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HomeMy Public PortalAbout5734 KAUFFMAN AVE_Building__ Y;"" WORKERS'COMPENSATION DECLARATION �res.y�affirm that I have a certificate of conseN'to self APPLICATION FOR BUI L D I N G PERMIT nsure, br'a certificate of Workers' Compensation Insurance, ` .or a certified copy thereof (Sec. 3800, Lab. C.) I Policy Nao c Z ompany 0_,, 16- COUNTY OF LOS ANGELES BUILDING AND SAFETY ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDINGADDRESS ^ �- Certified copy is filed with the county building inspec- BUILDING /� tion de ortme ,/��, ADDRESS a/ 1 Date' VCApplicant CITY P ZIP L LOCALITY CE TIFIC E OF EXEMPTION FROM WORKERS' P NO.OF BLDGS. NEAREST COMPENSATION INSURANCE SIZE OF LOT56k K(�(�b Now ON LOT CROSS ST. Ilia (This section need not be completed if the permit is for oneASSESSOR hundred dollars ($100)or less.) TRACT/gs–eyBLOCK LOT NO. MAP BOOK PAGE PARCEL TEL. '7USE ONE MAP / I certify that in the performance of the work for which this OWNER &W, ,- NO. permit is issued, I shall not employ any person in any manner ADDRESS ^I SPECIAL CONDITIONS so as to become subject to the Workers'Compensation Laws. /��� � U Date Applicant CITY f`t/ �/� ZIP ARCHITECT O TEL. NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER –� NO. /U4) t� DISTRICT GROUP TYPE FIRE PROCESSED BY Q Exemption, you should become subject to the Workers' CONST. ZONE U Compensation provisions of the Labor Code, you must forth- ADDRESS CBY �i W with comply with such provisions or this permit shall be ��y L. STATISTICAL CLASSIFICATION APT. C deemed revoked. CONTRACTO t�N l-�P7�i �t NO. / 1 - f Z LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. LJ DWELL. UNITS L_ I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. (commencing with Section 7000)of Division 3 of the Business and / LIC. SEWER MAP Professions Code, and m license is in full force and effect. CITY C( � CLASS VALIDATION L,j// SQ. FT INC. OF NO. OF / CHECK BK. �'' License Number ` Lic.Class �� SIZ STORIES FAMILIES C ONE l ,l VALU�ON Ov Contractor Dates v— 'c' DESCRIPTION OF WORK NEW $ ADD v ❑ I am exempt under Sec. ❑ ALTER B.BP.C. for this reasonW r REPAIR ❑ $ Date: USE OF p� ` / ❑ 1 1 '1. 1 A EXISTING BLDG. i +�-fT LC'tr DEMOL © 11+ A' Si nature APPLICANT TEL. FINA o t , g OWNER-BUILDER DECLARATION (PRINT) N NO. 2�� DA EL I hereby affirm that)am exempt from the Contractor's License ADDRESS � o� 'r•i•jo ;6 8 3:1,9 5.0 / �– ` r '='' Law for the following reason (Section 7031.5, Business and FIN Professions Code): PRESENT B ^�,jet 1, 1 D b$8 j,• ❑ BUILDING ; I, as owner of the property, or my employees with ADDRESS S TR: wages as their sole compensation,will do the work and the structure is not intended*or offered for sale(Section LOCALITY ® ;: ;:? 7044, Business and Professions Code). MOVING TEL. I HL ❑ CONTRACTOR NO. I, as owner of the property, am exclusively contracting t„• ')i;„�.��:' �`:�, t•,_._ with licensed contractors to construct the project (Sec- PADDR tion.7044, Business and Professions Code). =I•a� _I_ii YARD HWY TOTAL SETBACK FROM CONSTRUCTION LENDING AGENCY 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 (Sec. 3097, Civ. C.). f - �� ` .c..L.„'{ _ HIM "z Lender's Name /i Permit Fee SLDMA Ref. # Lender's Address I certif that I have read this a lication and state that theo Y PP issuance Fee (.©' �/ LDMA P/C#above informa' n is correct. I agree to comply with all County on Fee 0 ordinances S aws relating to building construction, o and here ori re resentatiYes of this County to enter Total Fee LDMA Perm. # m upon th e- enti ed property for inspection purrjpos . l Y 6i3��/ SEE REVERSE FOR EXPLANATORY LANGUAGE Sign of Applicant or Agent D to APPLICATION FOR BUILDING PERMIT � COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING BUILDING ADDRESS I hereby affirm that I have a certificate of consent to self insure, S-7 BV )kA or a certificate of Workers'Compensation Insurance,or a certified CITY !142�� C ZIP copy thereof(Sec.3800,Lab.C.) LOCALITY Policy No. Company SIZE OF LOT NO.OF BLDGS.NOW ON LOT ❑ Certified copy is hereby furnished. NEAREST NQ25 ❑ Certified copy is filed with the county building inspection TRACT BLOCK LOT NO. LDISTRICT MAP NO. department. ASSESSOR MAP BOOK PAGE PARCEL Date Applicant SPECIAL CONDITIONS OWNER TEL.NO.CERTIFICATE OF EXEMPTION FROM WORKERS' G "4 Z 1Q FT.OF SCHOOL? YEs No COMPENSATION INSURANCE ADDRESS(This section need not be completed if the permit is for one hundred 3 ����-�-���) GROUP TYPE CON FIREZONE P ESSED BY dollars($100)or less.) CITY ZIPI certify that in the performance of the work for which this p mitis Issued, I shall not employ any person in any manner S to ARCHITECT OR NGINEERTEL.NO.become Subject to the Work satlon LBWS. C IF CATION A CONDO Date 7-L7-9d Applica ADDRESS DWELL UNITS NOTICE TO APPLICANT. If, a ter making t s Certificate of CONTRACTORTEL.NO. REQUIRED TOTAL SETBACK FROM EXIST Exemption, you should become Subject O the Workers' /` SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith �a4D B�r Lo&zS 0Nr . ?!�/ 73s= 76 7 comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC.NO. FRONT l Ai LS t t CA ( Z SIDE LICENSED CONTRACTORS DECLARATION CITY LIc JSS PL C I hereby affirm that I am licensed under provisions of Chapter 9 (!:QP-0vSEWER MAP v (commencing with Section 7000)of Division 3 of the Business and SQ.FT.SIZE NO.OF STORES NO.OF F MILIES O Professions Code,and my license is in full force anAeeffect. 3 NEW ' BK PG U License Number:3 7&20 Z ( Lic.Class v DESCRIPTION OF WORK C ADD El VALUATION , a- 0z1v 4-4114 ContractorCc)OyD Bu tID05 Date 7— 12-970 C G Z ALTER ❑ �)-5 767 0 ® y_ z ❑ I am exempt under Sec. REPAIR ❑ B.BP.C.for this reason DEMOL ❑ LDMA P/C# Date: USE OF s�54of:F/Gt2 URM ❑ A $ Signature APPLI NT(PRINT) TEL.NO. LDMA Perm# ACCT v ❑ I, as owner of.the property, or my employees with wages as Gc-C If �� O .66L 10._:a their sole comensation,will do the work and the structure is ADDRESS f z not intended or offered for sale (Section 7044, Business and FINAL DATE I. G 1 ITEMS E�'S Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL lel. J ... I i 70 = 38 s�.F ❑ I, as owner of theproperty, am exclusively Contracting with OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN Y g THE AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE7, F L > t licensed contractors to construct the project (Section7044, YES 1:1 NO� I CHECK 'l��''' Business and Professions Code.) WILL THE INTENDED USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING CHANGE_ 1 OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR GUIDELINES. Q ' hereby affirm that there is a construction lending agency for YES 11 1,1644 ` 4 i J1�1)-I_ 5-d j -1/.1-r;1•�I the performance Of the Work for which this permit IS issued(Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD ' , 3097,CIV.C.). PERMITTING CHECKLIST.I UNDERSTAND MY REQUIRE UNDER THE LOS ANGELES AM 7 e �. COUNTY CODE 2,CHAPTER 2.20 SECTIONS .00 THROUGH 2.20.140 CONCERNING •' o Lenders Name HAZA A EPORTING ANDFIP8FTAINING A PERMIT FROM THE SCAQMD. L Lender's Address o I certify that I have read this application and state that the above g information is correct. I agree to comply with all county P.C.FEE PERMIT FEE N ordinances and State laws relating to building construction,and V a hereby authorize presentativeS is County to enter upon ISSUANCE FE t abov oned propert inspection purposes. r 7-1 7—q INVESTIGATION FEE TOTAL FEE n J ,uNre W � Dete SEE REVERSE FOR EXPLANATORY LANGUAGE 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 1004190051 PHONE: (626) 285-0488 EXT: LEGAL ID: NO. OF CONST BUILDING ADDRESS: IBK: 216 PG: 31 PC: 2 SQ. FT STORIES TYPE 5734 KAUFFMAN AV STRUCTURE: 200 V-B TEMP CA 917802505 ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET: 18587-023-033 THOMAS PAGE: 597 GRID: A3 LOCALITY: TEMPLE CITY, Cl TENANT: JEXIST BLDG USE: RESID USE ZONE: R-1 JISSUED ON: PROCESSED BY: EXIST OCC GRP: 104/19/10 SR OWNER: TEL. NO: IBLDGS. NOW ON LOT: VALUATION: IF NAL DATE FINAL BY: CODE: ITSAI, JANIS (626) 309-0019- 1 2,400 D 15734 KAUFFMAN AV I ITEMP 917802505 FEES PAID IDESCRIPTION OF WORK IREPAIR REMOVE 3 EXISTING OLD VALLEYS, INSTALL NEW 24" METAL IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT: IVALLEY INSTALL NEW FELT PAPER AN REPLACE REMOVED TILE I (APPLICANT: TEL. NO: I I I ISUNSHINE ROOFING (626) 581-7688- IAA BLDG PERMIT ISSUANCE 27.75 1 I 1516 N. DIAMOND BAR IAB STATE GREEN BLDG FEE 2400.00 VAL 1.00 ISPECIAL CONDITIONS: I IDIAMOND BAR CA 91765 IAC STRONG MOTION RESID 2400.00 VAL 0.50 1 I ID2 PERMIT W/O EN-HC 2400.00 VAL 99.00 IFR INV WORK W/O PERMIT 257.00 DOL 257.00 I ICONTRACTOR: TEL. NO: I TOTAL FEES 385.25 (APPROVALS DATE INSPECTOR SIGNATURE ISUNSHINE ROOFING, INC. (626) 581-7688- 1 1 I 1516 N DIAMOND BAR BLVD #183 LIC. NO ILOCATION AND SETBACKS I I 1 IDIAMOND BAR CA 91765 755126 C39 ISOILS ENGINEER APPROVAL (ARCHITECT OR ENGINEER: TEL. NO: I IFOUNDATION/TRENCH FORMS I LIC. NO: I (SLAB/UNDER FLOOR 1 1 I IRAISED FLOOR FRAMING I I I IMAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP:I (UNDERFLOOR INSULATION I I 1150H269 3 001 1 11 I I I IFLOOR SHEATHING I INO. OF FAMILIES: DWELLING UNITS: APT/GOND: STAT CLASS: I I I I I NO 21 1 IROOF SHEATHING I I I SCHOOL WITHIN HAZARDOUS I ISHEAR PANELS I I I (AIR QUALITY: 1000 FEET MATERIALS I I I NO NO NO IFRAME INSPECTION I IREQUIRED TOTAL SETBACK FROM EXIST I IFIRE SPRINKLER HANGERS I ISET BACK YARD: HWY: PROP LINE: WIDTH: IFRONT PL- I 11NSULATION/WEATHER STRIPI I I I SIDE PL- I 1 1-1 I I 11NTERIOR LATH/DRYWALL I I I I I (EXTERIOR LATH I I I i (RATED FLOOR/CELL ASSEM. 1 IRATED WALL ASSEMBLIES IAATED SHAFTS/OPENINGS IT-BAR CEILINGS 1 1 1 I ILOT DRAINAGE 1 1 I I I I I I IREPORT ID: DPR261 ROUTE TO: BS0508 1 1 I I I I I I