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HomeMy Public PortalAbout6128 IVAR AVE_Building__ 2a WORKERS COMPENSATION"DECLARATION w- nsurebaf oracertif cant e of Workers' consent elf /111 C' a O IJ V F©� O U ®�ml�' 1 F_-) V U or.a certified copy thereof.(Sec. 3800,;Lab':C.) f COUNTY OF LOS ANGELES BUILDING.-AILD SAFETY Pohcy.Cert fied'co s h Company py ereby,furnished.'" ' FOR APPLICANT TO FILL IN f f 2 �VAve No BUILDING _ ADDRESS �" Certified copy-is.filed;with the county building ins 'BUILDING tion department. ADDRESS, ?/ S' tl >, '.�AA /_ _P Date 'Applicant CITY N.4 �T ZIP LOCALITY CERTIFICATE OF EXEMPTION FROM,WORKERS' NO. OP BLDGS. NEARE T r S COMPENSATION"INSURANCE SIZE OF LOT' ,S NOW ON LOT '+. l`, CROSS ST., (This section need not;6e'c'ompleted,•if the per is for one ASSESSOR :'JP hundred dollars ($100)'or less.) %` . k` PARCEL TRACT BLOCK LOT•NO MAP.BOOK PAGE_ p e work for- this OWNER Al I' NO. .. I USE ZONE MAP I certifythat in,the er•formance`of ib Z1�3 NO. permit is issued,,l shall not employ any person:m any manner r-� SPECIAL so as to become''subject.to,'the'Workers'Compensation Laws. ADDRESS �J (}N 1 CONDITIONS Date;- 'Applicant.-.• . . - CITY ., �t ZIP �- ARCHITECT OR V .TEL." DISTRICT GROUP JTYPE FIRE PROCESS BY NOTICE, TO APPLICANT:.If after making this Certrficate..of ENGINEER NO: Exemption, you-should become subject. to the: Worker`s'- . ` 0� CONST.;.`/ ZOfyE Compensation provisions of the Labor Code, you,must forth- ADDRESS v C with.-eomply with such`provisions or. this permit shall be TEL., STATISTICAL CLASS FICATION APT. CONDO deemed revoked. CONTRACTOR NO. " LICENSED CONTRACTORS DECLARATION .' , LIC. .BASS NO. DWELL. UNITS I hereby affirm that I am'licensed uhderprovisionsof Chapter 9 ADDRESS;,' NO.- ER " (commencing"with Section 7000)-of Division 3 of the,Business and - LIC SEW MAP. Professions Code, and my license is in full force and effect CITY CLASS VALIDATION v SQ. FT NO.OF NO, OF CHECK BK. PG. License Number Lic.Class' SIZE - STORIES FAMILIES ONE DESCRIPTION OF WORK NEW a Contractor Date Q I am exempt under Sec. [r`yI, ADD 1 ,' r7 1• s ALTER �C / (J©'/ �v " B.BP.C. for this reason>. Q �— I�(<J"rl:f $ I3{ -` :-�.. REPAIR .0 J ..:.. ��•�t Date: USE OF i r 2 a z1. EXISTING BLDG.. MOL ❑ Signature — APPLICANT, TEL. FINAL 1 1+ +„ s _ '25-- TE s -T� A DE ? g O ER-BUILD CLARATION. " PRINT) �J"fT-Jv�V—S �" �t I NO. Z "11 J DATE + hereby affirm that f am exempt from'the Contractor's License ^ �I� Low-for the following reason (Section,7031.5, Business'and ADDRESS '. f'11LO Iv.M A FIN t {r t+ I n i.s? Professions Code).' j: PRE ENT UILDINBY - l � BG c E1, as owner,of 4he.property; or my"employees with' ADDRESS wages as their sole compensation;will do.the'work and q the structure is not intended or;offere'd for,'sale(Section LOCALITY f r • 7044, Business and-Professions Code) •`1 MOVING' TEL. • � + .1, as owner,of the property,•am•exclusively contracting. CONTRACTOR NO:-- 4 z 1.1 with Ii censed,controctors to construct4e.prolect (Sec- ADDRESS 'tion 7044, Business�and'Profe'ssions Code). REQUIRED TOTAL SETBACK. CONSTRUCTION LENDING AGENCY SETBACK YARD HWY PROP. CINE WIDTH .1 hereby affirm that there is a construction lending agency for FRONT, the performance of the work for which this permit is.issued P.L. ' :(Sec. 3097, Civ. C:). SIDE ' P.L. Lender's Name _ m P.C. Fee$ i e3it Pe�� LDMA Ref. # Lender's Address Ll gY I certify that I have read this application and:stote that the Issuance Fee �r 5V s LDMA P/Ci#: - above.inforrriation is correct. I agree to comply with all County Investigation Fee'; tol F�'ee LDMA Perm. 7 - " 0 ordinances and State laws relating to building construction, s o '# b ' and hereby outhorize:representatives•of this County taenter < upon the above-mentioned property for insp::.Murp ses.. SEE REVERSE FOR EXPLANATORY LANGUAGE ' Signature f Applicant or Agent iDate " _- -•, - - _ - _ .•_ ,. 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 1201040014 PHONE: (626) 285-0488 EXT: LEGAL ID: NO. OF CONST BUILDING ADDRESS: ITR: 5904 LT: 42 SQ. FT STORIES TYPE 6128 IVAR AV STRUCTURE: 24 V-B TEMP CA 917801523 ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET: GARIBALDI 15384-002-011 THOMAS PAGE: 596 GRID: H2 LOCALITY: TEMPLE CITY, Cl TENANT: IEXIST-BLDG USE: RESID USE ZONE: R-1 ISSUED ON: PROCESSED BY: IEXIST OCC GRP: 101/04/12 SR OWNER: TEL. NO: IBLDGS. NOW ON LOT: VALUATION: IFINAL DATE FINAL BY: CODE: ISUSAN 16128 IVAR AV i 5,500 i I -1-:2 TEMP 917801523 FEES PAID (DESCRIPTION OF WORK I ITEAR OFF #30 LB FELT 30 YRS SHINGLE I IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT: 1 APPLICANT: TEL. NO: ICHUNG, WAN _ (213) 500-2956- IAA BLDG PERMIT ISSUANCE 27.80 11612 KIOWA CREST DR. JAB STATE GREEN BLDG FEE 5500.00 VAL 1.00 ISPECIAL CONDITIONS: IDIAMOND BAR 91765 IAC STRONG MOTION RESID 5500.00 VAL 0.60 1 ID2 PERMIT W/O EN-HC 5500.00 VAL 149.70 1 TOTAL FEES 179.10 1 1 (CONTRACTOR: TEL. NO: I (APPROVALS DATE INSPECTOR SIGNATURE 1 IYZIS CONSTRUCTION, INC. (213) 500-2956- 11612 KIOWA CREST DR LIC. NO I (LOCATION AND SETBACKS 1 1 (DIAMOND BAR CA 91765 967270 ! 1 1 1 1 (SOILS ENGINEER APPROVAL I I 1ARCHITECT OR ENGINEER: TEL. NO: (FOUNDATION/TRENCH FORMS I I I i. LIC. NO: 1 (SLAB/UNDER FLOOR 1 IRAISFD FLOOR FRAMING I I I IMAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP:.( 1UNDERFLOOR INSULATION I 115OH265 3 001 1 1 I I (FLOOR SHEATHING INC. OF FAMILIES: DWELLING UNITS: APT/COND: STAT CLASS: 1 I- 0 0 NO 21 1ROOF SHEATHING 1 SCHOOL WITHIN HAZARDOUS ISHEAR PANELS 1 1 I (AIR QUALITY: 1000 FEET MATERIALS 1 1 1 NO NO NO (FRAME INSPECTION IFIRE,SPRINKLER HANGERS I 1 I 1 1 IINSULATION/WEATHER STRIP 1. 1 I i I I I I (INTERIOR LATH/DRYWALL I 1 1 1EXTERIOR LATH 1 1RATED FLOOR/CEIL ASSEM. I 1 IRATE? WALL ASSEMBLIES 1 I. 1 i 1RATED SHAFTS/OPENINGS I I I I I I i i; T-BAR CEILINGS 1 _ ILOT DRAINAGE I I 1 1REPORT ID: DPR261 ROUTE TO: BS0508 I I I I I I