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HomeMy Public PortalAbout10405 KEY WEST ST_Building__ WORKER OMPENSATION DECLARATION >' N, ': • .t` ' s; " 1 hereby`f.iffirm that have a certificate of consent to self -APPLICATION F O R :BUILDING PERMIT insure, 'or frcaie f Workers''Compensation Insurance, or a certified c y th f`(Sec 3800, Lab`C ) °' "- "' - t- ��� COUNTY OF LOS ANGELES BUILDING.AND SAFETY Policy No mpany ❑•nCertified copy is In re f fished FOR APPLICANT TO FILL IN ,' BUILDING /� �y f i 4 ADDRESS ;d (/_7 •r• ❑Fj Certified copy' s filed th s e'counfy bu d c- - BUILDING -� / ` n de�parrtme ' 'v ADDRESS Date-/ /G� Applrcant• _ CITY ZIP N LOCALITY CERTIFICATE OF'EXEMPTION FROM W S' - NO OF BLDGS NEAREST _ ` - COMPENSATION IN,UR AN• 1 3 6 • ' I „ SIZE OF LOT NOW ON LOT CROSS ST ,r (This section need not be completed if th ermit is for..one . - - - • - ASSESSOR - '� _hundred dollars ($100)or less ) i TRACT LOCK - LOT NO MAP BOOK<~' PAGEI PARCEL _ TEL USE ZONE MAP I,yertify rthat m the performance of tFie work for which this OWNER (�' ,(f ' �{, N / NO — 7�,.,< ;} permit is issued,"'shall not employ an`y per, in any manner �r _ _ �_�-• SPECIAL, - d 'sb,as to'become'sublect to the Workers'Compensation Laws ADDRESS �'/ _ , CONDITIONS w, , '1W*"!- t,v•.<, , + O CITY v. d __ _.-. ZIP i- 'Date .• ,. � •APPI leant'' _ �.1.. _.._ -: •- •-r rt_�<,,? .. NOTICE`TO APPLICANT•t If; after makin this Certificate of ARCHITECT OR lJ TEL 7' r DISTRICT_,_ GROUP TYPE' __ _ FIRE �ESE 0 g ENGINEER �7 / v1L N l / CONST' ZONE ~ Exernotion,' you'should 'become subject`to the' Workers' //IIQ �y • i Compensation-provisions of,the Labor:Code, you must forth- ADDRESS Q �vU = I7 - - with comply.with"such provisions or this.permit shall be"-'-- -• _ �� - N TEL ���p STATISTICAL CLASSIFICATION 3 APT CONDO t deemed revoked �, . / j��Q LC//% N _' CONTRACTOR LICENSED CONTRACTORS DECLARATION 1 - - LIC ) CLASS NO _DWELL UNITS 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 M _, LIC - SEWER MAP Professions Code, and'my hcense'is"in full'force and effect CITY Ei(li� CLASS v' - 'VALIDATION ` ! SQ FT NO OF__ S.LL NO OF CHECK License Number Li Class ! SIZE STORIES FAMILIES_ ONE +,-r;vt.'•„ 1 t F, .,s ,+ -j as .�J., . •a •+ � �t •' /� VALUATION Contract < �'�" ' Date DESCRIPTION OF W (,-LQ.S NEW $ ` ��,` ADD• , r ❑ I am exempt under Sec -- - -- - i �✓- -r_..- -�t ' ALTER •❑ . l" /� Q c� B&P C for this reason ..L ` sl .REPAIR -❑ s ""' " - t - USE OF S ` Date EXISTING BL I� DEMOL* ❑ __ _" 'v APPLICANT OLI L Signature _ - PRINT FINAL OWNER-BUILDER DECLARATION _ _ DATE - �• w• . - - I hereby affirm.that I am exempt from the Contractors License ADDRESS Law for the following reason'(Section 7031 5, Business and FIN Profess ions"Code) p , BY BUILDING �T ' -❑,- 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 t a 7044;Business'and Professions Code) ""' MOVING `- _,_ _ _ w _ TEL' _,JWIDTH' � __, _- )_ _ ❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO t n ' 'with'Incensed-contractors to construct the project-(Sec- tion 7044, Business and Professions Code) � - • •' , ' e. . _REQUIRED TOTAL SETBACK FRO _ _ _____ _ ..tt o 0 0 -CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP LINE - -^ i hereby affirm that there is a construction lending agency for FRONT T; `c;1,-'5 I the performonce-of the work for-which this permit is issued P L- - - - - "I5-95(Sec 3097, Civ CSIDE + o 0 0 5,9,2,5=Lender's Name PL 1.03`y8 UARef q b+'PC Fee$ - -- PermitFeeLender's Address 1 r r yry I rti that I hav rad i . licahon and state that the _. __. �.- _fY P Issuance FeeP/C ffe information rr t tee to coin I with all Count PY Y Investig."on Fee o_ nces and S t I sting to building construction,an , , y auth r e ntatrves of this County to enter Total Fee A�Perm'N upo e a v e roperty for inspection purposes a SEE REVERSE FOR EXPLANATORY LANGUAGE 'Signature f phcantorAgent- rDate - -••_ ._ ._, _ _.-_. .. .r. - _._ _..__ __ -. ... _ __-.,-:,.Lx - ', � .•. .�_ �, _ �.,,,, __. Qi 4 , n WORKERS' COMPENSATION DECLARATION hereby affirm,that I have a certificate of consent toc self App I CAT I®N *FO I� 1 L D 1111 G PERMIT , insure, or a certificate of Workers'Compen on Insurance, or (Sec a certified copy thereof ' 3800, Lab Policy! ���ompa COUNTY OF LOS ANG ES BUILDING' ND SAF TY Certified copy is hereby furnished i APPLICANT TO BUILDIN J�f�A1 FOR FILL IN ❑ ADDRES /oT°c Certified copy is filed with the'co_unt ud tng tnspec- BUILDING/"�L— tion departm'en't ADDRESS C� � LOCALIT „�, ' ' l 6, • r , I NEAREST Date Applicant r' / CITY J 1 ZIP ilep CROSS ST CERTIFICATE OF EXEMPTION FROM WORKERS" - 1 106,1 .NO OF BLDGS © ASSESSOR COMPENSATION INSURANCE SIZE OF LOT, NOW ON LOT MAP BOOK P PARCEL (This section need'riot be completed if the permit is for one 2 ZO MAP hundred dollafs ($100) or,less ) TRACT?767 BLOCK LOT NO ' NO (/ } TEL '` a,," SPECIAL d I certify^that Ln the performance of the work for which this OWNER r NO CONDITIONS O permit is issued, I shall not employ any person m any manner ISTRICT GROUP TYPE FIRE PROC SED BY tL1 ADDRESS CONS so as to become sublect'to the'Workers'Compensation Laws` ��� GC C 1 O Date Applicant CITY ZIP STATISTICAL)CLASSJFIGQTION A"CONDO V ARCHITECT-OR m- TEL C�✓i�/ NOTICE TO APPLICANT If, after making this Certificate of. ENGINEER NO CLASS NO DWELL UNITS 'Exemption,, you should become subject to the Workers'_ y Compensation provisions of the Labor Code, you.must forth-_ 1 with comply with such provisions or this permit,sholl be ADDRESS SEWER MAP deemed revokedTEL 1 VALIDATION CONTRACTOR 4NO BK PG, t •• LICENSED CONTRACTORS DECLARATION , LIC r,� I hereby affirm that I am licensed under provisions,of Chapter 9 ADDRESS 4 t NO �( S VALUATION f (commencing with Section 7000)of Division 3 of the Business and t LIC Professions Code, and my license'is in full force and effect CITY 9 CLASS $ /� /�� SQ FT NO 'OF NO OF CHECK License Number 26� 64 t'Lic Class SIZE STORIES FAMILIES ONE r ,,'11 UO-'VD - $ Contractor is r ha1.qTafe i DESCRIPTION OF WORK NEW O / cr-z5 n ` ❑ I am exempt from the licensing requirements as I"am a ADD z 4,9-4,3 n_, licensed architect ora registered professional engineer ` ALTER FINAL ,O �7 acting in my professional capacity (Section 7051, ❑ DATE _ 1 # o o,o ° 2 3 Business and"Professions Code) USE OF REPAIR 'FINAL /� EXISTING_BLDG DE OL -Q IF /1 2 0 o,9 1,2 Q Li* or Reg No Date - APPLICANT TEL OWNER-BUILDER'DECLARATION - �f-- p► (PRINT) NO /fG'/ °'0;° 9 1,2 0 50 • I hereby affirm that I am exempt from the Contractor's License , S j 7 ` Law for the following reason (Section 7031 5, Business and ADDRESS 4 E 1� I 07 0 k 2 4-8 1 Professions Code) _ ' PRESENT F] - "- BUILDING 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 7044, Business and Professions Code) MOVING TEL, ❑ 1, 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) i '4 9 G 4 A REQUIRED TOTAL SETBACK FROM EXIST, CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP LINE WIDTH I herebypperformance affirm that there rs a construction which t lenp r agency for' FRONT �. �a /� �� #;e o 0'0 0 1 tfie erformance of the work for which this permit is issued PL //(J�J , .(Sec 3097, Civ C ) _ SIDE . / + 5,5 4,5 Q P L / � '2,o�i , Lender's Name 3 3 4 5 0= m LP C Fee M1 Permit Fe Lender's Address ' 0IL24-81 w I certify that I have read this application-and state that the • �.• y� Issuance Fee �U aabove information is correct I agree to comply with dll County Investigation F6e -- ordinances-and State I-aws relating to building construction, and hereby authorize representahLes of this County to enter- Total Fe a upon"the abo�b-m�enlop6�rtyinspection purposes _ m r a % SEE REVERSE FOR EXPLANATORY LANGUAGE nature ,cant or Ag nt Date Os ,ti 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 9912140041 PHONE: (626) 285-0488 EXT: LEGAL ID: NO. OF EMT BUILDING ADDRESS: TR: 37579 LT: 9 SQ. FT STORIES TYPE 10405 KEY WEST ST STRUCTURE: 0 VN TEMP CA 917803479 ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET: HALIFAX 8585-018-030 THOMAS PAGE: 597 GRID: C4 LOCALITY: TEMPLE CITY T XIST BLDG USE: RESID USE ONE: R ISSUED PROCESS BY: EXPIRES ON: EXIST OCC GRP: 12/14/99 UT 06/11/00 OWNER: TEL. NO: BLDGS. NOW ON LOT: VALUATION: FINAL DAT FIN L BY: CODE: MEE•KYEN (626) 443-8694- 1 6,300 10405 KEY WEST ST TEMP 917803479 FEES PAID DESCRIPTION OF WORK TEAR OFF WOODSHAKE, INSTALL 1/2" PLYWOOD AND APPLYU. S. FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: CLAY LITE TILE ICBO #3523 APPLICANT: TEL. NO: DIAMOND ROOFING (909) 861-7663- AA BLDG PERMIT ISSUANCE 27.75 1636 FOX GLEN DR. AC STRONG MOTION RESID 6300.00 VAL 0.63 SPECIAL CONDITIONS: DIAMOND BAR, CA D2 PERMIT W/O.EN`C 6300.00 VAL 166.20 �OGELESTOTA -FEES 194.58 CONTRACTOR: TEL. NO: ®� ��� APPROVALS DATE INSPECTOR SIGNATURE DIAMOND ROOFING (909) 861-7663- 1636 FOX GLEN DR LIC. NO LOCATION AND SETBACKS DIAMOND BAR, CA. 91765 N/A SOILS ENGINEER APPROVAL L ARCHITECT OR ENGINEER: TEL. NO: FOUNDATION/TRE C R S LIC. N0: 1111111 SLAB/UNDER FLOOR RAISED FLOOR AMING MAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: PUBDMC UNDERFLOOR INSULATION 147H273 3nOUnSKS �RS NO. OF FAMILIES: DWELLING UNITS: APT/CO D: STAT CLASS:, NO 21 V c ROOF SHEATHING SCHOOL WITHIN HAZARDOUS p 19 (f:� SHEAR PA AIR QUALITY: 1000 FEET MATERIALS ! ❑ §w L'-� NO NO NO ® FRAME INSPECTION REQUIRED TOTAL SETBACK FROM EXIST �l�� El -w10d� FIRE SPRINKLER HANG FRONTTSET APL YARD: HWY: PROP LINE: WIDTH: ZC �@ rvic e lb���1tl INSULATION/WEATHER STRIP SIDE PL- NTERIOR LATH/DRYWALL EXTERIOR LATH RATED OOR/CEIL ASSEM. RATED WALL ASSEMBLIES RATED AFTS/OPENINGS T-BAR CEILINGS * ADDITIONAL DATA ON FILE OT DRAINAGE REPORT ID: DPR261 ROUTE TO: BS0508