HomeMy Public PortalAbout6123 LOMA AVE_Building__ a WORKERS'COMPENSATION DECLARATION
Insuref�y affirm that IIhave a certificate of consent to selfi�I� p n n, ®�Yn� [ �i Q
insure, or a certificate of Workers' Compensation Insurance, (/� �f'.L� (��`U IJ tJ v {J�J E (&
21
or a cei iified copy.iRereof (Sec-3800, Cab C )
COUNTY OF LOS ANGELES ' I 4BUILOWG AND SAFETY ---
Policy,No Company
.❑ : Certified co 'v is'kereby furnished BUILDINGFOAPPLICANT TOFIIN
ADDRESS
❑ ,Certified'copy is'�filed with The county building inspec- BUILDING
tion department . ADDRESS f-/-I L
Date'' •+•4 e° '., Applicant CITY -ZIP / - �L� LOCALITY`
CERTIFICATE OF EXEMPTION'FROM WORKERS' - --NO OF BLDGS- NEAREST- ! _
COMPENSATION`INSU RANCE <• SIZE OF LOT NOW ON LOT s CROSS ST ;
(This'isction^need not be completed if the permrt;is for••one - --- ASSESSOR
e �•'•+`","
hundred dollars ($100)or less ) TRACT BLOCK LOT NO MAP BOOK `" PAGE( PARCEL
r A y TEL USE ZONE MAP
certify that to the performance of the'work for which:this OWNER' /� I / NO NO
per'rnit is issued I'sli6ll not employ any person in'any mariner , t ) - , SPECIAL - •-
so'as'to bec r sulilect tdthe Woikers'Compensation Cows ADDRESS- ^�!� / �e7 ✓ CONDITIONS
t: 3+
:•SS•• n PT•. s' LGS ZIP or:
Dateld aPPltca CITY_. - - O
C/ CHITECT OR TEL DISTRICT GROUP TYPE �_ FIRE :___PRO CESSED,BY._
NOTI TO1,APPLICANT If, after making this Certificate of CONST - \'ZONE ;.�
r, ENGINEER - NO
Exem tion, you should ecame subject to The Workers' (x� 0 2
ComJAU
pensationaprovistons of:the Labon'Code, you must forth- ADDRESS SI��+ - N
,with comply, with such provisions or,this•,permit shall, be _ -- ti==+,
deemed revoked :, /1�i IJP C TEL J��y STATISTICAL CLASS C TION { . APT r• C
t =� ' +• "t ea +," CONTRACTOR 4� v NO'
LICENSED CONTRACTORS DECLARATION ,• -•- p' LIC- =• CLASS NO i DWELL UNITS- �' Tt
AhA
I hereby affirm that I am licensed under provisions of Chaptei 9 ADDRESS /�` NO -
commenciri with Section 7000 of Division 3 of the Busiriess and E:S.EWIER MAP
(_ e ). L uct
Professions Code,'and my'license is'in full foice and effect CITY �Q CLASS 'VALIDATION`
1• =1nu .• t• mI
�' SQ FT NO OF _ NO OF CHECK
L cense Number ` Lic Classf` SIZE ✓7 STORIES FAMILIES ONE ni ! _6�fiSL a;
` VALUA ION
Contractor /1�� Date DESCRIPTION OF WORK NEW ❑ /) �'y
❑ ra ` - - ADD ❑ $ tt
(�
1 am exempt under Sec lC. /i
1r` r'• t• P ALTER El
°'2�
B&P C for this reason ph REPAIR 1:3 8
/ ❑ ; - -
- _ -Date -` �2
EXISTING BLDG DEMOL ❑ ^ ___•__. 00 2.3 7-3-8
APPLICANT. — - - TEL - '
-Signature FINAL' —�8
PRINT NO 41
U, 6
• OW R- DE EGLA T __ _ _ __ _ _ _ _ _ DATE-- w� �. --.•- --- �- -•
�1.hereby affirm that I am exempt,from.The Contractor's License
Law for the following-reasoni,(Section'7031 5, Business and ADDRESS FINAL +
Professions'Cod'e)
PRESENT - BY:
❑ - I;
as-owner of,The ro ert ci m employees with ADDRESS
wages 6s`thetr sole compensation,will do the work'and r ff' '
the structure is not intended or offered for sale(Section LOCALITY - {
-'7044, Business and Professions Code) -'^' MOVING _TEL
CONTRACTOR NO
I, as owner of the property,,am exclusively contracting
a witli licensed contractors to construct the prolect'(Sec-
tion 7044, Business and Professions Code)
ADDRESS
REQUIRED TOTAL SETBACK Y,.
_ _ ,
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP LINE WIDTH
I hereby affirm that there is a construction lending agency for FRONT i t k ;}`t• t `.''''�; '`�-''''''
-the:performance of-the work-for-which this-permit•is-issued P L
(Sec 3097, Civ C )' , SIDE
-Lender's Name _ n
S _ Y _ LDMA.Ref q
- - -- - - - -- - - - - P C Fee$ - - Permit Fee -,-
-Lender's Addiess // �-j� ti' t";
I-certify that I_have read this application.and state.that.the _ _- - Issuance Fee -(}D V L/ - [(LDMA P/C --
a above information is correct I agree to comply with all County Investigation Fee
_ordinances and State laws relating to building construction, _ _ - - Total Fee 3. / LDMA Perm
and hereby authorize representatives oftkisCounty to enter
upon the above-mentioned roperty for ction p oses
o C SEE REVERSE FOR EXPLANATORY LANGUAGE y
-y =- -• Signature o Applicant or Agent - - Date - •- _ _. ..._ ...... ... _ ._ _ -. _._ - _ _-_
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 0807140003
PHONE (626) 285-0488 EXT
ILEGAL ID NO OF CONST BUILDING ADDRESS
ITR 5904 LT. 255 BL 001 I SQ FT STORIES TYPE 6123-LOMA AV
STRUCTURE 5 V-B TEMP'CA 917801633
(ASSESSOR INFORMATION NUMBER NEAREST CROSS STREET LAS TUNAS
15384-010-021 THOMAS PAGE 596 GRID H2 LOCALITY: TEMPLE-CITY, Cl
I � I
ITENANT IEXIST BLDG USE GARAG USE ZONE R-1 11SSUED ON- PROCESSED BY EXPIRES ON
EXIST OCC GRP 107/14/08 SR 01/10/09 1
(OWNER TEL NO: IBLDGS NOW ON LOT VALUATION IFINAL DATE FI Y CODE.
IHUYNH, JIM (626) 228-5289- 1 2,200 I' (,`�1��/j
16123 LOMA AVE 1 :� 6y"
ITEMPLE CITY CA 91780 I FEES PAID D SCRIPTION OF WORK
ITEAR,OFF & REROOF W/30 YR `SHINGLES
1 FEE DESCRIPTION QUANTITY UOM AMOUNT- (
(APPLICANT TEL NO
IRIOS (626) 444-7555- IAA BLDG PERMIT ISSUANCE 27 75 1
19613 GIDLEY ST IAC STRONG MOTION RESID 2200 00 VAL 0 50 ISPECIAL CONDITIONS
ITEMPLE CITY CA 91780 ID2 PERMIT W/O EN-HC 2200 00 VAL 99 00
TOTAL FEES 127 25
CONTRACTOR TEL NO I (APPROVALS DATE INSPECTOR SIGNATURE I
ITILLY'S ROOFING SERVICE, INC (626) 444-7555- I 1 1
19613 GIDLEY ST LIC NO I ILOCATION AND SETBACKS 1 1
ITEMPLE CITY CA 91780 - 901287 C39 I I 1 I
1 I ISOILS ENGINEER APPROVAL 1 1
(ARCHITECT OR ENGINEER TEL NO IFOUNDATION/TRENCH FORMS I I I
LIC NO ISLAB/UNDER FLOOR I I I
I I I I I
IRAISED FLOOR FRAMING I I
IMAP NO SEWER MAP BOOK PAGE FIRE ZONE CMP (UNDERFLOOR INSULATION I I I
1150H265 3 Oil I 11 I
I I IFLOOR SHEATHING I 1
INO OF FAMILIES DWELLING UNITS APT/COND STAT CLASS I I
NO 21 I (ROOF SHEATHING P
SCHOOL WITHIN HAZARDOUS I SHEAR PANELS
(AIR QUALITY 1000 FEET MATERIALS I 1 I 1
NO NO NO I FRAME INSPECTION
I I
(REQUIRED TOTAL SETBACK FROM EXIST 1 (FIRE SPRINKLER HANGERS
(SET BACK YARD HWY PROP LINE- WIDTH
IFRONT PL- (INSULATION/WEATHER STRIPI I I
I SIDE PL- I 11 11 I
1 .1 (INTERIOR LATH/DRYWALL I I
1 I IEXTERIOR LATH I I I
IRATED FLOOR/CEIL ASSEM I
I I I I I I
IRATED WALL ASSEMBLIES
I I I
1 1 (RATED SHAFTS/OPENINGS 1 1 1
I I I
1 I IT-BAR CEILINGS I 1
I I I
I ILOT DRAINAGE
I I I I I I
REPORT ID DPR261 ROUTE TO BS0508