HomeMy Public PortalAbout5224 HALLOWELL AVE_Miscellaneous__ WORISILTPENSATIONDECLARATION CE8754(t,_84) MISCELLANEOUS APPLICATION
I hereby affirm that I have a certificate of consent to self. COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION '
insure,*or a certificate of Workers'Compensation Insurance,or fl
•a certified copy thereof(Sec. 3800,Lab.C.). -
Policy No. Company FOR APPLICANT ADDRESS TO FI LL IN
_ ADDRESS
Certified copy is hereby furnished. BUDILDING. /�IJL0.� J`yLG �f� LocwLlrY ��!�,✓
ADRESS, 62
Y
0 Certified'copy is filed with the county building inspection LOCALITY NEAREST //�^ •
department. zT CROSS ST. `"�i(7�iY/V
Date Applicant NEAREST - DISTRT'y roup
' CONS PROC SED By,
CROSS ST. N rU, -5
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
-COMPENSATION INSURANCE. DEscRIPn oN 'LOT.No. BLOCK MAP HIGHWAY +'
NO. '(CIR CLE) STATE MAJOR SEC O D LOCAL
NO. OF BLDGS.
(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS _
by the permit is for one hundred dollars ($100) or less.) USE OF
SIZE OF LOT EXISTING BLDG. L �
/vG0
I certify that in the performance of the work for which this o
permit is issued, I shall not employ any person in any manner OWNER •r/t/�L �✓�' Q�� ,�/ +t ' `�'
so as to become subject to the Workers' Compensation Laws. rJ�� OCCUP.•ANGY�GROUPAIL ��� �s
,�'..i;t ��•��� t���• •. `tet O
Date Applicant ,� w
NOTICE TO APPLICANT: If, after making this Certificate of CITY TEL. OCCUPANT LOAD
�al�/✓ G�� lZv "DZl 2 �
Exemption, you should become subject to the Workers' Z
APPLICATION FOR EXIT. HARDWARE:
Compensation provisions'of the Labor Code, you mustforth-
with comply with such provisions or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ _ NO Spec. Knowl. ❑ ,
deemed revoked. Panic Devices
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION
I hereby affirm that I am licensed under provisions of ChapterSwF ETY;"PERMIT ❑ (LIST ITEMS BELOW)
9 (commencing with Section 7000) of Division 3-of the Busi- NO. OF EXITS
ness and Professions Code, and my license is in full force and ,1 �jA/
effect. �/� I_` �^��'rw PARKING,
SPACES I"Q�D PROVIDED
License Number Lic. Class
LIMITED TIME USE
Contractor Date - -DATE DATE
FROM: TO:
0 I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S
li '1 SIGNATURE
acting in my professional capacity (Section 7051, Bus EXISTING BLDG. STORIES (/
iness and Professions Code). 'rPRESENT USE OF BUIL ,
Z.�L /� FINAL APPROVAL
DING A
G
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO. OF-EXISTING BUILDI Gs
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's % � -, rr�
License Law for the following reason (Section 7031.5, Busi- ��.CJs r
ness and Professions Code): NO. PARKING
SPACES PROVIDED "
I, as owner of the property, will do the work and the 1
structure is not intended or offered for sale (Section ,
7044,Business and Professions Code). $4.9 9.7 A
PROPOSED USE OF BUILDING
CONSTRUCTION LENDING AGENCY # • • • . 30
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is ° ° 8(15,0
issued(Sec. 3097,Civ.C.). $a 5 0 U
Lender's Name • • •
PROPOSED MAX. OCC.
Lender's Address O •0 7, 1 0=g 6
PERMIT FEE '
I certify that I have read this application and state that the I
above information is correct.I agree to comply with all County ISSUANCE FEE t
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL FEE --
upon t e above- entioned' roperty for inspection purposes. jyz
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signat re o ermittee Date J
COUNTY OF LOS ANGELES _ TEMPLE CITY - # 0508 MISCELLANEOUS PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS MP•0508 0508220002
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL ID: NO. OF CONST NEW BUILDING ADDRESS:
TR: 14053 LT: 23 SQ. FT STORIES TYPE OCCUP GROUP 5224 HALLOWELL AV
STRUCTURE: 1 VN R1 TEMP CA 917803460
ASSESSOR INFORMATION NUMBER: NEAREST'CROSS STREET:
8585-019-036 EXIST BLDG USE: THOMAS PAGE: 597 GRID: C4 LOCALITY: TEMPLE CITY, C
EXIST OCC GRP: USE ZONE:
TENANT: ISSUED ON: PROCESSED BY: EXPIRES ON:
BLDGS. NOW ON LOT: VALUATION: 08/22/05 JK 02/18/06
0
OWNER: - TEL. NO. F L D�JATE FINAL . CODE:
LOI PETER;TRAN ANH M - -LIST ITEMS:
5224 HALLOWELL AV _
TEMP 917803460 - DESCRIPTION OF WORK
FINALED 2 WINDOWS INSTALL WITHOUT PERMIT
OCCUP LOAD EXIST:
APPLICANT- TEL. NO: OCCUP LOAD NEW:
SAME AS OWNER -
PARKING-SPACES REQUIRED: _ SPECIAL CONDITIONS:
PARKING SPACES PROVIDED:
EXIT HARDWARE: -
CONTRACTOR: - TEL. NO: LIMITED TIME USE -
SAME AS OWNER - NBR OF EXITS: - FROM TO
LIC. NO
FEES PAID
APPROVALS DATE INSPECTOR SIGNATURE
FEE DESCRIPTION: QUANTITY: UOM- AMOUNT:
ARCHITECT OR ENGINEER_ : , TEL NO: TRAILER'USE•
- - OA PERMIT ISSUANCE X27.75
LIC. NO: 01 R/M OCC/USE INSPECT 145.95 SAFETY PERMIT
TOTAL FEES 173.70
• TEMP. STRUCT. APPROVED
MAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP: TEMP. STRUCT. REMOVED
NO. OF FAMILIES: DWELLING UNITS: APT/COND: STAT•CLASS: _
NO
SCHOOL WITHIN HAZARDOUS
AIR QUALITY: 1000 FEET MATERIALS -NO NO NO
REQUIRED TOTAL SETBACK FROM EXIST
SET BACK YARD: HWY: PROP LINE: WIDTH: -
FRONT PL-
SIDE PL-
REPORT ID: DPR267 ROUTE TO: BS0508