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HomeMy Public PortalAbout5804 PRIMROSE AVE_Building__ WORKERS'COMPENSATION DECLARATION ® Job #870470 BG 04�I hereaffirm to self insurebor a certif carte of Workers'Compensat on I have a certificate of coent Insurance, A® L 1 CAT O U'L®I PERMIT or a certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No.W00071 46 Company Beaver Inc_ ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING Q �� ADDRESS p O © Certified copy is filed with the county building inspec- BUILDING tion department. ADDRESS 5804 Date 12-7—R7 _Applicant Virgin Roof CA_ CITY Temnle City ZIP LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. NNEAREST COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MCROSS ST. (This section need not be completed if the permit is for one t ASSESSOR hundred dollars($100)or less.) TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL TEL. USE ZONE MAP r .y I certify that in the performance of the work for which this OWNER NO. }. NO. -�(P permit is issued,I shall not employ any person in any manner �3 SPECIALS so as to become subject to the Workers'Compensation Laws. ADDRESS ti CONDITIONS Date Applicant CITY ZIP Ir NOTICE TO APPLICANT: If, offer making this Certificate of ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY OO g ENGINEER NO. CONST. ZONE Exemption, you should become subject to the Workers' ' 0 Compensation provisions of the Labor Code, you must forth- ADDRESS with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION APT. CONDO, fA deemed revoked. CONTRACTOR NO. 287-0 LICENSED CONTRACTORS DECLARATION LIC, CLASS NO. DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS N . 6O6 O SEWER AAAP (commencing with Section 7000)of Division 3 of the Business and LIC. Professions Code, and my license is in full force and effect. CITY San Gabriel CLASS C39 BK PG VALIDATION SQ.FT. NO.OF NO.OF CHECK License Number 160650 Lic.Class C39— SIZE STORIES FAMILIES ONE VALUATION Contractor Virgin Roof Co.Date 12-7-R7 DESCRIPTION OF WORKNEW ADD $2000.00 ❑I am exempt under Sec. "All ALTER ❑ B.BP.C. for this reason shingles, 24 S S REPAIR ❑ $ Date: USE OF DEMOL EXISTING BLDG. ❑ v. Signature APPLICANT TEL. FINAL OWNER-BUILDER DECLARATION PRINT NO. 8 -O O DAT 1 hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and ADDRESS FI Professions Code): E N ❑ BUILDING I, as owner of the property, ormy employees with ADDRESS wages as their sole compensation,will do the work and the structure is not intended or offered for sale(Section LOCALITY 93 7044, Business and Professions Code). MOVING TEL. ❑ I,as owner of the property,am exclusively contracting CONTRACTOR NO. 1 8 with licensed contractors to construct the project (Sec- _ tion 7044, Business and Professions Code). ADDRESS o 0 0 9 REQUIRED TOTAL SETBACK Q ` 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 P.L. Lender's Name LDMA Ref. # S P.C.Fee$ Permit Fee Lender's Address $39-38 Pr I certify that I have read this application and state that the Issuance Fee LDMA P/C H R above information is correct. I agree to comply with all County Investigation Fee °q ordinances and State laws relating to building construction, Total Fee LDMA Perm,q R and hereby authorize representatives of this County to enter upon the above-mentioned pro err, for inspection purposes.W4 A SEE REVERSE FOR EXPLANATORY LANGUAGE nature of 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 1201310073 PHONE: (626) 285-0488 EXT: ILEGAL ID: I NO. OF CONST BIIILDING ADDRESS: I ITR: 6561 IT: 650 I SQ. FT STORIES TYPE 1 5804 PRIMROSE AV 1 ISTRUCTURE: 21 V-B I TEMP CA 917802110 ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET: WORKMAN 18587-015-030 1 I THOMAS PAGE: 596 GRID: J3 LOCALITY: TEMPLE CITY, Cl ITENANT: IEXIST BLDG USE: RESID USE ZONE: R-2 TISSUED ON: PROCESSED BY: 1 1 1EXIST OCC GRP: 101/31/12 SR I IOWNER: TEL. NO: JBLDGS. NOW ON LOT: VALUATION: 1FINAL TE FIN BY• CODE: 1 IDARDON MARCO A;GLORIA H - 1 7,800 1 14549 BARTLETT AV I I / •/ 1ROSM 917701252 FEES PAID 1 SCRI ION OF WORK 1 ITEAR OFF EXISTING SHEET AND XROOF WITH 40 YEAR DIMENSIONAL 1 I IFEE DESCRIPTION: QUANTITY: DOM: AMOUNT:JSHINGLE (APPLICANT: TEL. NO: [LLOYD, WAYNE REASER (562) 677-6499- TAA BLDG PERMIT ISSUANCE 27.80 1 I I JAB STATE GREEN BLDG FEE 7800.00 VAL 1.00 ISPECIAL CONDITIONS: I I 1AC STRONG MOTION RESID 7800.00 VAL 0.80 1 D2 PERMIT W/O EN-HC 7800.00 VAL 183.40 1 I I TOTAL FEES 213.00 _ 1 (CONTRACTOR: TEL. NO: 1 JAPPROVALS DATE INSPECTOR SIGNATURE 1 JALL WEATHERPROOF ROOFING (562) 677-6499- 1 15538 CLOVERLY AVENUE LIC. NO 1 ILOCATION AND SETBACKS I I I ITEMPLE CITY, CA 91780 863094 C39 I _ 1 1SOILS ENGINEER APPROVAL J I I 1ARCHITECT OR ENGINEER: TEL. NO: - � 1 IFOUNDATION/TRENCH FORMS I I I 1 LIC. NO: 1 1SLAB/UNDER FLOOR I I I I 1 IRAISED FLOOR FRAMING I 1 1 JMAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP:J JUNDERFLOOR INSULATION T 1 1150H269 3 001 1 I 1 I 1 FLOOR SHEATHING INO. OF FAMILIES: DWELLING UNITS: APT/COND: STAT CLASS: 1 1 0 NO 21 1 1ROOF SHEATHING T^-r J SCHOOL WITHIN HAZARDOUS J 1SHEAR PANELS ] 1AIR QUALITY: 1000 FEET MATERIALS 1 I I I I NO NO NO IFRAME INSPECTION I I I I 1 1 JFIRE SPRINKLER HANGERS J I I JINSULATION/WEATHER STRIP( I I 1 I JINTERIOR LATH/DRYWALL I I I 1I I I I 1EXTERIOR LATH 1 1 IRATED FLOOR/CEIL ASSEM. I J I I (RATED WALL ASSEMBLIES 1 I I 1RATED SHAFTS/OPENINGS I 1 1T-BAR CEILINGS 1 I I I 1 1LOT DRAINAGE I I 1 IREPORT ID: DPR261 ROUTE TO: BS0508 1 I I I I I I I