HomeMy Public PortalAbout4905 HALLOWELL AVE_Building__ WORKERS' COMPENSATION DECLARATION
hereby
that I have a certificate of e - BUILDING D I N G P E RM I T
insure, ra;eifcate of Workers' Compensation Insurance, APPLICATION FOR
or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF,LOS ANGELES BUILDING AND SAFETY
Policy No. Com pony
!
BUILDING r
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS `� 10< �4�idcc�E�i
❑ Certified copy is filed with the county building inspec- BUILDING (Q
tion department. ADDRESS
Date Applicant CITY \(K401,6MV ?,9t9ZIP � LOCALITY
pp NO. OF BLDGS. NEAREST J _
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NOW ON LOT CROSS S7.
COMPENSATION INSURANCE ASSESSOR p� J �J
(This section need not be completed if the permit �
is for one TRACT / Q BLOCK LOT NO. MAP BOOK Z7 � PAGE { PARCEL• 0—J
hundred dollars ($100) or less.) USE ZONE MAP �L
TEL.
O � �/ �t
OWNER
NO. —t y�
SPECIAL UC
I certify that in the performance of the work for which this ( L NO. R
Imo'
permit is issued, I shall not employ any person in any manner ADDRESS ` �41_ CONDITIONS O_
so as to become subject to the Workers'Compensation Laws. 0
CITY ZIP
Date Applicant ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY
NOTICE TO APPLICANT: If, after making-this Certificate of ENGINEER NO. CONST. ZONE
Exemption, you. should become subject to the Workers' C 3
Compensation provisions of the Labor Code, you must forth- ADDRESS j V w
a
with comply with such provisions or this permit shall beTEL- STATISTICAL CLASSIFICATION APT. CONDO. N
deemed revoked. CONTRACTOR0JJJWJ0F_LNO. -7Z
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. r / DWELL UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS No. SEWER MAP
(commencing with Section 7000)of Division 3 o the Business LIC.
and Professions Code,and my license is in full force and effect. CITY CLASS BK PG VALIDATION
SQ. FT. NO. OF NO. OF CHECK
License Number Lic..Class SIZE STORIES FAMILIES ONE
V�LUATION
Contractor Date _
DESCRIPTION F WORA&_Mll0 4 NEW ❑ s
ADD ❑ ►
❑I am exempt under Sec. btu
ALTER
B.BP.C. for this reason REPAIR ❑
Date: USE OF
EXISTING BLDG. RACZ, DEMOL ❑
Signature
APPLICANT TEL. ✓'�' '�i
NO. FINAL
(PRINT)
OWNER-BUILDER DECLARATION DATE
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and ADDRESS FINAL) _
r fessions Code): PRESENT BY /`� ��
BUILDING c•. _ v
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 _ Y
7044, Business and Professions Code.) MOVING TEL. , i _., i_?
_
❑ I, as owner of the property, am.exclusively contracting CONTRACTOR NO.
_ y.
with licensed contractors,to construct the project (Sec- F `
ADDRESS
tion 7044,'Business and.Professions Code.) !; kr. 70 G_.
REQUIRED TOTAL SETBACK FROM EXIST.
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH
I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued P.L.(Sec. 3097, Civ. C.). SIpE
Lender's Name PLDMARef. # — rs�. -
[FRONT
C. Fee$ Permit Fee �O` =3•�-'F� S N --2_
Lender's Address p
0 1 certify that I have read this application and state that the Issuance Fee O 76— LDMA P/C# ,
0
above information is correct. I agree to comply with all County Investigation Fee 9
8 ordinances and State laws relating to building construction, Total Fee / LDMA Perm. #
¢ and hereby aut rize r re tat
of this County to enter
upo t above entio d r perty for inspection urp ses. ,
All tv ft. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent D e
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 BUILDING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS RESIDENTIAL ADD -
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 BL 0508 1107270052
PHONE: (626) 285-0488 EXT:
ILEGAL ID: I NO. OF CONST NEW BUILDING ADDRESS:
ON FILE SQ. FT STORIES TYPE OCCUP GROUPI 4905 HALLOWELL AV J
ISTRUCTURE: 88 1 V-B R-3 I TEMP CA 917803459 J
(ASSESSOR INFORMATION NUMBER: GARAGE: I NEAREST CROSS STREET: LOWER AZUSA 1
18585-016-007 I OTHER: I THOMAS PAGE: 597 GRID: C4 LOCALITY: TEMPLE CITY CAI
I I_ I
(TENANT: IEXIST BLDG USE: USE ZONE: (ISSUED ON: PROCESSED BY: I
1 IEXIST OCC GRP: 109/26/11 SR I
I I I I
DOWNER: TEL. NO: IBLDGS. NOW ON LOT: VALUATION: 1FT.NAL DATE� FINAL BY: CODE:
IDAVIS MICHAEL D;SUZANNE M - 15,000 1 I 1
14901 HALLOWELL AV J J J
ITEMP 917803459 FEES PAID IDESCRIPTION OF WORK 1
I I JADD 88 SQFT. TO MAIN HOUSE (DINING ROOM) 1
I IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT: ( I
JAPPLICANT: TEL. NO: I I I
JEDGLEY & SONS (626) 818-9385- 121 PLANCHECK W/ENERGY 15000.00 VAL 281.90 1 I
14847 KAUFFMAN AVE IAA BLDG PERMIT ISSUANCE 27.80 ISPECIAL CONDITIONS:
ITEMPLE CITY CA 91780 JAB STATE GREEN BLDG FEE 15000.00 VAL 1.00 I 1
I JAC STRONG MOTION RESID 15000.00 VAL 1.50 I 1
1 JB2 PERMIT W/ENERGY 15000.00 VAL 331.60 1
(CONTRACTOR: TEL. NO: 108 CERTIF OF OCCUPANCY 101.30 APPF:OVALS DATE INSPECTOR SIGNATURE J
IEDGLEY AND SONS (626) 818-9385- 1 TOTAL FEES 745.10 z1
14847 KAUFFMAN AVENUE LIC. NO I ILOCATION AND SETBACKS J � 1
ITEMPLE CITY, CA 91780 528990 B I I I 1 I
I I ISOILS ENGINEER APPROVAL I 1 I
I I I I I I
JARCHITECT OR ENGINEER: TEL. NO: I IFOUNDATION/TRENCH FORMS I I
IINING LU CONSULTING STRUCTUAL (818) 795-1250- i I I
12500 E FOOTHILL BLVD SUITE 211 LIC. NO: 1 1SLAB/UNDER FLOOR I
1PASADENA CA 91107 RPE 3042 I 1 I 1
1 IRAISED FLOOR FRAMING I I
I I I I I I
IMAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP: I JUNDERFLOOR INSULATION I I I
1 3 001 1 11 I
I I 11ST LEVEL FLOOR SHEATH 1 1 I
IND. OF FAMILIES: DWELLING UNITS: APT/COND: STAT CLASS: I I 1 1
0 NO 21 1 12ND LEVEL FLOOR SHEATH I I
I � I
1 SCHOOL WITHIN HAZARDOUS IROOF SHEATHING I a
(AIR QUALITY: 1000 FEET MATERIALS I I 1
NO NO NO I IFIRE DEPT. FRAME INSPECTI ISI
IBLDG DEPT. FRAME INSPECTI fl
I
I ISHEAR PANELS I
I I I I
I I 11NSULATIGN/WEATHER STRIP( I
I
J 11NTERIOR LATH/DRYWALL 1
I I I I I
1 I 1EXTERIOR LATH
I I I I 1 I
I 1 ILOT DRAINAGE I 1 I
I I I I I I
I I ISMGKE DETECTION DEVICES 1 1 1
1 1 IFIRE DEPARTMENT APPROVALI I I
I I I I I I
I I I I I I
I I I I I I
I IREPORT ID: DPR261 ROUTE TO: SS0508 1 1 1 1