HomeMy Public PortalAbout6141 LOMA AVE_Miscellaneous__ I
WORKERS'COMPENSATION DECLARATION 76M444
_ CE 875 (11-84) MISCELLANEOUS APPLICATION
I hereby-affirm That I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
msure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec 3800,Lab C).
Policy No Company FOR APPLICANT TO FI LL IN BUILDING /�/ !�
r /� ADDRESS LCL
Certified copy is hereby furnished. ADDRESS
/1`B L�vv%.A ao— . `�Qt 1A, `;' LOCALITY
UILDING
ADDRESS b
0 Certified copy is filed with the county building inspection 0CALITY NEAREST
department. L CROSS ST.
Date Applicant NEAREST IF, DISTRICT NOJ GROUP TYPE PR CE ED BY
CROSS ST - CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY
_ NO (CIRCLE) STATE MAJOR SECOND LOCAL
NO OF BLDGS.
(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIA CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE OF
SIZE OF LOT EXISTING BLDG. 1
I certify that in the performance of the work for which this n ^ o
permit is issued, I shall not employ any person in any manner OWNER ?4-TAl �l� - s>
so as 'to become subject to the Workers' Compensation Laws MAIL /I {1 OCCUPANCY GROUP �
ADDRESS bI LOY",A RVt• O
Date Applicant f3
N- Ca�I y NO
TEL __I
NOTICE TO APPLICANT If, after making this Certificate of clrr_ IA 8 O OCCUPANT LOAD °-
Exemption, you should'become subject to the Workers' vZ
Compensation provisions of the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE
with comply with such provisions or this permit shall be TRAILER USEGEOLOGY INSPECTION ❑
❑ E] No Spec. Knowl.
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices
El
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT E] (LIST ITEMS BELOW)
9 (commencing with Section 7000) of Division 3 of the Busi- NO. OF EXITS
ness and Professions Code, and uiy license is in full force and `
effect. PARKING SPACES REQ•D PROVIDED
License Number Lic. Class _ LIMITED TIME USE
Contractor Date DATE DATE
FI am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S
acting m my professional capacity (Section 7051, Bus- EXISTING BLDG STORIES FROM SIGNATURE
mess and Professions Code). FINAL APPROVAL
PRESENT USE OF BUILDING
Lic or Reg.No Date
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE •,1••'i
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code). NO. PARKING
SPACES PROVIDED
El I, as owner of the property, will do the work and the —
structure is not intended or offered for sale (Section i O 41L 238 ® 6�
7044,Business and Professions Code) _
CONSTRUCTION LENDING AGENCY
PROPOSED USE OF BUILDING ��...?i!, i:f�1a•�� I
I hereby affirm that there is a construction lending agency CHANGE
for the performance of the work for wluch this permit is
issued(Sec. 3097,Civ C.)
Lender's Name
(+to k_i'i I_il,+
PROPOSED MAX OCC
Lender's Address—
.9
''''' R�!�11=-.9
PERMIT FEE
I certify that I have read this application and state that the G
above information is correct I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction,
and hereby a thorize representatives of this County to enter TOTAL FEE r, 6
upon theb -mentro ed proper y for inspectio purposes
pIs— SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date
If',
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MISCELLANEOUS PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS MP 0508 0304020002
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
0. .
TR: 5904 LT: 253 SQ. FT STORIES TYPE OCCUP GROUP 6141 LOMA AV
STRUCTURE: 1 VN R3 TEMP CA 917801633
ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET: LONGDEN
5384-010-018 EXIST BLDG USE: THOMAS PAGE: 596 GRID: H2 LOCALITY: TEMPLE CITY
EXIST OCC GRP: USE ZONE: ISSUED ON: PROCESSED BY: EXPIRES ON:
BLDGS. N 04/02/03 JK 09/29/03
0
OWNER: TEL. NO: FINAL DATE FINALBY: CODE:
CHANDRA RITA (626) 285-0135- LIST ITEMS:
6141 LOMA AV
TEMP 917801633 UNEUMN-bT WORK
HOUSE-REMOVE EXTERIOR DOOR FROM BEDRM;CONVERT SLEEPING RM TO
OCCUP LOAD EXIST: INTENDED USE-REMOVE WALLS/DOORS TO CREATE 2SR,18A & LAUNDRY
APPLICANT: OCCUP LOAD NEW:
SAME AS OWNER
PARKING SPACES REQUIRED: SPECIAL CONDITIONS:
PARKING SPACES.PROVIDED:
EXIT HARD ARE -,Pl _ \\
CONTRACTOR: TEL. NO: /j � ��'�� "�.i��A,�� LIMITED TIME USE
SAME AS OWNER NBR=OFIEXILTS: FROM TO
LIC. NOFEES PAID
%� �'✓�� .✓ ������.
APPROVALS DATE INSPECTOR SIGNATURE
FEE/SCRIPTION: QUANTITY: UOM: AMOUNT:
ARCHITECTnr )—" %_ TRA LP USE
OA PERMIT ISSUANCE 27.75
LIC. NO- U1 RIM OCC SE INSPECT <<�--� 145.95 A MIT
f TOTAL FEES'11 111� 173.70
MAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: r TEMP. STRUCT. REMOVED
N0. UNITS: AP /C D: STAT CL S: -
NO - --
SCHOOL WITHIN HAZARDOUS
AIR QUALITY: 1000 FEET MATERIALS
NO NO NO "
REQUIRED TOTAL SETBACK FROM EXIST
SET BACK YARD: HWY: PROP LINE: WIDTH:
FRONT PL- = '-
SIDE PL — --- "
REPORT ID: DPR267 ROUTE TO: BS0508