HomeMy Public PortalAbout11011 GREEN TREE LN_Building__ WORKERS'COMPENSATION DECLARATION
I+ urey affirm that I havecertificate of consent to self A P P L I CATION F O R ,B U I L.D I N G -PERMIT C
insure,
, or a certificate of Workers' Compensation Insurance,
or a certified copy thereof (Sec. 3800, La )
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy N ompany
❑ Certified copy is tereby furnis ed. FOR APPLICANT TO FILLJN BUILDING
ADDRESS A- `(,/k/
yl� ertifiecl copy is,filed with the county building inspe - BUILDING
tion'department. � ADDRESS
Date Applican = CITY ZIP ##2^::� LOCALITY c �.
CERTIFICATE OF EXEMPTIO ROM WORKERS' NO. DF BLDGS. /� NEAREST
COMPENSATION INSURANCE', ' SIZE OF LOT �xJ .NOW ON LOT `/ CROSS ST.
(This section_need not be completed if the permit is for one TRACT ��/ BLOCK LOT NOASSESSOR_
hundred dollars ($100)or less.) MAP BOOK PAGE PARCEL
OWNER n USE Z NE MAP //�� -�
I'certify that in the performance'of the work for which this `� I NO. O L }
permit is issued, I shall not employ any person in any manner ADDRESS + �J � SPECIAL �
so as to become subject to the Workers'Compensation Laws. / CONDITIONS 0
CITY ' ZIP Q�O
Date_'. '_ Applicant ARCHITECT OR O
NOTICE TO APPLICANT: If, after making this Certificate of — DISTRICT GROUP 'TYPE FIRE PROC SSED BY
Exemption, '.you should become subject to' the Workers' ENGINEER �( CONST. ZONE V
Compensation provisions of the Labor Code, you must forth- S�Jb 3 9L
with -comply,with such provisions or this permit shall be ADDRESS V- . y
deemed revoked.-. TELSTATISTICAL CLASSIFICATION APT. CON Z
CONTRACTOR NO.
LICENSED CONTRACTORS DECLARATION Ll cj yrr CLASS NO. DWELL, UNI7S
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS Nf�F
(commencing with Section 7000)of Division 3 of the Business and LIC. SEWER MAP
Professions Code, and'my license'is in full force and effect. CITY CLASS 4tv BK PG _ I '` ' VALIDATION
SQ. FT. I� NO. OF NO. OF CHECK
License Number Lic.Class SIZE �(� STORIES FAMILIES ONE
LUATION._
Contraci9w,/ _- lLry � Date DESCRIPTION OF WORK NEW
ADD [:]El1 am exempt under Sec. I
ALTER ❑ , 2 1 1.8A
B.BP.C. for this reason REPAIR ❑ $ 06 # 0 0 o 0 2 3
Date"' USE OF
EXISTING BLDG. DEMOL ❑
Signature APPLICANT TEL. FINAL I a 3 9 4,9 4
OWNER-BUILDER DECLARATION (PRINT) NO. DATE " r:
I hereby affirm that-I am exempt from the Contractor's License - a 03,9 4 9 45
Law for the following reason (Section 7031.5, Business and ADDRESS FINAL
Professions Code): PRESENT BY 43-0-8 5
BUILDING
❑ I, as owner 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 ' zG 2 1 LI 9 A
7044, Business and Professions Code). ' MOVING TEL.
❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO. # 0 0 0 0 0 1 .
with'licensed contractors to construct the project (Sec-. FADDR - I b 4 U 2 5
tion 7044, Business and Professions Code).
D._ TOTAL SETBACK FROM EXIST..
CONSTRUCTION LENDING AGENCY K YARD HWY PROP. LINE WIDTH o^�a 6.4 4 2 5 5
I hereby affirm that there is a construction lending agency for l� 3 O_8Jr•the performance of the work for which this permit is issued(Sec. 3097, Civ. C.). -
Lender's NameLDMARef. #
Lender's Address Permit Fee33 �'> Q +.I certify that I have read this application and.state that thel Issuance FeeLDMA P/C#
above information is correct. I agree to comply with all County on ee
ordina ces and State law relating to building construction,
Total Fee LDMA Perm. #
u and
by auth e r r se fives of this County to enter
up a above ti e p perty for inspection purposes.
�- .7 7
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date - (k
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 BUILDING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS DEMOLITION
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 BL 0508 1110130105
PHONE: (626) 285-0488 EXT: DUPLICATE
ILEGAL ID: NO. OF CONST BUILDING ADDRESS: 1
ITR: 43111 LT: 3 SQ. FT STORIES TYPE 11011 GREEN TREE LN
I (STRUCTURE: 1 TEMP CA 917803676
(ASSESSOR INFORMATION NUMBER: 1 1 NEAREST CROSS STREET: SANTA ANITA
18573-031-054 I THOMAS PAGE: 597 GRID: D3 LOCALITY: TEMPLE CITY, Cl
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(TENANT: (EXIST BLDG USE: SPA USE ZONE: (ISSUED ON: PROCESSED BY:
IEXIST OCC GRP: 110/13/11 SR
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(OWNER: TEL. NO: IBLDGS. NOW ON LOT: VALUATION: (FINAL DATE FINAL BY: CODE: 1
(JUNG, MIN CHU (626) 579-3525- 1 0 r I
111011 GREEN TREE LN 1 IIh:p�AI Y
ITEMP 917803676 1 FEES PAID 6EStRIP=0N'OR WORK 1
I I IPARTIAL REMOVAL OF IN GROUND SPA FILL IS UN-COMPACTED AND
I IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT: INOT SUITABLE FOR BUILDINGS
(APPLICANT: TEL. NO: I I I
ISAME AS OWNER - JAA BLDG PERMIT ISSUANCE 27.80 1 1
1 102 DEMOLITION INSPECTN 163.60' ISPECIAL CONDITIONS: 1
TOTAL FEES 191.40 (RESTRICTED AREA ON SITE, NOT SUITABLE FOR BUILDING
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(CONTRACTOR: TEL. NO: I (APPROVALS DATE INSPECTOR SIGNATURE
ISAME AS OWNER - I I I
I LIC. NO 1 1PEDESTRIAN PROTECTION
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ISEWER DISCONNECTION
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(ARCHITECT OR ENGINEER: TEL. NO: 1 (ABANDON PRIVATE DISPOSALI I I
I - 1 11
LIC. NO: IUNDERGRND STRUCT REMOVALI II
I (AND SOIL RECOMPACTION
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IMAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP: (
11 150H277 001 f v ILu
INO. OF FAMILIES: DWELLING UNITS: APT/COND: STAT CLASS: I I
0 NO 24 1 1 1
1 SCHOOL WITHIN HAZARDOUS I
(AIR QUALITY: 1000 FEET MATERIALS I I I
NO NO NO
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(REPORT ID: DPR261 ROUTE TO: BS0508
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