Contractor's License (%4 J' /�_/)�A 56—
Low D
for the following reason (Section 7031.5,Business.and ADDRESS V w �l l
Professions Code):.
PRESENT
aBUILDING
I; as'own'er 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
7044,Business and Professions Code). y MOVING TEL..
I, as owner of:the property,'am excl usivelycontrocti rig ° CONTRACTOR NO.
with licensed contractors to construct the.project, ADDRESS
tion 7044, Business arid Professions Code). . '
REQUIRED -YARDTOTAL SETBACK FROM EXIST.
CONSTRUCTION-LENDING AGENCY SET BACK HWY PROP. LINE WIDTH
I hereby affirm that.there is a construction lending agency for. FRONT D
` the performance`of the work for which'this permit is-issued P.L.
(Sec. 3097, civ. C.). SIDE z 7'9 6 5 A
O iV 'PLL
v Lender's Name # 0101 o.'o o 1 '
P.C. Fee$ ` Permit Fee G�"'
Lender's Address _ 2 ° ° 9,7
I certifr that"I'have read this application and state"that the `zlIssuance Fee
°1.° o97.00x
above information is correct. I agree to comply with all County Investigation Fee x'
$ ordinances and'State-laws relating to building construction, Total Fee Q
u and hereby authorize representatives of this County to enter (,1,3 —82,L7 82.
upon the,�bo men n d•property for inspection purposes.
a, "� /9- -7j�I`-g7� SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date .Y �_
I
COUNTY 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 0111160034
PHONE: (626) 285-0488 EXT:
LEGA ID: NO. OF CONST BUILDING ADDR SS:
TR: 3623. LT: 100 SQ. FT STORIES TYPE- .8833 ELM AV
STRUCTURE: VN TEMP CA 917801807 A: H3
JASSESSOR NFORMA ION NUMBE : NEAREST CROSS STREET: AD
5387-010-029 THOMAS PAGE: 596 GR LOCALITY: TEMPLE CITY
TENANT: EXIST BLDG USE: RESID USE ZONE: R-3 ISSUED ON: PROCESSED BY: EXPIRES ON:
EXIST OCC GRP: 11/16/01 '- JK 05/15/02
OWNER: TEL. NO: BLDGS. NOW ON LOT: VALUATION: FINAL DATE F NAL BY: CODE:
WILLIAMSON THEODORE E;PATRICIA E (626) 447-0153- 2,500 21
1044 OAKDALE AV G
ARCD 910062222 FEES PAID DESCRIPTION OF WORK
STRIP OFF EXISTING OOF; REROOF W/ CLASS A 20YR RATED COMP
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: SHINGLE OVER EXIST. NG SHEATHING
APPLICANT: TEL. NO:
JAMES WRIGHT ROOFING (626) 914-9461- AA BLDG PERMIT ISSUANCE 27.75
1015. SAN JOSE DRIVE AC STRONG MOTION RESID 2500.00 VAL 0.50 SPECIAL CONDITIONS:
GLENDORA 91741 D2 PERMIT W/O_EN=HC2500.00 UAL 99.00
GELE�T ®FEES 127.25
CONTRACTOR: TEL. NO: APPROVALS�/� APPROVALS DATE INSPECTOR SIGNATURE
JAMES WRIGHT ROOFING (626) 914-9461-
101 S. SAN JOSE DRIVE LIC. NO LOCATION AND SETBACKS
GLENDORA, CA 91741 641827,C39
/ SOILS ENGINEER APPROVAL
N,
ARCHITECT OR ENGINEER: TEL. NO: FOUNDATION/TRENCH FORMS
LIC. N0: / 1111111 SLAB/UNDER FLOOR
L RAISED FLOOR FRAMING
MAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP:: (� (� n (} ��� (}/� UNDERFLOOR.INSULATION
150H261 3 u 01- U �I I \�J V l 11)I��`
U L����/// L/ ��J u u U v+ FLOOR SHEATHING
NO. OF FAMILIES: DWELLING UNITS: APT/CO D: STAT CLASS:-
NO 21 � ROOF SHEATHING
C
SCHOOL WITHIN HAZARDOUS
O D' '�"�i�t.�n - SHEAR PANELS
S' ('
AIR QUAALITY: 10N0 FEET MATERIALS FRAME INSPECTION
NO NO
0-
REQUIRED TOTAL SETBACK FROM EXIST4 ploQ� FIRE SPRINKLER HANGERS
SET BACK YARD: HWY: PROP LINE: WIDTH: %%� 1 FRONT PL- Se"viCe �$ INSULATION/WEATHER STRIP
�Ol
SIDE PL-
INTERIOR LATH/DRYWALL
EXTERIOR LATH
RATED FLOOR/CEIL ASSEM.
RATED WALL ASSEMBLIES
RATED SHAFTS/OPENINGS
T-BAR CEILINGS
LOT DRAINAGE
REPORT ID: DPR261 ROUTE TO: BS0508