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HomeMy Public PortalAbout10336 KEY WEST ST_Building__ WORKERS' COMPENSATION DECLARATION I„ hereby affirm that I havecertificate of consent to self A P PL I CAT LO N. FOR B U I L D I NG PERMIT insure, or a certificate of Worr kers' Compensation Insurance, or a certified copy thereof'(Sec. 38W, Lab. C. COUNTY OF LOS ANGELES LES BUILDING D S FETY Policy No.•' Company Certified co is hereby furnished. BUILDING ❑ copy y F.OR APPLICANT TO:FILL IN ADDRESS ElCertified copy is filed with the county building inspec- BUILDING $ `' Tion department. ADDRESS Date Applicant CITY %.,� ZIP LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' 7 NO. OF BLDGS. NEAREST 00, COMPENSATION INSURANCE .., SIZE OF LOT ` ��© NOW ON LOT CROSS ST. (T.his section need not be completed if the permit is for'oneB / ASSESSOR -hundred dollars ($100)or less.) ., TRAC s BLOCK LOT NO. �/ MAP BOOK PAGE PARCEL TEL. USE ZONE MAP OWN �' /� �%�� NO� 5_4 I certify that.in the performance of the work•for which this NO. 6>o 1.6 permit is issued, I shall not employ any person in any manner ��/ SPECIAL so as to become subject to the Workers'Compensation Laws. ADDRESS-,/,4'0_4— CONDITIONS DategPPlicant CITY ZIP. G 9_,d!G7 NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL. DISTRICT GROUP TYPE —F—FIRE PROCESSED BY ENGINEER NO. CONST. ZONE w I� Exemption, you should become subject to the. Workers' tj Compensation provisions of the Labor Code, you must forth- with comply with such provisions or this permit shall be` ADDRESS S'o- I V 3 STATISTICAL CLASSIFICATION P . CONDO. deemed revoked. . CON / ,lJ LICENSED CONTRACTORS DECLARATIONLIC- NO. o r DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS✓ 11__ OGL/ (commencing with Section 7000)of Division 3 of the Business and LIC SEWER MAP Professions Code, and my license is in full force and effect. CITY CLASS AL>` VALIDATION SQ. F / NO.OF _ NO. OF CHECK BK. PG. .. License Number Lic.Class SIZ /� STORIES FAMILIES / ONE VALUATION_ Contractor Date DESCRIPTION OF WORK NEW $ �{p -��//Yb. /�f//y� / f. ADD ❑ C/fJ ❑ I am exempt under Sec. ALTER ❑ , rr 2166A''" B.&P.C. for this reason ❑ $ - REPAIR Date: USE OF # co a o 2 3 EXISTING BLDG. DEMOL ❑ i Signature APPU ' FINAL i� 2 ° b 1 0, 1 0 OWNER-BUILDER DECLARATION DATE Z. I hereby affirm that I am exempt from the Contractor's Licensee ,° ().6 1 0, 1 0 cam... Law for the following reason(Section 7031.5, Business and ADDRESS FI Professions Code): PRESENT -06 21 8 4 ❑ BUILDING I, as owner of The property, or my employees with ADDRESS _ L t wages as their sole compensation,will do the work and `=�,' �; 4 ; y .` %N\ ' ' the structure is not intended or offered for sale(Section LOCALITY �E 1 7044, Business and Professions Code). MOVING TEL. ❑ I, as owner of the property, am exclusively contracting rADDR TOR NO. with licensed contractors to construct The project (Sec- tion 7044, Business and Professions Code). 2 6 '�9 A ED TOTAL SETBACK FROM . ST. . CONSTRUCTION LENDING AGENCY K YARD HWY PROP. LINE WIDTH' 1 I hereby affirm that there is a construction lending agency for # ° ° o'a 23 the-performance of the work for which this permit is issued (Sec. 3097, Civ. C.). a .1 - 61 0 1 0 Lender's Nameo ° 61 Q1 0�.LDMA Ref. # O op 3* Lender's Address $ /�i Permit Fee M o p %8 8 5 t I certify that f have read this application-and.state that the Issuance Fee r LDMA P/C# - ' r\ N..o O, above information is correct. I agree to comply with all County ion Feen Sp Qp o v ordinances and State laws relating to building construction, Total Fee logy LDMA Perm. # - OD['NJ N .000 ' U and hereby authorize representatives of this County to enter 01 upon the bove-mentioned proper r ins ection purposes. �� CH a SEE REVERSE FOR EXPLANATORY LANGUAGE a C i Si' ure of ppli nt ent Date Oo i 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 1203280011 PHONE: (626) 285-0488 EXT: LEGAL ID: NO. OF CONST BUILDING ADDRESS: 1TR: 36735 LT: 11 SQ. FT STORIES TYPE 10336 KEY WEST ST I (STRUCTURE: V-B TEMP CA 917803476 ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET: 18585-018-075 I THOMAS PAGE: 597 GRID: C4 LOCALITY: TEMPLE CITY, Cl TENANT: (EXIST BLDG USE: RESID USE ZONE: R-1 JISSUED ON: PROCESSED BY: IEXIST OCC GRP: , 103/28/12 SR TOWNER: TEL. N0: iBLDGS. NOW ON LOT: VALUATION: (FIN V F�NAj(VY: CODE: I SHIRAZI, ALI � 4,500 10336 KEY WEST ST TEMP 917803476 FEES PAID IDES RIP ION OF WORK BATHROOM REMODELING TILE INSTALLATION WALL, FLOOR AND BASE IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT: IBOARD APPLICANT: TEL. NO: I I IHOME IMPROVEMENT & MAINTENANCE (626) 733-2228- 1AA BLDG PERMIT ISSUANCE 27.80 1 118824 E. ARMSTEAD ST IAB STATE GREEN BLDG FEE 4500.00 VAL 1.00 ISPECIAL CONDITIONS: I 1AZUSA, CA 91702 IAC STRONG MOTION RESID 4500.00 VAL 0.50 1 1 JB2 PERMIT W/ENERGY 4500.00 VAL 145.90 1 IFR INV WORK W/O PERMIT 342.20 DOL 342.20 ICONTRACTOR: TEL. NO: I TOTAL FEES 517.40 (APPROVALS DATE INSPECTOR SIGNATURE IHOME IMPROVEMENT AND MAINTENANCE (626) 738-2228- 1 11 118824 E. ARMSTEAD STREET LIC. NO 1 (LOCATION AND SETBACKS I i IAZUSA, CA 91702 913493 B I1 1 1 ISOILS ENGINEER APPROVAL I I I I I I 1ARCHITECT OR ENGINEER: TEL. NO: 1 (FOUNDATION/TRENCH FORMS I LIC. NO: i 1SLAB/UNDER FLOOR I I I I 1 IRAISED FLOOR FRAMING I I I IMAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP: ( (UNDERFLOOR INSULATION I I I147H273 3 001 1 111 I I IFLOOR SHEATHING I I I INO. OF FAMILIES: DWELLING UNITS: APT/GOND: STAT CLASS: I I I I I 0 NO 21 1 IROOF SHEATHING I I I SCHOOL WITHIN HAZARDOUS I ISHEAR PANELS I I I 1AIR QUALITY: 1000 FEET MATERIALS NO NO NO (FRAME INSPECTION I I I IFIRE SPRINKLER HANGERS 1 I 1 I I I 1 1 11NSULATION/WEATHER STRIPI I I 1 I 11NTERIOR LATH/DRYWALL 1 I I I 1EXTERIOR LATH I 1 I I I I IRATED'FLOOR/CEIL ASSEM. I I I I IRATED WALL ASSEMBLIES 1 1 I I I 1 I IRATED SHAFTS/OPENINGS I 1 I I I I IT-BAR CEILINGS 1 1I (LOT DRAINAGE 1 I I I I I 1 IREPORT ID: DPR261 ROUTE TO: BS0508 I I I 1 I