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Home My Public Portal About9592 LOWER AZUSA RD_Building__ - WORKERS COMPENSATION DECLARATION 7 r °ocetifcoteo certificate of APPLICATION FOR BUILDING PERMIT air or a certified co6y thereof{Sec 3800 lab C ) ��,��D COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No Company ak 1:1Certified copy is hereby f0rnished FOR APPLICANT TO FILL IN BUILDING ADDRESS �ertified copy is filed with the county building inspec FADDRESS, DING �f tion department oc aDate 8 Applicant u VAID1S00JI BUILT M t: t ZIP LOCALITY , CERTIFICATE OF EXEMPTION FROM WORKERS No SIZE OF LOT NOW F LOT NEAREST COMPENSATION INSURANCE (This section need not be completed if the permit is for one ASSESSOR hundred dollars($100)or less ) TRACT BLOCK LOT NO r MAP BOOK PAGE PARCEL TEL - USE ZONE MAP I certify that in the performance of the work for which this OWER �}RS NO NO permit is issued I shall not employ any person in any manner 2 SPECIAL so as to become subject to the Workers Compensation T Compensation Laws Z CONDITIONS CITY t Pn l X- trC ZIP Date Applicant NOTICE TO APPLICANT If after making this Certificate of ARCHITECT OR TEL DISTRICT GROUP TYPE FIRE CESSED BY O Exemption you should become subject to the Workers ENGINEER �Z..10 NO '6 6 Z CONST ZONE Compensation provisions of the Labor Code you must forth ADDRESS / /3 /LLETZ l� �/✓A/�IE/ ✓` U�j �- W with comply with such provisions or this permit shall be �+w d.' deemed revoked CONTRACTOR IAN A� gnC.S TEL X-6MZ STATISTICAL CLASSIFICATION APT CONDO N LICENSED CONTRACTORS DECLARATION LIC CLASS NO Z DWELL UNITS Z I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS 31 /V MILL Cit O SiV/-/O 6 (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 ANA14ci '' CA CLASS SK PG VALIDATION SQ FT NO OF NO OF CHECK License Number ��`/d 6 Lic ClassSIZE JtVOg ISTORIES FAMILIES ONE VALUATION Contractor CAN"AM C OIL Date /e DESCRIPTION OF WORK JAW ()IFP11M NEW Q $ /"6 ,00 0110.I am exempt under Sec �L WAX vy10 V1'aQ /I�OtfJ ADD ALTER J* 13 B&P C for this reason WeAf AVV7Wv = REPAIR $ USE OF Date EXISTING BLDG l DEMOL Signature APPLICANT TEL ' FINAL Gyt OWNER BUILDER DECLARATION PRINT A conT NO Z- DATE O 1 hereby affirm that I am exempt from the Contractor s license ADDRESS 1 N 1M14L12 �/� �1 Low for the following reason (Section 7031 S Business and Professions Code) 8 BUILDING 1 as owner of the property or my employees with ADDRESS wages as their sole compensation will do the work and LOCALITY , the structure is not intended or offered for sale(Section _ 7044 Business and Professions Code) MOVING TEL &7 2 7 9 A (, I 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) REQUIRED TOTAL SETBACK-FROMti ti♦b}� CONSTRUCTION LENDING AGENCY PFRONT YARD HWY PROP LINE WIDTH I hereby affirm that there is a construction lending agency for # •t• • • • , the performance of the work for which this permit is issued(Sec 3097 Civ C ) • • 4Q50 Lender s Name Permit Fee -30 LDMA Ref 4 • • • 4 Q 5 0 Lender s Address y 0619-87 I certify that I have read this application and state that the Issuance Fee / `�7-� LDMA P/C# above information is correct 1 agree to comply with all County Investigation Fee ` $ ordinances and State laws relating to building construction R and hereby authorize representatives of this County to enter Total Fee LDMA Perm N upon the above mentioned property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE -P'v Q Signature of Applicant or Agent me o 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 0601240039 PHONE (626) 285-0488 ERT LEGAL ID NO OF CONST BUILDING ADDRESS TR 12998 IT 20 SL 001 SQ FT STORIES TYPE 9592 LOWER AZUSA RD STRUCTURE VN TEMP CA 917804224 ASSESSOR INFORMATION NUMBER NEAREST CROSS STREET TEMPLE CITY BLVD 8592-001-061 THOMAS PAGE 597 GRID AS LOCALITY TEMPLE CITY C TENANT EXIST BLDG USE COMME USE ZONE R-3 ISSUED ON PROCESSED BY EXPIRES ON EXIST OCC GRP 01/24/06 JK 01/19/07 OWNER TEL NO BLDGS NOW ON LOT VALUATION FINAL DATE FINAL BY CODE LEE DERICX (323) 823-3138- 700 9592 LOWER AZUSA RD 1- TEMPLE CITY CA 91780 FEES PAID DESCRIPTION OF WORK REMOVE 2 OFFICES AND BUILT 2 CHANGING ROOMS FEE DESCRIPTION QUANTITY UOM AMOUNT APPLICANT TEL NO SAME AS OWNER - AA BLDG PERMIT ISSUANCE 27 75 AC STRONG MOTION REBID 700 00 VAL 0 50 SPECIAL CONDITIONS AX BUILDING REVIEW FEE 54 70 D2 PERMIT W/O EN-HC 700 00 VAL 43 65 r TOTAL FEES 126 60 CONTRACTOR TEL NO APPROVALS DATE INSPECTOR SIGNATURE SAME AS OWNER - - LIC NO LOCATION AND SETBACKS SOILS ENGINEER APPROVAL ARCHITECT OR ENGINEER TEL NO FOUNDATION TRENCH FORMS LIC NO SLAB UNDER FLOOR RAISED FLOOR FRAMING MAP NO SEWER MAP BOOK PAGE FIRE ZONE CMP UNDERFLOOR INSULATION 144H269 3 01 FLOOR SHEATHING NO OF FAMILIES DWELLING UNITS APT COND STAT CLASS NO 22 ROOF SHEATHING SCHOOL WITHIN HAZARDOUS SHEAR PANELS AIR QUALITY 1000 FEET MATERIALS NO NO NO FRAME INSPECTION - REQUIRED TOTAL SETBACK FROM EXIST FIRE SPRINKLER HANGERS SET BACK YARD HWY PROP LINE WIDTH FRONT PL- INSULATION WEATHER STRIP SIDE PL INTERIOR LATH DRYWALL EXTERIOR LATH RATED FLOOR CBIL ASSEM RATED WALL ASSEMBLIES RATED SHAPTS OPENINGS T-BAR CEILINGS LOT DRAINAGE REPORT ID DPR261 ROUTE TO BSO508 APPLICATION FOR BUIL' DING PERMIT COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER S COMPENSATION DECLARATION FOR APPLIC /ANT ,T_.�O FILL IN a BU PING DRESS I hereby affirm that 1 have a certificate of consent to self Insure BUILDING ADDRESS Sq 2 `�w�� T e► or a certificate of Workers Compensation Insurance or a certified copy thereof(Sec 3800 Lab C) CITY T C-M PL E CITY LP LOCALITY _ rPolicy No Company SIZE OF LOT NO OF BLDGS NOW ON LOT ❑ Certified copy is hereby furnished I NEAREST CROSS S7 ❑ Certified copy Is filed with the county budding Inspection TRACT BLOCK LOT NO � department USE ZONE MAP NO Date Applicant ASSESSOR MAP BOOK PAGE PARCEL SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS OWNER S u l-Ali C 146 TEL NO COMPENSATION INSURANCE WITHIN 1000 FT OF SCHOOL? Yes No (This section need not be completed If the permit Is for one hundred ADDRESS dollars($100)or less) DISTRICT GROUP TYPE CONST FIRE ZONE PROCESSED BY CITY ZIP I certify that In the performance of the work for which this permit is Issued I shall not employ any person in any manner so as to ARCHITECT OR ENGINEER TEL NO become Subject to the Workers Compensation Laws STATISTICAL CLASSIFICATION APT CONDO Date — Applicant Je— - ADDRESS CLASS NO DWELL UNITS NOTICE TO APPLICANT If after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST Exemption you should become subject to the Workers CONTRACTOR p / TEL NO SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code you must forthwith �TV�K �Q� CB MS FRONT comply with such provisions or this permit shall be deemed revoked ADDRESS LIC NO PL L 5 Z LOWE0. 14uSA bS 33 PILE LICENSED CONTRACTORS DECLARATION CITY LIC CLASSpp P L I hereby affirm that I am licensed underprovisions of Chapter 9 6'�PLIS & SEWER MAP (commencing with Section 7000)of Division 3 of the Business and SQ FT SIZE NO OF STORIES I NO OF FAMILIES Professions Code and my license is In full force and effect NEW ❑ BK PG d B DESCRIPTIO OF RK ADD ❑ VALUATION , V License Number .�4a��; Lac Class /� �6 Contractor ly ,/I(��C1Lt a Date 2 w�G siAh ALTER $ 3 �/ ❑ 1 am exempt under Sec INAL4 t&A-C REPAIR ❑ $ U BAPC for this reason 15C DEMOL ❑ LOMA Date USE OF EXISTING BLDG URM 1-1PIC# ,�., CL Signature APPLICANT(PRINT) TEL NO LOMA Perm# Z ❑ I as owner of the property or my employees with wages as Z AU 3 a their sole compensation will do the work and the structure Is ADDRESS F �- r, not intended or offered for sale (Section 7044 Business and FINAL DATE X501 Joe 11I Professions Code) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL = i ❑ 1 as owner of the property am exclusive) contracting with OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE P Y y g licensed contractors to construct the project (Section 7044 AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY ves 1:1 No❑ Business and Professions Code), `ry C WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING 3301 12 OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH `" CONSTRUCTION LENDING AGENCY CCOOADSET AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FOR 2 ITEMS GUI1 hereby affirm that there Is a construction lending agency for YES❑ NO❑ i J} w the performance of the work for which this permit is issued(Sec I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING d "'$' ® 5 ..A N 3097 CIV C) CHECKLIST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE TITLE 2 CHAPTER 2 20 SECTIONS 2 20 100 THROUGH 2 20 140 CONCERNING HAZARDOUS CHECK 174 1`9 Lenders Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD oLender's Address CHANGE 00 0 OWNER OR AGENT o I certify that I have read this application and state under penalty 0 of perjury that the above information Is correct I agree to comply PC FEE PERMIT FEE p $ with all county ordinances and State laws relating to building 'O O 0000-0001 ?/ 9/95 construction and hereby authorize representatives of this County ISSUANCE FEE /' a to enter upon Bbove menti roperty for Inspection purposes li 902 1 PM 1;.04 ro T// INVESTIGATION FEE TOTAL FEE Sq Wu cent W A90M ' Gat �O SEE REVERSE FOR EXPLANATORY LANGUAGE