HomeMy Public PortalAbout6013 GOLDEN WEST AVE_Building__ WORKERS' COMPENSATION DECLARATION
,{irisuretor afcertif cane of Workers' Compensation eInsuran nt to of APPLICATION FOR BUILDING PERMIT
4 a Certified copy thereof (Sec. 3800, Lab: C..) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
i
El Certified BUILDING
.copy is hereby furnished. " FOR APPLICANT TO FILL IN ADDRESS Lo
❑ Certified copy is filed with the county building inspec- BUILDING
tion department. ADDRESS C) Awt�Ef) ear SIE.
Date Applicant CITY—EL PLC- CI'—( ZIP q 1 t0 LOCALITY
r NO. OF BLDGS. NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT I X 00 NOW ON LOT CROSS ST.
COMPENSATION INSURANCE, ASSESSOR
(This section need not be completed if the permit is for one TRACT BLOCK LOT NO. MAP BOOK PAGE'S PARCEL
hundred dollars ($100) or.less.) TJ �
EL.
OWNER vi + [ NO.(%I$ "I USE ZONE MAP
J certify that in the performance of The work for which this NO.SPECIAL �
permit is issued, I shall not employ.a rson in any manner ADDRESS too j3 G oL r c 6. CONDITIONS
so as to become subject to The W ers' ompensation a s. `�/� /� O
CITY eM p d•-- lel j ZIP /' O C U
Date t — pplica ARCHITECT OR TEC.
NOTICE TO APPLICANT: If, after m ing this. Certificate of ENGINEER NO DISTR GROUPA TYPE FIRE RO 55 D BY O
Exemption, you should become subject to the Workers' COE ! U
Compensation provisions of the Labor Code, you must forth- ADDRESS
with comply with such revisions .or,thisN
p y p permit shall be TEL. STATISTICALC O r APT FON50. Z
deemed revoked. CONTRACTOR NO. _
LICENSED.CONTRACTORS DECLARATION LIC. CLASS NO. DWELL. UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO.
(commencing.with Section 7000).of Division 3,of the Business V LIC. SEWER MAP
and Professions Code,and my license is in full force and effect. CITY CLASS gK PG. VALIDATION
SQ. FT. NO. OF NO. OF CHECK
License Number Lic. Class SIZE STORIES ' FAMILIES ONE
- VALUAT ON
.Contractor Date DESCRIPTION OF WORKRoc,mUorno I-) NEW ❑ ,�
❑I am exempt under Sec. ADD
ALTER ❑
B.&P.C. for this reason REPAIR ❑ $
Date: USEOF
EXISTING BLDG. O DEMOL ❑
Signature APPLICANTTEL. FINAL
OWNER-BUILDER DECLARATION (PRINT)'I tI�R� NO.�Sj� r -"�.
I hereby affirm that I am exempt from the Contractor's License DATE
Law'for the following reason (Section 7031.5, Business and ADDRESS M7 FINA'
Professions Code): PRESENT B
❑ I, as owner of the property, or m employees with BUILDING Y ~! \ 17441 Ar
P P Y• YADDRESS _ 07 162.138
wages as their sole compensation,will do The work and
Oi �{y
8
the structure is not intended or offered for sale Section LOCALITY , �_ I .
7044, Business and Professions Code.) MOVING . ' TEL. 1 ITEM
I, as owner of theproperty,
am exclusively contracting i.
CONTRACTOR NO. TOTAL i� -��
�' """ —+
with licensed contractors to construct the project (Sec-
tion 7044, Business and Professions Code.) ADDRESS - 4Eirr i t?•'M
ED TOTAL SETBACK FROM EXIST.
CHECK 10
CONSTRUCTION LENDING AGENCY BACK YARD HWY PROP. LINE WIDTH ' �••����(^r
I hereby affirm that there is a construction lending agency for FRONT. trFAffiL- •�
the performance of the work for.which this permit is issued P.L.
(Sec. 3097, Civ. C.). IDE
P
Lender's Name 01M1 9/ 6/89
LDMA Ref. #. ... r� i �p� p iG
Lender's Address
P.C."Fee$ Permit Fee 1t5 ) , L3 1 FRI 7
1 certify that I have read this application and state that the Issuance Fee LDMA P/C#
above information is correct. I agree to comply with all County Investigation'Fee
8 ordina and State laws relating to building construction, Total Fee ,9 a LDMA Perm.#
and ereb authorize re
Lives of this County to enter
a , u n thk a ove`mentioerty fo�,inspe purpdses.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Si aur of Applicant or'Age ' Date I
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 BUILDING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS RESIDENTIAL ADD/ALT/REP
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 BL 0508 0302120050
PHONE: (626) 285-0488 EXT:
LEGAL ID: NO. OF CONST NEW BUILDING ADDRESS:
TR: 6561 LT: 94 SQ. FT STORIES TYPE OCCUP GROUP 6013 GOLDEN WEST AV
STRUCTURE: 490 1 VN R3 TEMP CA 917801719
ASSESSOR INFORMATION NUMBER: GARAGE: NEAREST CROSS STREET: WOODRUFF
5385-019-010 OTHER: 59 1 VN U1 THOMAS PAGE: 597 GRID: A2 LOCALITY: TEMPLE CITY
TENANT: EXIST BLDG USE: USE ZONE: ISSUED ON: PROCESSED BY: EXPIRES ON:
EXIST OCC GRP: 02/25/03 JK 02/20/04
OWNER: TEL. N0: BLDGS. NOW ON LOT: VALUATION: FINIL DATJI ' CODE:
SAPIA DANNY K;TERESA L (626) 287-1032- 45,000
6013 GOLDEN WEST AV
TEMP 917801719 FEES PAID DESCRY 01
F WORK
CONVERT EXISTING LIVING RM TO BDRM, ADD BDRM & LIVING RM
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: ADD FRONT PORCH
APPLICANT: TEL. NO:
SAME AS OWNER - B1 PLANCHECK W/ENERGY 45000.00 VAL 684.84
AA BLDG PERMIT ISSUANCE 27.75 SPECIAL CONDITIONS:
AC STRONG MOTION RESID 45000.00 VAL 4.50
B2 PERMIT W/ENERGY 45000.00 VAL 805.70
TOTAL FEES 1,522.79
CONTRACTOR: TEL. NO: APPROVALS DATE INSPECTOR SIGNATURE
SAME AS OWNER
LIC. NO LOCATION AND SETBACKS
SOILS ENGINEER APPROVAL
ARCHITECT OR ENGINEER: TEL. NO: FOUNDATION/TRENCH FORMS
0�A
LIC. NO: SLAB/UNDER FLOOR
RAISED FLOOR FRAMING
MAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP: UNDERFLOOR INSULATION
3 01
ST LEVEL FLOOR SHEATH
NO. OF FAMILIES: DWELLING UNITS: APT/COND: STAT CLASS:
NO 21 2ND LEVEL FLOOR SHEATH
SCHOOL WITHIN HAZARDOUS ROOF SHEATHING
AIR QUALITY: 1000 FEET MATERIALS
NO NO NO FIRE DEPT. FRAME INSPECT
REQUIRED TOTAL SETBACK FROM EXIST BLDG DEPT. FRAME INSPE Lr
SET BACK YARD: HWY: PROP LINE: WIDTH:
FRONT PL- SHEAR PANELS
SIDE PL-
INSULATION/WEATHER STR
INTERIOR LATH/DRYWALL
EXTERIOR LATH
LOT DRAINAGE
SMOKE DETECTION DEVICES
FIRE DEPARTMENT APPROVAL
REPORT ID: DPR261 ROUTE TO: BS0508