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HomeMy Public PortalAbout9930 OLIVE ST_Building__ i WORKERS'COMPENSATION DECLARATION �III__IIII I have a certificate of coent to insure, or a certif catte of Workers'Compensat on Insuran elf APPLICATION FOR BUILDING PERMIT or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company ❑ Certified copy is hereby furnished. BUILDING pR APPLICANT TO FILL IN ADDRESS F1Certified copy is filed with the county building inspec. BUILDING tion department. ADDRESS Date Applicant CITY ZIP LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. Z NEAREST COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS ST. (This section need not be completed if the permit is for one ASSESSOR hundred dollars($100)or less.) TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL USE ONE OWNER 11} CW T �O MAP 7� I certify that in the performance of the work for which this LL�' 1 ,r� NO. permit is issued, I shall not employ any person in any manner ADDRESS Z-04�V KSTD(�1 �,`, I SPECIAL CONDITIONS so as to become subject to the Workers'Compensation Laws. CITY NO ZIP R//D cr Date Applicant ARCHITECT Ogg,,�� EL.. DISTRICT P TYPE FIRE PROCESSED BY O NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER (%1°1{�^�1c NO.'� — $ CONST.t Z NE 11-- Exemption, you should become subject to the Workers' ll tV/ Compensation provisions of the Labor Code, you must forth- ADDRESS U fn (/ pW„ with comply with such provisions or this permit shall be TEL. STATISTIC4 LAS I TION APT. C Cl) deemed revoked. CONTRACTOR NO. / Z LICENSED CONTRACTORS DECLARATION LIC. CLASS 1V6 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 LIC SEWER MAP Professions Code, and my license is in full force and effect. CITY CLASS BK PG VALIDATION SQ. FT 1 11 NO.OF NO.OF CHECK License Number Lic.Class SIZE STORIES 1 FAMILIES D ONE VALUATION Contractor Date DESCRIPTION OF WORK NEW ❑ $ ❑ CNU 0 12.1 LJAW10� F'AtC.t L1-11� ADD 1:1I am exempt under Sec. ALTER ❑ �3 B.&P.C. for this reason 1=0 t2.. W REPAIR ❑ $ D /_ Date: USE OF DEMOL El (� EXISTING BLDG. tV N E APPLICANT TEL. MrA Signature PRINT) NO.Z 9 -- Zl FINAL (J OWNER-BUILDER DECLARATION DATE (� I hereby affirm that I am exempt from the Contractor's License ADDRESS Zd 11 N� �L• FINAL Law for the following reason (Section 7031.5, Business and Professions Code): PRE EN By ❑ BUILDING I, 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. ❑ 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). CONSTRUCTION LENDING AGENCY SEREQUIRED'CK YARD HWY TOTAL SETBACK L NEFR WIDTH I hereby affirm that there is a construction lending agency for FRONT the performance of the work for which this permit is issued PA (Sec. 3097, Civ. C.). SIDE P.L. Lender's Name P.C. Fee$ O� � � Permit Fee LDMA Ref. # Lender's Address I certify that I have read this application and state that the Issuance Fee LDMA P/C# above information is correct. I agree to comply with all County Investigation Fee ordinances and State laws relating to building construction, Total Fee LDMA Perm. # and hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date I COUNTY OF LOS ANGELES TEMPLE CITY # 0508 BUILDING PERMIT DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS DEMOLITION BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 BL 0508 0011200039 PHONE: (626) 285-0488 EXT: t LEGAL 10: NO. OF CONST BUILDING A DRESS: TR: 6755 LT: 9 BL: .001 SQ. FT STORIES TYPE 9930 OLIVE ST STRUCTURE: TEMP CA 917803238 ASSESSOR INFORMATION NU BER: NEAREST CROSS STREET: BALDWIN 8589-005-004 THOMAS PAGE: 597 GRID: A4 LOCALITY: TEMPLE CITY TENANT: EXIST BLDG USE: COMME USE ZONE: ISSUED ON: PROCESSED BY- EXPIRES ON: EXIST OCC GRP: 11/20/00 UT 05/20/01 OWNER: TEL. NO: BLDGS. NOW ON LOT: VALUATION: FINAL DATE FINAL BY: CODE: CALIFORNIA AMERICAN WATER CO (818) 445-3151- 1 0 2020 HUNTINGTON DR r SMAR 911082022 FES AID OF-SCRIPTLON PF WURK WATER TOWER DEMOLIT N FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: APPLICANT: L. ISELER DEMOLITION INC (810) 752-7335- AA BLDG PERMIT ISSUANCE 27.75 71231 BURLISON LN. 02 DEMOLITIO�INSP JN163.50 SPECIAL CONDITIONS: ROMEO, MI 48093 T0. 'L ES 191.25 (;EL.ES CO CONTRACTOR: TEL. NO: OGJ ��/,. APPROVALS DATE INSPECTOR SIGNATURE ISELER DEMOLITION, INC. (810) 752-7335- �, �► 71231 BURLISON LANE LIC. NO PEDESTRIAN PROTECTION ROMEO, MI 48093 706887 C21 SEWER DISCONNECTION RCHITECT OR ENGINEER: TEL. NO: ABANDON PRIVATE DISPOSAL LIC. NO / 1111111 UNDERGRND STRUCT REMOVAL L � AND SOIL RECOMPACTION MAP NO: f 147H269 SEWER MAP 800K: PAGE: FIRE ZONE: C Uj l U -- L J C W Oluo---,la K S it NO. OF FAMILIES: D E I G S: A T/CO D: STAT CLASS. NO 240 0 SC 00 ITHIN A RDO S o 0 �I' ;�t AIR QUALITY: 1000 FEET MATERIALS ❑ 'i NO NO NO A El ©, 1�y 46,�c service Tha��ct ti REPORT ID: DPR261 ROUTE TO: BS0508 y ..