HomeMy Public PortalAbout4817 HALLOWELL AVE_Building__ . VyQRKERS' COMPENSATION DECLARATION
' I hereby affirm that•1 have a certificate of consent to-self
insure; or a certificate of Workers' Compensation Insurance, APPLICATION FOR BUILDING PERMIT
or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
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❑ Certified copy is hereby furnished. FOR APPLICANT TO FI BUILDING ADDRESS Q Lo
&A (i(,�
❑ Certified copy is filed with the county building inspec- BUILDING !
tion department. AD
DRESSCf'i `^,
Date Applicant CITY' ZIP LOCALITY E7 `�
NO. OF BLDGS. NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT ( O 7.7 NOW ON LOT CROSS ST.
COMPENSATION INSURANCE j ASSESSOR
(This section need not be completed if the permit is for one TRACT 1 J 1 BLOCK LOT NO. (d MAP BOOK PAGE PARCEL
hundred dollars ($100) or less.) AJ TEL.
OWNE o(J NO. USE ZONE MAP
I certify,that in the performance of the work for which this SPE
permit is issued, I shall not employ any person in any manner ADDRESS• .0 �� CONDITIONS D_
so as to become subject to the Workers'Compensation Laws. O
CITY M 6/V ZIP If 17
Date Applicant ARCHITECT OR 9 TEL. DISTRICT GROUP TYPE FIRE PROCE D BY
NOTICE TO APPLICANT: If,,after 'making this Certificate of ENGINEER C / NO. CONS E
Exemption, you should become subject to the Workers' C5� / CL
Compensation provisions of the Labor Code; you must forth-, ADDRESS S '-� ` J w
with comply with such provisions or this permit shall be TEL. TION A DO. 'I)deemed revoked. CONTRACTOR d(J NO. Z—
LICENSED CONTRACTORS DECLARATIONLIC. 3 j die) CLASS NO. DWELL. UNITS
—
I hereby affirm that I am licensed under provisions of Chapter 9 . ADDRESS � �� S, /G<s O.
SEWER MAP
(commencing with Section 7000)of Division 3.of the Business LIC. bb
and Professions Code,and my license is in full force and effect. . CITY CLASS p BK PG �-J VALIDATION
SQ. FT. NO. OF NO. OF CHECK ACCT.
License Number Lic.-Class SIZE Z STORIES FAMILIES ONE r-C t ,Y
DESCRIPTION OF WORK �p �rI�VI NEW ❑ VALUATION `Vit% Jv, )
Contractor Date e• - ADD ❑ $ � � ��
❑I am exempt under Sec. y�-�y
JJC LQ R x c ITEMS► _
B.BP.C. for this reason ( 1( $LTER ED]
9'911L• -�'
• � REPAIR ❑ �._,� .Z3.
Date: USE OF CHECK ••t., 4,.r:1
EXISTING BLDG. DEMOL ❑
Signature
o APPLICANT
(PRINT) NO. FINAL CHANGE 'LI)
OWNER-BUILDER DECLARATION. DATE
/'3/
I hereby affirm that I am exempt from.the Contractor's License
Low for the following reason (Section 7031.5, Business and ADDRESS FINAL
1_71 i1}j €_
Professions Code): PRESENT BY �!"
IIG�T BUILDING 9026 PM1 tiFlI, as owner of The property, or my employees with ADDRESS
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section LOCALITY
s
' 7044, Business and Professions Code.) _
CONTRACTOR NO. 3
r7MOVING TEL.
1, as owner of the property, am exclusively contracting
ACt:(tea
with licensed contractor's to construct,the project (Sec-
ADDRESS V ", �'
tion 7044, Business and Professions Code.) t,;* t ~.x`07 6''3.
REQUIRED- TOTAL SETBACK FROM EXIST.
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH 1 ITEM
I hereby affirm that there is a construction lending agency for FRONT
the performance of the work for which this permit is issued P L. TOTAL i)AL 65.,E= 26
(Sec. 3097, Civ. C.). SIDE .
P.L. -C PECK 5Jni6
Lender's Name _
i LDMA Ref. # - i. l' �� ,;t,i
P.C. Fee$ � Permit Fee rE
3 Lender's Address
0 1 certify that I have read this application and state that the Issuance Fee 3 L00 LDMA P/C#
above informal' n is correct. I agree to comply with all-County Investigation Fee- OWL: 9.!�j :S� 'i 1 T%i
8 ordinances a d State laws relating to building construction, Total Fee ILDMA Perm. #
Q and hereb"authorize r presentatives of This County to enter it c 4 `
upon he bove-ment' ed property for=nspection urpose .
a
O •V SEE REVERSE FOR EXPLANATORY LANGUAGE
e5elodUre-of p icon or Agent Date
Z, 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 0807090036
PHONE: (626) 285-0488 EXT:
ILEGAL ID: I NO. OF CONST BUILDING ADDRESS:
ITR: 15098 LT: 6 I SQ. FT STORIES TYPE 1 4817 HALLOWELL AV
ISTRUCTURE: V-B I TEMP CA 917803457
(ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET: 1
18585-016-014 I I THOMAS PAGE: 597 GRID: C5 LOCALITY: TEMPLE CITY, Cl
(TENANT: (EXIST BLDG USE: RESID USE ZONE: R-2 (ISSUED ON:. PROCESSED BY: EXPIRES ON: I
(EXIST OCC GRP: 107/09/08 SR 01/05/09
(OWNER: I �NAL DATE FIN Y: CODE:
TEL. N0: 1BLDG5. NOW ON LOT: � VALUATION: �/g1KHAN, DEBRA (626) 442-0556- i 4,000 - 1 �/
4817 HALLOWELL AV 1
ITEMP 917803457 I FEES PAID DIESCRIPTION OF WORK 1
IBATHROOM REMODEL MINOR DRY WALL PATCHING IN BATH, LIVING I
IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT: IROOM AND BEDROOM 1
(APPLICANT: TEL. NO: I I 1
(UNIVERSAL REMODELING (888) '343-9111- IAA BLDG PERMIT ISSUANCE 27.75 I 1
19135-A RESEDA BLVD. IAC STRONG MOTION RESID 4000.00 VAL 0.50 ISPECIAL CONDITIONS: I
INORTHRIDGE CA 91324 IB2 PERMIT W/ENERGY 4000.00 VAL 127.38
I 1 TOTAL FEES 155.63 1
ICONTRACTOR: TEL. NO: I (APPROVALS DATE INSPECTOR SIGNATURE I
(UNIVERSAL REMODELING, INC. (818) 285-6939- 1 1 1
19135-A RESEDA BLVD., SUITE 195 LIC. NO ILOCATION AND SETBACKS
INORTHRIDGE, CA 91324 617830B 1 1 I I I
I 1 ISOILS ENGINEER APPROVAL I 1 1
1ARCHITECT OR ENGINEER: TEL. NO: (FOUNDATION/TRENCH FORMS I I
LIC. NO: 1SLAB/UNDER FLOOR
. I (RAISED FLOOR FRAMING I 1
IMAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP: ( 1UNDERFLOOR INSULATION I I I
1144H273 3 011 1 11 I
I I IFLGOR SHEATHING I I I
INC. OF FAMILIES: DWELLING UNITS: APT/COND: STAT CLASS: I I I I I
1 NO 21 1 IROOF SHEATHING I 1 I
I I I I I I
1 SCHOOL WITHIN HAZARDOUS 1 ISHEAR PANELS 1 1 I
1AIR QUALITY: 1000 FEET MATERIALS 1 I I I 1
NO NO NO I IFRAME INSPECTION I 1
IREQUIRED TOTAL SETBACK FROM EXIST I IFIRE SPRINKLER HANGERS I I
ISET BACK YARD: HWY: PROP LINE: WIDTH:
I
IFRONT PL- 1 (INSULATION/WEATHER STRIPI I I
SIDE PL- I
I 11NTERIOR LATH/DRYWALL 1 I
I IEXTERIOR LATH I I I
IRATED FLOOR/CEIL ASSEM. I 1
1 I IRATED WALL ASSEMBLIES I
I 1 IRATED SHAFTS/OPENINGS 1 I
1 1 IT-BAR CEILINGS 1 1
1 1 ILOT DRAINAGE I 1 1
I IREPORT ID: DPR261 ROUTE TO: BS0508 I I
I I I I I I