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HomeMy Public PortalAbout4509 FIESTA AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76M444 MISCELLANEOUS APPLICATION I hereby affirm that 1 have certificate of consent to self CE 875 (2-80)COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers' rs'Compensation Insurance,or a certified copy thereof(Sec. 3800,Lab.C.) Policy No. Company FOR APPLICANT TO FILL IN BUILDING ADDRESS ❑ Certified copy is hereby furnished. BUILDING LOCALITY ADDRESS ❑ Certified copy is filed with the county building inspection NEAREST department. LOCALITY CROSS ST. - -- Date Applicant NEAREST DISTRICT NO. I GROUP TYPE PROCESSED BY >_CROSS ST. C, NST. EL CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL Q COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY U NO. (CIRCLE) STATE MAJOR SECOND LOCAL w NO. OF BLDGS. (This section need not be completed if the Work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS J by the permit is for one hundred dollars ($100) or less.) LL OF SIZE OF LOT EXISTING BLDG. I certify that in the performance of the work for which this _ } permit is issued, I shall not employ any person-.in any manner OWNER t}e so as to become subject to the Workers' Comp(*sation Laws. MAIL -. OCCUPANCY GROUP •�: � ADDRESS 0 Date �" Applicant .. - ..-. '-TEL. d NOTICE TO APPLICANT: If, after making this Certificate of CITY No. OCCUPANT LOAD Exemption, you should become subject to the Workers' LU APPLICATION FOR EXIT HARDWARE: f' Compensation provisions of the Labor Code, you must forth- with comply with such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION deemed revoked. ❑ No Spec. Knowl. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices ❑ I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) NO. OF EXITS ❑ 9 (commencing with Section 7000) of Division 3 of the Busi- ness and Professions Code, and my license is in full force and effect. PARKINGSPACES REO D O PROVIDED D 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 INSPECTORS acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE iness and Professions Code). FINAL APPROVAL PRESENT USE OF BUILDING I Lic.or Reg.No. Date ` HOME OWNER-BUILDER DECLARATION NO.OF EXISTING BUILDINGS 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 SPACES PROVIDED I, as owner of the property, will do the work and the structure is not intended or offered for sale (Section 7044, Business and Professions Code). PROPOSED USE OF BUILDING CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued(Sec. 3097,Civ.C.). Lender's Name PROPOSED MAX. OCC. Lender's Address PERMIT FEE _ I certify that I have read this application and state that the above information is correct. I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter TOTAL FEE _� J upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date WORKERS'COMPENSATION DECLARATION CE 875(2-80) IVB I SC E L LA•N EO U S APPLICATION `ry I t ,y af3cert that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insu!�, or a certificate of Workers'Compensation Insurance,or ' a certified copy thereof(Sec. 3800,Lab. C.) Policy No. Company FOR APPLICANT TO FILL IN BUILDING - Ffj IZ J / -/�/,/� {j ' ADDRESS � (� ❑ Certified copy is hereby furnished. BUILDING i —�, `/' �. 7 " i� LOCALITY 1•'/`=h , �3 �:• e ADDRESS (/ G. J / /T I+- G- ,NI /— ❑ Certified copy is tiled with the county building inspection NEAREST y department. LOCALITY `= G �" cRoss sT. IVG l Date Applicant NEAREST DISTRICT NO. G UP TYPE CROC SSED BY CROSS ST. L© �' A? 4 � (3 ' CONST. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL 7V1 COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP �/ ) HIGHWAY } NO. Q`r{,//� (CIRCLE) STATE MAJOR SECOND LOCAL a NO. OF BLDGS. O (This section need not be completed if the Work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS V by the permit is for' one hundred dollars ($100) or less.) NO of SIZE OF LOT EXISTING BLDG. Cr I certify that in the performance of the workK which this 0 permit is issued, I shall not employ any persony manner OWNER U so as to become subject to the Workers' Com MAIL /r/ [�_ OCCUPANCY GROUP �, tL ADDRESS ��' ! l iJ /� 1/' ���111��` N„ Date-1� Applicant I/ G NOTICE T APPLICANT: I , after making this Certificate of CITY �E� OCCUPANT LOAD z Exemptio you should become subject to the Workers' APPLICATIOIN FOR EXIT HARDWARE: Compensation provisions of the Labor Code, you must forth- with comply with such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION ❑ ❑ No Spec. Knowl. ❑ deemed revoked. Panic DeVICES ElLICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) NO. OF EXITS 9 (commencing with Section 7000)of Division 3 of the Busi- ness and Professions Code, and my license is in full forceandPARKING effect. SPACES REQ'D PROVIDED LTJ 1� License Number Lie.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 SIG ATURE iness and Professions Code). PRESENT USE OF BUILDING FINAL APPROVAL _ Lie,or Reg.No. Date Ala `�. HOME OWNER-BUILDER DECLARATION Ko•OF AXID U G BUILDINGS ON LOT AND U E , 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 SPACES PROVIDED I, as.owner of the property, will do the work and the . structure is not intended or offered for sale (Section 7044, Business and Professions Code). PROPOSED USE OF BUILDING - CONSTRUCTION LENDING AGENCY 2231.3A I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is 0 9 ,30 issued (Sec. 3097,Civ.C.). Lender's Name PROPOSED MAX. OCC. 8 Q.5 0 Lender's Address — PERMIT FEE ' 06 o 0 0 8 Q 5 0 I certify that I have read this application and state that the v above information is correct.I agree to comply with all County ISSUANCE FEE �j/� '0 6 2 4 8 5 ordinances and State laws relating'to building construction, TOTAL FEE' and hereby,authorize representatives of this County to eater upon the above-mentioedd, 'roperty for inspection purposes• SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MISCELLANEOUS PERMIT DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS MP 0508 0307020002 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE: (626) 285-0488 EXT: LEGAL D: NO. OF CONST NEW BUILDING ADDRESS: TR: 12998 LT: 32 SQ. FT STORIES TYPE OCCUP GROUP 4509 FIESTA AV STRUCTURE: 550 1 VN R3 TEMP CA 917804210 ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET: LOWER AZUSA 8592-002-031 EXIST BLDG USE: THOMAS PAGE: 597 GRID: A5 LOCALITY: TEMPLE CITY EXIST OCC GRP: USE ZONE: TENANT: ISSUED ON: PROCESSED BY: EXPIRES ON: BLDGS. NOW ON LOT: VALUATION: 07/02/03 JK 12/29/03 3,000 OWNER: TEL. NO: FINAL DATE CODE: CONSOLI BETTE A (626) 286-5507- LIST ITEMS: 4509 FIESTA AV EXPIRED TEMP 917804210 DESCRIPTION OF WORK LEGALIZE ADDITION OF FAMILY ROOM IN REAR OF HSE;REROOF AREA; OCCUP LOAD EXIST: REPLACE ANY DRYROT DAMAGE; INSULATE; C/O ENTRY DOOR APPLICANT: TEL. NO: OCCUP LOAD NEW: SAME AS OWNER (626) 354-2526-CELL PARKING SPACES REQUIRED: SPECIAL CONDITIONS: KEVIN KRESSLY �5�'L� �^ �AePARKING 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. NO: 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 N0. OF FAMILIES: DWELLING UNITS: APT/COND: 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 , I