HomeMy Public PortalAbout5519 HILTON AVE_Building__ WORKERS' COMPENSATION DECLARATION �•E
hereby affirm That I have certificate of consent Lae - APPLICATION FOR BUILDING PERMIT ,CIIIfIS
insure, or a certificate of Workers' Compensation Insurannce,,
or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. - Company
EJCertifiedcopy BUILDING is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS
El Certified copy is filed with the county building inspec- ADDRESS ./i W 61V
tion department. ADDRESS
Date Applicant Clry CST ZIP LOCALITY
NO. OF III NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT /O 7' NOW ON LOT CROSS ST. O
COMPENSATION INSURANCE - ASSESSOR A Z /p
(This section need not be completed if the permit is for one TRACT BLOCK LOT NO. MAP BOOK �J�O PAGE ee PARCEL 4 O
hundred dollars ($100) or less.) TEL -70
OWNER CU/JG NO.ZC7'0370
D USE ZONE MAP "
I certify that in the performance of the work for which this NO
.permit is issued, I shall not employ any person in any manner ADDRESSS /9 1�111LT41VSPECIAL
CONDITIONS d
so as to became subject to the Workers' Compensatiori Laws. r.f - 0
o CITY C/r ZIP
Dote Applicant ARCHITECT OR -Y / TEL ��/ F' Of
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER N., I 40�V NO.+/3 p0// DISTRICT' GROUP rvPE FIRE PROCESSED BY ,
CONST. ZOin O
Exemption, you should become subject to the Workers' h / >EL /� �•ie D � e_2 I/ �.
Compensation provisions of the Labor Code, you must forth- 'd ADDRESS D iwJ J
with comply with such provisions or this permit shall be TEL STATISTICAL CLASSIFICATION I--.- CONDO. N
deemed revoked. CONTRACTOR NO. - Z
LICENSED CONTRACTORS DECLARATION
LIC. CLASS NO. DWELL. UNITS_'j' i Yl.I Y
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO.
1. 1 L
(commencing with Section 7000)of Division 3 of the Business LIC. SEWER MAP G11J_
and Professions Code,and my license is in full force and effect. CITY CLASS 1( VA LIDATION i
SQ. F NO. OF ].,_ NO. OF CHECK BK. PG,
License Number Lic. Class SIZ STORIES FAMILIES / ONE GF���:3!. 1i L�jJ :
VALUATION Z.ZD 000
Contractor Date DESCRIPTION OF WORK NEW S 7 T.ialit3L'. ,l111
ADD ❑ t ►
❑I am exempt under Sec. ��Q` ALTER ❑
B.BP.C. for this reason V $ �hP�11-LILt=11 1_•11_`f
REPAIR ❑
USE OF 6S/At7Nj1/�(_ DEMot I'1=74 } ; il -
Date: EXISTING BLDG. •�R ❑
Signature APPLICANT
PRI T) r♦tT /�NC� L�ioL'.•r 13 -�6� FINAL -
OWNER-BUILDER DECLARATION `/ 7� �qA Q a Cr- q� 7� DATE -
hereby affirm that g r exempt from the Contractor's License ADDRESS �JrS //'-L •�E'T/\ 7�O.�c ✓iV '
' Law for the following.reason (Section 7031.5, Business and FINAL
Professions Code): PRESENT By '
El1,I, as owner of'the property, or my employees with ADDRESS
wages ct their sole compensation,ffere l do the work and , L_1� ('•
the structure'is�not intended or offered for sale(Section OCALITY /-"
7044, Business and Professions Code.) MOVING TEL. 1
❑ I, asowner of the property, am exclusively contracting CONTRACTOR NO.
with licensed contractors to construct the project (Sec-
tion 7044, Business and Professions Code.) ADDRESS 'J
s REQUIRED TOTAL SETBACK FROM EXIST.
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH '^ ,
I hereby affirm that there is o construction lending agency for FRONT
the performance of the work for which this permit is issued P.I. -
(Sec. 3097, Civ. C.). SIDE
P.t.
Lender's Nome
Q -LDMA Ref. IF
Permit Fee ,
Lender's Address -
a I certify that I have read this application and state that the Issuance Fee LDMA P/C q
8 above information is correct. I agree to comply with all County Investigation Fee
ordinances and State laws relating to building construction, Total Fee LDMA Perm. R
a and hereby authorize representatives of this County to enter _
upon the above-mentioned property for inspection purposes. - -
SEE REVERSE FOR EXPLANATORY LANGUAGE -
Signature of Applicant or Agent Date
�IVJORKERS' COMPENSATION DECLARATION �I
I
t insureby affirm thdt havecertificate consent to self APPLICATION FOR BUILDING PERMIT s,Irull
insure, aria cerci�icdre of Workers'Compensation
ation Insurance,
ora cer ifigd cooy-tfiereof (Sec. 3800, Lab. C.)
Polley No, Company- Y7-ATC F✓/JIO COUNTY OF LOS ANGELES BUILDING AND SAFETY _ -
Certified copy is hereby furnished. - FOR APPLICANT TO FILL IN - BUILDING _ S/
ADDRESS
® Certified copy is filed with thg°u my buildin pec- BUILDING
tion department. (1� ,! ADDRESS S&1,7
q Hxl--T�OJN
Date-006- O'7�f✓7Applicont &PSIS-Q .Co 'M_ CITY 'C'M/6 ✓G 47.LT / zip LOCALITY s
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. NEAREST
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS ST. Af /
.(This section need not be completed if the permit is for one - ASSESSOR
hundred dollars ($100)or less.) TRACT BLOCK - LOT NO. - MAP BOOK I P4rE I PARCEL
OWNER /' jyAAJNR Np. USE ZONE MAP
I certify that�in the performance of the work for which this ,VAI-� NO.
permit is issued, I shall not employ any person in any mannerSPECIAL
gDDRESS V 5 / N C'TOxIJ �— CONDITIONS
so as to become subject to the Workers'Compensation Laws. //i� Q
CITY 7iF1n1JC/� C�j. .. ZIP U
Date Applicant ARCHITECT OR TEL
NOTICE TO APPLICANT: If, after making this Certificate of DISTRICT G OUP TYPE FIRE PR ESSED BY Q
Exemption, you should become subject to the Workers' ENGINEER NO. �/? CONST. / ZONE h
Compensation provisions of the Labor Code,you must forth- ADDRESS 6-,(Y tV/ W
with comply with such provisions or this permit shall be - 1 d
TEL. / STATISTICAL CLASSIFI ATION APT. C NDO.
deemed revoked. Gll(s/�4 Ore �" NO. /'Z J Z
CONTRACTOR '
LICENSED CONTRACTORS DECLARATION LIC p _ CLASS NO.—DWELL. UNITS_
I hereby-affirm that I am licensed under provisions of Chapter 9 ADDRESS f s} 2 ALJ GTM-4 N NO. /y �/
(commencing with Section 7000)of Division 3 of the Business andn �t LIC y� SEWER MAP
Professions Code, and my license is in full force and effect. CITY PJeG14Oy/� C—••p CLASS V BK. PG. VALIDATION
SO. FT. NO.OF NO.OF CHECK
License Numbi/,JJ Lic.Class 47 SIZE STORIES FAMILIES ONE VALUATION ` V
Contractor rzvt•z Date UC 0-1/10 DESCRIPTION OF WORK RL5AAYR 6:1112~ NEW ❑ t CONO./� y ADD - ❑
❑ I am exempt under Sec. Af.10WO /T IQ c:CZ ! '1 ALTER ❑
B.BP.C. for this reason REPAIR ® S
Date: USE TI / /I /r46-,5 n�gCI140 DEMOL ❑
EXISTING BLDG. L"/1 K7 "-'V
Signature APPLICANT �+ z� TEL.gf FINAL
OWNER-BUILDER DECLARATION PRINT G"6 AS CA 601J-5 NO. /�20 DATE � �7622.A
I hereby affirm that I am exempt from the Contractor's License M
Law for the following reason (Section 7031.5, Business and ADDRESS ),5"Z � LI�•M OrZ AP-6 CIl- FIN #la • e e,a
Professions Code): PRE EN BY
❑ BUILDING �.e 4 a CJ 0
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 ' e - 4G505
7044, Business and Professions Code). MOVING TEL' O a O 7`8 7
I, as owner of the property, am exclusively contracting CONTRACTOR NO.
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY REQUIRED
YARD HWY TOTALPROP.ETS INE WIDTH - - '
I hereby affirm that there is a construction lending agency for' FRONT -
Ihe performance of the work for which this permit is issued P.I.
(Sec. 3097, Civ. C.). SIDE
P.I.
Lender's Name
LDMA Ref. 8 -
m Lender's Address - P.C. Fee$ Permit Fee ( (lv
I certify that I have read this application and state that the - Issuance Fee LDMA P/C R
above information is correct. I gree to comply with all County Investigation Fee
q ordinances and State laws r acing to building construction, Total tae LDMA Perm. R
and er by authorize rep a ntotives of this County to enter '
up n t above-m ntio ,r{operty for inspection purposes. t
m r 'Vr
_z1Qv SEE REVERSE FOR EXPLANATORY LANGUAGE -
J
Signature of App nl or AgentD' dte -
APPLICATION FOR BUILDING PERMIT
l COUNTY OF LOS ANGELES - BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION ' FOR APPLICANT TO FILL IN BUILDIEg ADDRESS A
hereby affirm that I have a certificate consent to self insure, r / /L OXT/AVC-Al' �
or a certificate of Workers'Compensationn BUILDING ADDRESS 5 / C
Insurance,Or a certified 7
copy thereof(Sec.3800, Lab. C.) CIT G/7 ZIP ^d, 9170"
/7 p0 LOCALITY
Policy No. Company SIZE OF LOT -NO.OF BLDGS.NOW ON LOOT
❑ Certified copy is hereby furnished. O J�0 •S6Z. '
` NEAREST CROSS ST.
❑ Certified copy is filed with the county building inspection TRACT BLOCK - LOT NO,
Z� 0 USE ZONE MAP NO.
department. '
Date Applicant ASSESSOR MAP,BOOKPAGEPARCEL a
A. !A-A ,��0 SPECIAL CONDITIONS _ O/
CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER ` - TEL O.
COMPENSATION INSURANCE 7/111 AD 14 N'V /8 - 3300' WITHIN 1000 FT OF SCHOOL? YES NO
(This section need not be completed if the permit is for one hundred ADDRESS p.��
dollars($100)Or less.) J�/ //i OA/ �"V�1✓u DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY
1 certify that in the performance of the work for which this permit CITT�� L� G/7 ZIP ^�} a/ 7Q QO
is issued, I Shall not employ any person in any manner so as to ARCHITECT OR ENGINEER TEL NO. / S��•K
become Subject to the Workers'Compensation Laws. 003_r-0 STATISTICAL CLASSIFICATION APT CONDO
Date Applicant - ADDRESS CLASSING. � DWELL UNITS
W. WoOD/¢N ftvET/y� i}RC9o�A
NOTICE 70 APPLICANT. If, after making this Certificate Of I REQUIRED TOTAL SETBACK FROM EXIST
Exemption, you should become Subject to the Workers' CONTRACTOR - - - TEL NO. SET BACK YARD MY PROP LINE WIDTH
Compensation provisions of the Labor Code, you must forthwith -ewd r� FRONT
comply with such provisions or this permit shall be deemed revoked. ADDRESS / IG NO. FF L
LICENSED CONTRACTORS DECLARATIONSIDE
CITY LIG.CLASS P L
I hereby affirm that I am licensed underprovisions of Chapter 9 SEWER MAP
(commencing with Section 7000)of Division 3 of the Business and SO.FT.SIZE NO,OF STORIES NO.OF FAMILIES
Professions Code,and my license is in full force and effect. Soo NEW ❑ BK PG
POP.
License Number Lic.Class DESCRIPTION OF WORK ADD ❑ VALUATION'
QAC O C—X S /N $ ��T 1 11h{i_• 0
Contractor Date ��• -�- � -„- --
/N �h/G ON ALTER ❑ 4jl L s.= ' d
❑ I am exempt under Sec. gPAIR ❑ $ M'4;<<-t; j yy�a;^Ic o
B.&P.C. for this reason - t- V
Date: USE OF EXISTING BLOC. L ❑ LUMA P/C+` Mril {i a- gill a
/IJ�iV /}G URM ❑ l� _ -f CO
Signature - 1G':' Z
APPLICANT(PRINT) TEL 0. LOW Perm k -
1�,( A/ .03 a ! !lit i' r.
W 1, as owner of the property, or my employees with wages as ,W / 7 - 2 I-2'!
their Sole compensation, will do the work and the structure is A/D.DRESS y.� '" C/ / O -.+
not intended Or Offered for sale (Section 7044, RUSIne$$ and J /� 0AI 4 t-• `�"/ �� 7 FINAL DATE a js.. -1� t �ry''y h°7
Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL PEEK t j �'i f
❑ I, a5 owner of the y y 9 OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE
property, am a%CIUSivel COOtraC110 Wlih AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATON GUIDE? FINAL BY I y_
licensed contractors to construct the project (Section 7044,
Business and Professions Code.) - YES❑ NO❑ _
OCCUPANT
.LLCC THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FROM T ESOUBUILDING
OOASTA IR REQUIRE A PERMIT FOR CONSTRUCTION SCAQ OR EE PERMITTING
G CH THE SOUTH
CONSTRUCTION LENDING AGENCY GUIDE AIR Quaun MANAGEMENT DISTRICT IscAornol SEE RERMnnNG cHEcrcusT FOR
GUIpEIINES.
I hereby affirm that there is a construction lending agency for YES El No El r -r: mm
the performance of the work for which this permit is issued(Sec. 7 2i P!
W I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING
3097,CIV.C.) CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THELOS ANGELES COUNTY CODE,
TITLE 2,CHAPTER 2.20 SECTIONS 220.100 THROUGH 2.20.I40 CONCERNING HAZARDOUS
Lenders Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD.
o Lender's Address
o wmen oR wVJT
o I certify that I have read this application and state under penalty
PC FEE FEE JO PERMIT FEE A
N of perjury that the above information is correct. agree to comply Si (.'
with all county ordinances and State laws relating to building
m construction, and hereby authorize representatives of this County ISSUANCE FEE .
m toenter u/pP a the'b v mentioned property for inspection purposes. 2 UA
INVESTIGATION FEE TOTAL FEE
spn.I,..a Mpmn u Das
SEE REVERSE FOR EXPLANATORY LANGUAGE
1
• 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 0506 1309120062
PHONE: (626) 285-0488 EXT:
ILEGAL ID: NO. OF CONST BUILDING ADDRESS:
ITR: 12410 LT: 18 SQ. FT STORIES TYPE
I 5519 HILTON AV I
I ISTRUCTURE: 3200 V-B TEMP CA 917802406
(ASSESSOR INFORMATION NUMBER: 1 NEAREST CROSS STREET:
8588-002-018 THOMAS PAGE: 596 GRID: S4 LOCALITY: TEMPLE CITY CAI
I I
I TENANT: [EXIST BLDG USE: RESID USE ZONE: R-1 (ISSUED ON: PROCESSED BY: I
I 1EXIST OCC GRP: 109/12/13 SR 1
IOWNER: TEL. NO: IBLDGS. NOW ON LOT: VALUATION: 1F TE FINAL Y. CODE: 1
(KUNG, EDWARD (626) 285-0370- 1 11,000
5519 HILTON AV
(TEMP 917802406 FEES PAID IDESC�RIPTION OF WORK
I I ITEAR OFF INSTALL COMP SHr9GLES 50 YRS HOUSE 6 GARAGE
I IEEE DESCRIPTION: QUANTITY: DOM: AMOUNT: (
(APPLICANT: TEL. N0:
ISUE, CARMEN (626) 709-7866- IAA BLDG PERMIT ISSUANCE 27.80 1
11428 AMELUXEN AVE IAB STATE GREEN BLDG FEE 11000.00 VAL 1.00 ISPECIAL CONDITIONS:
IHACIENDA HIS 91745 IAC STRONG MOTION RESID 11000.00 VAL 1.10
I ID2 PERMIT W/O EN-HC 11000.00 VAL 233.40
1 TOTAL FEES 263.30
CONTRACTOR: TEL. NO: (APPROVALS DATE INSPECTOR SIGNATURE
ISWIFT-MEND ROOFING, INC. (626) 709-7866- 1-
11428 AMELUXEN AVE LIC. NO (LOCATION AND SETBACKS
(HACIENDA HEIGHTS, CA 91745 918419 I I
SOILS ENGINEER APPROVAL I I
ARCHITECT OR ENGINEER: TEL. NO: 11FOUNDATION/TRENCH FORMS I I
I LIC. NO: ISLAB/UNDER FLOOR I I I
I I (RAISED FLOOR FRAMING I
1
I I I
(MAP NO: SEWER MAP g00K: PAGE: FIRE ZONE: CMP:( UNDERFLOOR INSULATION
I 3 001 IFLOOR SHEATHING I I I
INO. OF FAMILIES: DWELLING UNITS: APT/COND: STAT CLASS: I I
I NO 21 IROOF SHEATHING I I
I I-
I SCHOOL WITHIN HAZARDOUS ISHEAR PANELS
(AIR QUALITY: 1000 FEET MATERIALS
I NO NO NO (FRAME INSPECTION
IFIRE SPRINKLER HANGERS I
I I
11NSULATION/WEATHER STRIPI I
1 (INTERIOR LATH/DRYWALL
1 (EXTERIOR LATH I I I
IRATED FLOOR/CEIL ASSEM.
I
IRATED WALL ASSEMBLIES
1 I
IRATED SHAFTS/OPENINGS
T-BAR CEILINGS
I I I I I
LOT DRAINAGE
I
(REPORT ID: DPR261 ROUTE T0: HS0508 I I I 1
I I