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HomeMy Public PortalAbout10415 KEY WEST ST_Building__ WORKERS' COMPENSATION DECLARATION hereby affirm that I have a certificate of consent to Self APPLICATION �,�OR ILDING PERMIT Insure, or a certificate of Workers'Compenst n Insurance, ora certlfle�ciop re%of (SecLabCOUNTY OF LOS ANGBUILDING AND SAFE Policy IVb �( /Comn -" '`�� BUILDING ❑ Certified copy is hereby furn shed d'� FOR APPLICANT TO FILL IN ADDRESS Certified copy Is filed with the county bull Ing Inspec- BUILDING tion department ` ADDRESS Q LOCALIT /� j NEAREST Date Applicant CITY (i 1t ZIP 1 © CROSS ST, 'CERTIFICATE OF EXEMPTION FROM WORKERS' 1 NO OF BLDGS ASSESSOR COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT © MAP BOOK PAGE PARCEL (This section need not be completed if the permit Is for oneUS ONE MAP hundred dollars ($100) or•less ) TRACT �� BLOCK LOT NO NO SPECIAL OWNER , V CONDITIO NO NS O I cepfy that In the performance of the workJor which this — , IS RICT GROUP JTYP.E FIRE P CE ED BY permit is issued; I shall nADDRESS'not employ any person in any manner E V so as to become subject.to the Workers'Compensation Laws 1 0 / Date ' t Applicant CITY _ G ZIP O© STATISTICAL CLASSIF}GA;ION ly APT CONDO NOTICE TO'APPLICANT If,+'after making this Certificate of, ARCHITECT OR p TEL 4 _ Uv LU - Exemption, you should become subject to the Workers' ENGINEER O CLASS NO DWELL UNITS d Compensation provisions of the Labor Code, you must forth- ADDRESS v N ' SEWER MAP Z with comply with such provisions or tHis permit shall be TE deemed revoked ,- CONTRACTOR NO '2 BK ' PG, VALIDATION LICENSED CONTRACTORS DECLARATION AA L1C I hereby affirm that I am licensed under provisions of Chapter 9' . ADDRESS NO, VALUATION _ (commencing with Section 7000)of Division 3 of the Business andLIC - Professions Code, and my license'Is in full force and effect CITY - 1 CLASS $ SQ FT NO OF NO OF CHECK License Number• Lic Class r �' SIZE STORIES FAMILIES ONE 4,9 4, 1 A ContraclorFattir{'aa.f/er) DeVote DESCRIPTION OF WORK )l NEW $ -#Io 0 o o 2 3 ❑ 1 ADD ALTER L ❑ 2 I exempt from the licensing requirements as am a ❑ yr 0 ° 9 1,2 liam censed architect or a registered professional engineer DATE acting in rry professional capacity (Section 7051, REPAIR ❑ ° ° ° 9 1,2 0 0 Business and Professions Code) USE OF DEMOL ❑ 'FINAL Od�`—p+� EXISTING BLDG By O A24-8 1 Lic or Reg No Date APPLICANT TEL OWNER-BUILDER DECLARATION PRINT) NO I hereby'affirm that I am exempt from the Contractor's License ADDRESS 14 2S lie lie Law for the following reason (Section 7031 5, Business and Professions Code) PRESENT BUILDING ❑ I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and C the structure Is not intended or offered for sale(Section LOCALITY. - ;.9-4 94,2 A ' 7044, Business and Professions Code) MOVING TEL ❑ 1, as owner of the property, am exclusively contracting CONTRACTOR NO # o o o o o 1 with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code) - 21°,515 41,5 0 REQUIRED TOTAL SETBACK FROM EXIST CONSTRUCTION LENDING AGENCYSET BACK WIDTH YARD HWY PROP LINE o`0 5-5 IL 5 0 = — I hereby affirm that there is a construction lending agency for FRONT the performance of the work for'which this permit Is_Issued PL �' 04 24-8'1 , (Sec 3097, Gv C ) SIDE - Lender's Name P L ' P C Fe�� Permit Fee Lender's Address w I certify that I have read this application and state that the Issuance Fee - above information Is correct I ogree�to comply with all County Investigation Fee a ordinances and State laws relating to building construction, � Total Fe and hereby authorize representatives of this County to enter' a upon t e above-m phoned arty for spection purposes ; I m a / SEE REVERSE FOR EXPLANATORY LANGUAGE ©s I ;gnat e of pp t or Agent . Dote • I I �. WORKERS'COMPENSATION'DECLARATION hereb` affirm that I,have,a certificate of consent to self �' insure, or a cert,ficate of Workers' Compensation Insurance, I�P P L I CAT I O N FOR B U I LjD I N G P E RM I T or'a certified copy thereof (Sec 3800,'Lob C ) - :, -,+•, COUNTY OF LOS ANGELES ' BUILDING',AND SAFETY Policy No Y- Co,�po^y - - . - - ❑• Certifiec6copy is hereby furnished FOR APPLICANT TO FILL IN BUILDING ADDRESS ADDRESS t J t ❑; Certified copy is filed with the county building mspec- BUILDING -( 1 tion department r ' ADDRESS / ' Dare `' Applicant v CITY _ ZIP 0- LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' NO OF BLDG NEAREST _ t - COMPENSATION,INSU RANCE {ti SIZE OF LOT NOW ON LOT CROSS ST (This'section needtnot be completed if the permit is for''one TRACT » BLOCK~ LOT NO L ASSESSOR `"�^F"" • •• hundred,dollars ($100)or less )• MAP BOOK'^` PAGE. PARCEL TEL - USEwZ�NE MAP °` F/f No I (,certify that m the performance of tFie work for wh ch this OWNER- - NO 3 r in•.• SPECIAL-SPECIAL - - _ d per is issued, l shall noi'employ any person in any manner ,, 1111 I • O so'as to become 'sublect to the Workers'+Compensation Laws ADDRESS- W ��� t / CONDITIONS - V Date Applicant ,4 L. _. CITY ZIP. O NOTICE'TO APPLICANT •If, after making'this Certificate of ARCHITE TOR TEL _-DISTRICT _GROUP, TYPE FIRE PRO ED BY ENGINEER NO CONST i _ ZO Exemption, you ;should become subject to the Workers' W Compensatiowprovisions of the Labof:Code,.you must.forth- ADDRESS 'V /`��- -=- ✓ y with comply with' such provisions or,this permit shall be - --- TEL STATISTICAL CLASSIFICATION APT CO - Z deemed revoked',t , ,,_• „ CONTRACTOR NO LICENSED CONTRACTORS DECLARATION - I., - - , • - -- - - y LIC' CLASS NO -BSI-DWELL UNITS I hereby affirm that I am licensed under provisions of Chapter 9 of NO (commencing with Section 7000)of Division 3 of the Business and _ _ __ _ LIC SEWER MAP 1 t' Professions;Code, and my license is in full force and-effect CITY CLASS '" i - VALIDATION t " SQ FT NO OF NO OF _ CHECK t BK, PG License Number Lic Class SIZE STORIES- FAMILIES ONE' VAL ATI N i E i DESCRIPTION OF WORK NEW ❑ u= DO Contractor Date ❑ S ADD $ ❑ I am exempt under Sec -- - _ __ __ .❑ - 1 , f - ` ALTER B 8P C for this reason _ _ _ _ REPAIR _❑ $ � Date USE OF DEMOL � 47.3 A- ❑ I - EXISTING BLDG it'' APPLICANT TEL �o e o e o Signature -- G FINAL t OWNER-BUILDER DECLARATION PRINT NO -� DATE• - ,I,hereby affirm that,l am,exempt from•the Contractor.'s LicenseS <T FINAL T ° ° 6'a b 3 Law for the following reason (Section 7031 5, Business and ADDRESS Professions Code) "' PRESENT BUILDING 6 8 6 3�, 1, as owner of the property, or my employees with ADDRESS '_ wages a`s their sole compensation,will do the work and } »�, .1 ^j Q (�2 3-8 E5- the , the structure is not intended or offerer for sale(Section LOCALITY _ - , .T a {_,i' , - 1 ; 7044, Business and Professions Code MOVING TEL' i' 1 ❑+ 1, as owner of the property, am exclusively contracting CONTRACTOR _ J NO with-licensed contractors to construct the project-(Sec- ,t ADDRESS tion 7044, Business and Professions Code) - � , � ;�` r1`��`' -ty J�'i�✓�; , s REQUIRED- TOTAL SETBACK - CONSTRUCTION LENDING AGENCY ' SET BACK YARD 'HWPROP LINE WIDTH: I 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 1 P L Lender's No Y !�/ �/ ►v�� - [DMA Ref # ',. f' Lender's Address - _ - - - PC Fee$ - - Permit•Fee - > y t x L.certify.that I have read this application and state that the » _ _ Issuance Fee• Or�O kLD P/C•# - - - -- above information is correct I agree to comply with all County Investigation Fee_ 2 c o ordinances-and State laws relating to building construction, _ _, fJJ I- and hereby authorize representatives of this County to enter - Total-Fee b LD"Perm # I:, upo thebove for inspectionpurposes dS SEE REVERSE FOR EXPLANATORY LANGUAGE - SignaturVoT Applicant or Agent Date t 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 0310100018 PHONE: (626) 285-0488 EXT: LEGAL CONST BUILDING ADDRM TR: 37579 LT: 8 SQ. FT STORIES TYPE 10415 KEY WEST ST STRUCTURE: VN TEMP CA 917803479 ASSESSOR R A IO NEAREST CROSS STREET: HALIFAX 8585-018-029 THOMAS PAGE: 597 GRID: C4 LOCALITY: TEMPLE CITY IST BLDG USE: D USE ZONE: - S ON: PROCESSED BY:- -EXPIRES . EXIST OCC GRP: _ 10/10/03 JK 10/04/04 OWNER: TEL. NO: B DGS. NOW ON LOT: VALUATION: I AL T FIN BY: CODE: GORDON KENNETH W;JO ANN (626) 443-0684- 10,000 , 10415 KEY WEST ST TEMP 917803479 FEES PAID D46CRIPONOF WORK FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: ROOF 4USE & GARAGE; INSTALL 1/2"CDX & 30YR CLASS A COMP APPLICANT: MUSULMAN ROOFING (626) 339-0394- AA BLDG PERMIT ISSUANCE 27.75 1066 EDNA AC STRONG MOTION RESID 10000.00 VAL 1.00 SPECIAL CONDITIONS: COVINA, CA D2 PERMIT W/O=EN=HC 0000.00 VAL 216.60 GELES �®AL�aEEES 245.35 MUSUCONTLMANO ROOFING CO., INC. (626)N339-0394 APPROVALS DATE INSPECTOR SIGNATURE 1066 E EDNA PL LIC. NO LOCATION AND SETBACKS COVINA CA 91724 420356 C39 //G// SOII S ENGINEER APPROVK-L- ARCHITECT OR GINEER: T O/ FI N/TRENC S t LIC. NO, I 1111111 SLAT,/UNDER FLOOR RAIS OOR FRAMflTT-- MAP NO: SEWER MAP BOOK: AGE: FIRE NE: � CMP: 1 n � i�����K �� UNDIRFLOOR INSULAT147H273 3 X01 J OL � \J `Ju F C' HING NO. OF AMIL : DWELLING UN T/CO LASS:- NO 1 ROOF SHEATHING WITHINSCHOOL HAZARDOUS �t SHEAR A ELSAIR QUALITY: 1000 FEET MATERIALS Ute_; NO NO NO n 1 � FRAh,E INSPECTION REQUIRED TOTAL SETBACKST �J FIPT SPRINKLER HANG SET BACK YARD: HWY. PROP LINE: WIDTH:FROSebvniceTh� INSULATIONNETTHER STRIP SIDE PL- INTERIOR AT EXTERIOR LATH RATED LOOR ASSEM. RATED WALL ASSEMBL S i RTTTE D SHAFTS/OPENINGS T-BPR CEILINGS LOT DRAINAGE _ REPORT ID: DPR261 ROUTE TO: BS0508 i