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HomeMy Public PortalAbout4901 HALLOWELL AVE_Building__ WORKERS' COMPENSATION DECLARATION hereby affirm that I have a certificate of consent to Self APPLICATION F O BUILDING PERMIT, insure, or a certificate of Workers'Compenstion Insurance, or t a.certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES 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 `(k tion department. ADDRESS � + LOCALIT "- NEAREST Date Applicant CITY ` �+ ('16 ,ZIP CROSS ST. CERTIFICATE OF EXEMPTION FROM WORKERS' a "4 NO. OF BLDGS. ASSESSOR COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK IPAGE PARCEL (This section need not be completed if the permit is for one '�`�� US ZOy E. MAP hundred dollars ($100)or less.) TRACT` .,I\ BLOCK LOT NO. w kil TEL SPECIAL OWNER (% ��� - NO. '` CONDITIONS I certify that in the performance of the work for which this ]" STRICT GROUP TYPE / FIRE SED BY k® permit is issued, I shall not employ any person in any manner ADDRESS y� le- '� \ L?7A s Y , CONST. / Z so as to become.subject to the Workers'Compensation Laws. _/J /Qi• lam/ CITY km � +f• ZIP �, �`�. Date Applicant TEL STATISTICAL CLASS�JCATION APT. CONDO. U NOTICE TO APPLICANT: If, after makingthis Certificate of . ARCHITECT OR r �!S�/ U ENGINEER F i ey�J NO. CLASS NO. DWELL. UNITS 9L Exemption, you should become subject to the Workers' ta Compensation provisions of the Labor Code, you must forth- ADDRESS SEWER MAP _Z with comply with such ,provisions or this permit shall be TEL. deemed revoked. CONTRACTOR \ NO BK. PG, VALIDATION LICENSED CONTRACTORS DECLARATION LIC. I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. VALUATION (commencing with Section 7000)of Division 3 of the Business and LIC. ` Professions Code, and my license is in full force and effect. CITY CLASS $ SQ. FT. NO. OF NO. OF CHECK License Number Lic. Class SIZE STORIECS FAMILIES ONE a DESCRIPTION OF WORK rii •� ��rIrO;, c NEW El $ Contractor Date ( t ADD FI am exempt from the licensing requirements as I am a � J(jii i/A �.�-� licensed architect or o registered professional engineer ALTER E] FINAL ❑ DATE acting in my professional.capacity (Section 7051, REPAIR Business and Professions Code). USE OF FINAL EXISTNG BLDG. DEMOL By ✓' L Lic. or Reg. No. Date APPLICANT TEL. OWNER-BUILDER DECLARATION (PRINT) NO. I hereby affirm that I am exempt from the Contractor's License Law for the-following reason (Section 7031.5, Business and ADDRESS Prof? ns'Code): _ _ PRESENT - BUILDING I, as owner of the property, or my employees with ADDRESS wages as their sole compensation, will do the work and z 0 8 1,3 A the structure is not-intended or offered for sale"(Section LOCALITY 7044, Business and Professions Code). MOVING TEL. # o 0.0,0,0 1 l I,as owner of the property,-am exclusively contracting CONTRACTOR NO. with licensed contractors to construct the project (Sec- ADDRESS 2 o o 4 3.00 tion 7044, Business and Professions Code). REQUIRED YARD HWY TOTAL SETBACK FROM EXIST. so 0 0 4 3, 00 v CONSTRUCTION LENDING AGENCY SET BACK PROP. LINE WIDTH 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 0 a 19—8 1 (Sec. 3097,"Civ. C.). SIDE P.L., Lender's Name P.C. Fee$ Permit Fee ' Lender's Address W 1 certify that I have read this application and state that the Issuance Fee above information is correct. I agree to comply with all County Investigation Fee „7 a ordinances and State laws relating to building construction, (/p T and hereby authorize representatives of this County to enter -Total Fee Wupon thea ove- ent.ion property f0finspection purposes. e SEE REVERSE FOR EXPLANATORY LANGUAGE ^ Signature of Applicant or Agent D to ©s COUNTY OF L_sS ANGELES TEMPLE CITY # 0508 DEPARTS",E?JT OF PUBLIC WORKS 5701 LAS TUNAS,1r. -;Tt;i. DD/ALT/REP 'BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA +;7fr 8L 08, i;'>d9010041 PHONE: (62G EXT: LEGAL TD: -�—� -- y- � N0. Or CONST ?tE':: BUILDING ADCR"Z;! !I ONFILE i S0. FT STORIES TYPE OCCUP un`:)P — 4901 HALLOWELL FV 4905 iC;KI_ TUBE• 0 ^ VI'I R3 TEMP CA 9178031,59 IASSESSUR INFORMATION NUMBER: ­­I u,°AGE: 960 1 .,'J U1 NEAREST CROSS STREET. LOWER AZUSA ja585-015-007 OTHER: 186 1 ?rFJ U1 i THOMAS PAGE: 597 =R! C4 LOCALITY: TEMPLE CITY, C ITENAIN T: ;E`,';ST BLDG USE: USE ZONE: • ".SUED ON: PROCESSED BY: EXPIRES ON: IEyIS�± OCC CRP: 10/15/04 10/10/05 CR -T TEL. NO: !RL'I)GS. NOW ON LOT: VALUATION: ;FI� DATE � vR.1. I.Y; CODE; IDAVIS MiCHAEL D;SUZANNE M (626) 622-2774- I 32,140 14901 HALLOWELL AV _ TEi•;R 917303459 FEES PAID —^ 1DESCRIPTION OF WORK -- WD:TG.ED 2 CAR GAKA"_ 960 SF- A'D WORK SHOP 1836 _ . �FEE DESCRIPTION: OUANTiT'(: L'OM: Ah;-OI1''iT:1 IAPPL`•CANT: TEL. NO: i t (SAME AS OWNER IDI PLANCHECK W/O EN-HO 32140.00 VAL i OAA Es'DG PERMIT ISSUANCE %5 SPECIAL CONDITIONS- ;AC STRONG MOTION RESID 32140.00 VAL 2i I ABCHECK W/O EN"';C 32 40.00 VAL I :.. ir Cl OR: ;'El NO: N0; i A «._ Ii.JPEi+-'. tt .�I--Ri:- ;S An CWNFR LIC. AND 5ETE; -- --- --- I I tiff i,SNG`NE R t E PPR,!ls_rq i-__' A. .. I I �r^rCHi7ECT GR cNGINtE.: ___ .NDAV!;ON/TRENCH F IS:AgirUNDER FLOOR -.00K: PAGE: -- ; . ..SE~ER MAPZONE: I `f LEVEL FLOOR SHEATH I i IhG. OF FAMILIES: DWELLIB:G uS�IT�: AY'iiCONj: S"i AT CLnS NO 211 I SCHOCL WITHIN HA-'ARDOUS —_i iOCT SHEATHING ;Fiat: QUAL.TY: 1000 12ET i'ATERIALS NO NO NO ,t1r.::: DEPT. FRAME 1rvSrc i _I REQUIRED TOTAL Srl'BACC SROM EY.IST I .nLGU DEPT. FRAME IR:EFcCT' Z ISET BACK YARD: HWY: CROP LINE: WIDT!i_ _I FRONT PL- I 1SHEAR PANELS —�— I SIDE PL- I _ i SULATION/WEATHER ¢+"IP ONTERIOR LATH/DRYWAiL— I-__s 1 EXTERIOR LATH I LOT DRAINAGE i ISOKE DETECTION DE'IS:'i FIRE DEPARTMENT APPaO`JSLI REPORT ID: DPR261 - ROUTE TO: BS0508 ----