HomeMy Public PortalAbout5614 PERSIMMON AVE_Building__ • ) x WORKERS'COMPENSATION DECLARATION `\
S .i.�tel!•'affirm that I have a certificate of consent to self
` insurer or a•certificate of Workeirs'Compensation Insurance, APPLICATION F®R BUIL®I N G P E RM I T
or a certified copy-thereof(Sec. 3800, lab. C.) COUNTY OF LOS ANGELES ' BUILDING AND SAFETY
Policy No. •Company
BUIL G
.Certified copy is hereby furnished. - FOR APPLICANT TO FILL IN ADDR ss� Z3�.SIA4J)J J
❑ Certified copy is filed with the county building inspec- BUILDING'
' tion department. ADDRESS V G
Date Applicant CITY ZIP +LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGt. NEAREST
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT ;.;CROSS ST. L �i
(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
TEL. Jh k,USE I MAP
I certify that in the'performarice'of the work for which this ' OWNE N 7�/ NO.
permit is'issued, I shall not'employ any person in an manner �r SPECIAL
so at to become subject to the rkers'Compensat n•La s. ADDRESS /. CONDITIONS �O
/ CITY ZIP V09
Ddte!�&'� Applicant
ARCHITECT E }�SjRICi GROUP TYPE FIRE P SSED Y
NOTICE TO APPLICANT: If, after making this Certificate of �i ' ( CONST. ZONE ,10
Exemption, you should become subject to the Workers' ENGINEER �j 1 /
Compensation provisions of the Labor Code, you must forth- ADDRESS d' SrU� �✓ V ,� IL
IL
with comply with such provisions or this-permit shall -be N
deemed revoked. . . _ 7EL. STATISTICAL CLASSIFICATION APT. NDO.
CONTRACTOR { NO. CLASSNO.�DWELL. UNITS
LICENSED CONTRACTORS DECLARATION- - • LIC. •-
I hereby affirm that•1 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.: NO.OF NO.OF / CHECK
License Number Lic.Class SIZE STORIES FAMILIES ( ONE
VALUATION
Contractor
DESCRIPTION OF WORK NEW ❑• uv
Date $ 4 3:5 7 A
O
❑ DD
I am exempt under Sec. a15A ALTER # o 0-00 23"
B.&P.C. for this reason $
REPAIR. ❑ 1 - 23-7.80
Date: USE OF DEMOL ❑',
EXISTING BLDG.APPLICANT . ° o23-7.805-
TEL '
Signature PRINT ps — FINAL• k
OWNER-BUILDER DECLARATION v N , , DAT . 0.402 8 b
I-hereby affirm that,[am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and ! ADDRES /J p' /►
Prof ssions Code): PRESENT
BUILDING
I as owner of the property, or my employees with ADDRESS ' C--.. , It
wages as their sole compensation,will do the work and �;l i r, Ap l
the structure is not intended or offered for sale(Section LOCALITY z '
s
7044, Business and Professions Code). MOVING TEL.
CONTRACTOR NO. n ��ll`` yi o
I,as owner of the property,am exclusively contracting � �; z 55 8,3 A •
with licensed contractors to construct the project (Sec- ':'
tion 7044, Business and Professions Code). ADDRESS
{�o`'��.-a, 0 0 0 '.
REQUIRED TOTAL SETBACK FROM
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. 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
o P.L.
Lender's Name '
r LDMA Ref. #
P.C. Fee$ 7 t Permit Fee e5?7f,
Lender's Address
> ff
[..certify that I have read this application and state that the Issuance Fee l P• - LDMA P/C# ,E-o,.o o,o o
_ above information is correct. I agree to comply with all County Investigation Fee �l
ordinances and State laws relating to building,construction, Total Fee C/ [ LDMA PBrm. # ° 2 9 Q 2 5
and hereby a orize representatives of this County to enter
S pan the ablz.
entioned property for inspection purposes. ° ° 2 9 Q 2 5
D 'SEE REVERSE FOR EXPLANATORY LANGUAGE b
Iv^�Sr
Signature of Applicant or Agent Date
COUNTY OF LOS ANGELES TEMPLE CITY # 0508
DEPARTMENT OF PUBLIC WORKS BUILDING PERMIT
BUILDING AND SAFETY / LAND DEVELOPMENT 9701 LAS TUNAS ALTERATION/REPAIR
TEMPLE CITY CA 91780 BL 0508 1009080002
PHONE: (626) 285-0488 EXT:
LEGAL ID: N0. OF CONST
ITR: 13935 IT: 34 SQ. FT STORIES TYPE 5614 PEON AV
BUILDING ADDRESS:
ASSESSOR INFORMATION NUMBER: 1STRUCTURE: 12 V-8 TEMP CAR917802808
8573-010-010 1 NEAREST CROSS STREET: LIVE OAK( THOMAS PAGE: 597 GRID: C3 LOCALITY: TEMPLE CITY, Cl TENANT' (EXIST BLDG USE: RESID
USE ZONE: R-1 ISSUED ON: PROCESSED BY:
EXIST OCC GRP: 109/08/10 SR
OWNER: TEL. NO: 1BLDGS. NOW ON LOT: VALUATION:
10ELANO, TIM (626) 579-5627- 3,000 1 TE FINAL BY: CODE:
5614 PERSIMMON AV
TEMP 917802808
1 FEES PAID ID CRI IO OF WORK 1
FEE DESCRIPTION: TEAR OFF, RE-SHEET, 30 YEAR COMP.
1 QUANTITY: UOM: AMOUNT:I
APPLICANT: I I
TSL. NO:
APEX ROOFING CO. (951) 637-5534- IAA BLDG PERMIT ISSUANCE
15782 BENEOA DR. 27.80 I
RIVERSIDE CA 92504 IAB STATE GREEN BLDG FEE 3000.00 VAL 1.00 ISPECIAL CONDITIONS:
ID2 PERMIT AC STRONG MOTION RESID 3000.00 VAL 0.50
/ EN-HC 3000.00 VAL 99.10
CONTRACTOR: TEL. NO: _IFR INV WORK W/OPERMIT 257.00 DOL 257.00
APEX ROOFING CO. (951) 637-5534- TOTAL FEES 385.40 APPROVALS DATE INSPECTOR SIGNATURE
15782 BENECIA DRIVE
LIC. NO I I
RIVERSIDE CA 92504825641 ILOCATION AND SETBACKS
I
SOILS ENGINEER APPROVAL 1
ARCHITECT OR ENGINEER: TEL. NO:
1 _ I FOUNDATION/TRENCH FORMS 1
LIC. N0: SLAB/UNDER FLOOR 1
I
RAISED FLOOR FRAMING I
MAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP:I I
1150H273 3 001 11 1
UNDERFLOOR INSULATION
INO. OF FAMILIES: DWELLING UNITS: APT/GOND: STAT CLASS: I
1FLOOR SHEATHING
NO 21 1 IROOF SHEATHING
SCHOOL WITHIN HAZARDOUSI
1AIR QNUALITY: 10I0O0 FEET MATERIALS I ISHEAR PANELS
I NO I IFRAME INSPECTION
1 I 1FIRE SPRINKLER HANGERS 1
I
IINSULATION/WEATHER STRIPI
I I I I I
1 IINTERIOR LATH/DRYWALL
I I
1 1EXTERIOR LATH I
1 I 1RATED FLOOR/CEIL ASSEM.
I 1RATED WALL ASSEMBLIES 1
1 I i 1RATfiD SHAFTS/OPENINGS 1 I I
IT-BAR CEILINGS
I I I1 I I I 1LOT DRAINAGE 1 1
1REPORT ID: DPR261 ROUTE TO: BS0508 I I I 1
I I I I