HomeMy Public PortalAbout5616 GOLDEN WEST AVE_Building__ WORKERS' COMPENSATION DECLARATION
ser affcthat I havecertificate of consent to self A P P li I.CATION FOR BUILDING PERMIT
insure`,
o or o certificate of Workers' Compensation Insurance, P
or a certified copy thereof (Sec..3800, Lab. C.) C66NTY OFtOS�A#GELAS � � BUILDING AND SAFETY
Policy No. Company
BUILDING
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS
❑ Certified copy is filed with the county building inspec- BUILDING
tion department. ADDRESS d
CITY:_• L ZIP 7 a LOCALITY
Dare Applicant NO.•OF BLDGS.
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LO7 (7 'A Z) NOW ON LOT NEAREST
CROSS ST.
COMPENSATION INSURANCE ASSESSOR 2
(This section need not be completed if the permit is for one TRACT BLOCK LOT NO. MAP BOOK Qa PAGE �Xs PARCELe-PIo
hundred dollars ($100) or less.) TEL. 7 USE ZONE MAP Al,
OWNER NO.' �/of
I certify that in the performance of the work for which this NO.
permit is issued, I shall not employ any person-in any manner ADDRESS ° 0L 6A) i� SPECIAL d
CONDITIONS O
so as to become subject to the Workers' Compensation Laws.
CI ^ G V
TY ZIP
Date Applicant ARCHITECT OR ` t TEL,2/ Q
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER N �1 Q -W NO 2 DISTRICT GROUP TYPE FIRE PROCESSED BY O
CONST. ZONE
Exemption, you should become subject to The Workers' w
Compensation provisions of The Labor Code, you must forth- ADDRESS f} J = 3 o..
with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION APT. CONDO. to
deemed revoked. CONTRACTOR NO.
/ Z
LICENSED CONTRACTORS DECLARATION uC. CLASS NO. 40 DWELL. UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS O.
(commencing with Section 7000)of Division 3 of the Business LIC. SEWER MAP
and Professions Code,and my license is in full force and effect. CIT - CLASS BK. PG. Q VALIDATION
SQ. FT / NO. OF . NO. OF CHECK
License Number Lic. Class SIZE .S 3(po STORIES FAMILIES ONE j
VALUATION _
Contractor Date DESCRIPTION OF WORK NEW ` Hi•C{ va
�+ ADD E9 -.;..
Elam exempt under Sec. pop- ,130 1 4
B.&P.C. for this reason ALTER ❑ st® f
• REPAIR ❑ $ i tTEi tES i
Date: USE OF
EXISTING BLDG. DEMOL ED ,OTAL•• 1D1134.=t'
APPLICANT TEL.
Signature (PRINT) NL FINAL �•1# 1f 1•�Z161 o:7_
OWNER-BUILDER DECLARATION. DATE /Z"/ '� 3
I hereby affirm that I am exempt from the Contractor's License
Law for the-following reason (Section 7031.5, Business and ADDRESS V' _ - FINAL 3307 10-3.1it
t
Pjfessions Code): PRESENT By ��
LTJ I, as owner of the property, or m employees with BUILDING : boolo_00 r•i•y,• +AL
P P Y+ YADDRESS �; �1 ��•� .iv.
wages as their sole compensation,will do The.work and A 4 ,s.-
the structure is not intended or offered for sale(Section LOCALITY ► 'O'1t`t�p� i AM 10:j-6
7044, Business and Professions Code.) MOVING TEL. 3307
❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO.
with licensed contractors to construct the.project (Sec- ADDRESS E�•-�''�R
_
0 . ^^
tion.7044, Business and Professions.Code.) t
REQUIRED TOTAL SETBACK FROM EXIST. __,
CONSTRUCTION LENDING AGENCY SET BACK YARD. HWY PROP. LINE WIDTH � 'tC'! +'SC
I hereby affirm that there is a construction lending agency for FRONT 3307 1 5.2.25
the performance of the work for.which this.permit is issued P.L.
(Sec. 3097, Civ. C.). SIDE t t �
Lender's Name, P.I. AULT
Lender's Address P.C. Fee$ v�JOT Permit Fee LDMA Ref. # :+il ( y081.l l i
0 3 ITEM"
1 certify that I have read this application and state that the A41019, Issuance FeePilo
LDMA P/C#
8 above information is correct. I agree to comply with all County Investigation Fee OTAL t
d ordinances and State laws relating to building construction, Total Fee �s� LDMA Perm. #
a and hereby authorizer resentatives of this County to enter Ci�E�;i
�
aD u the above- enti d property for inspection purposes.
CHANGE
pt it
SEE REVERSE FOR EXPLANATORY LANGUAGE � 6 '
SigrdiLure of Applicant or gent Dat 1 J
r •rY�. �E1"Ifl''�—i'i!'if't9 t 1i:,s iD'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 1101200004
PHONE: (626) 285-0488 EXT:
(LEGAL ID: NO. OF CONST 1 BUILDING ADDRESS: 1
ITR: 11131 LT: 16 SQ. FT STORIES TYPE ( 5616 GOLDEN WEST AV 1
I ISTRUCTURE: 800 V-B TEMP CA 917802520
(ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET:
18588-012-026 1 THOMAS PAGE: 597 GRID: A3 LOCALITY: TEMPLE CITY, Cl
(TENANT: (EXIST BLDG USE: RESID USE ZONE: R-1 (ISSUED ON: PROCESSED BY: 1
1 IEXIST OCC GRP: 101/20/11 SR
1OWNER: TEL. NO: JBLDGS. NOW ON LOT: VALUATION: IFINAL DATE FI AL BY: CODE: 1
IZENG, YANLIN (213) 327-7723- 1 1,500
15616 GOLDEN WEST AV i I '�� I
ITEMP 917802520 FEES PAID ID SCRIPTION OF WORK
I I IREPAIR LEAKING ROOF LAYER OVER TO PARTIAL ONE SIDE OF THE
I IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT: IHOUSE ROOF SOUTHSIDE I
(APPLICANT: TEL. NO: I I
(SAME AS OWNER - IAA BLDG PERMIT ISSUANCE 27.80 1
JAB STATE GREEN BLDG FEE 1500.00 VAL 1.00 ISPECIAL CONDITIONS:
JAC STRONG MOTION RESID 1500.00 VAL 0.50 1
ID2 PERMIT W/O EN-HC 1500.00 VAL 82.20
JFR INV WORK W/O PERMIT 257.00 DOL 257.00 1
CONTRACTOR: TEL. NO: TOTAL FEES 368.50 1APPROVALS DATE INSPECTOR SIGNATURE
ISAME AS OWNER I
I LIC. NO 1 (LOCATION AND SETBACKS I I I
(SOILS ENGINEER APPROVAL I
JARCHTTECT OR ENGINEER: TEL. NO: I (FOUNDATION/TRENCH FORMS
1 LIC. NO: 1 JSLAB/UNDER FLOOR
I I I
I I IRAISED FLOOR FRAMING 1 1
IMAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP: J JUNDERFLOOR INSULATION I I
1147H269 3 001 _ I
I I IFLOOR SHEATHING
INC. OF FAMILIES: DWELLING UNITS: APT/COND: STAT CLASS: I I I I I
1 NO 21 1 IROOF SHEATHING I I
SCHOOL WITHIN HAZARDOUS (SHEAR PANELS
JAIR QUALITY: 1000 FEET MATERIALS I
1 NO NO NO 1 IFRAME INSPECTION 1
IFIRE SPRINKLER HANGERS 1
I JINSULATION/WEATHER STRIPI I
I 11NTERIOR LATH/DRYWALL I I
(EXTERIOR LATH
IRATED FLOOR/CEIL ASSEM.
(RATED WALL ASSEMBLIES I I
RATED SHAFTS/OPENINGS 1
I 1 I I I I
J IT-BAR CEILINGS
J ILOT DRAINAGE
I I I I I I
1 IREPORT ID: DPR261 ROUTE TO: BS0508 I
I I I I I