HomeMy Public PortalAbout6017 ROWLAND AVE_Building__ WORKERS' COMPENSATION DECLARATION
hereby
irm that I have a certificate Insurance,insureracertifcate of Workers' Compensation APPLICATION FOR BUILDING PERMIT
or a certified•cop;%thereof(Sec. 3800, Lob. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
❑ Certified copy is hereby furnished. . FOR APPLICANT TO FILL IN BUILDING
ADDRESS
❑ Certified copy is filed with the county building inspec- BUILDING �t_
tion department. ADDRESS 7 ✓—� OW />�H n
Date Applicant CITY ' i` ZIP f dr!0 LOCALITY women V JC S—' `17ARC1644 %
Vv-- NO.OF BLDGS. NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT S O x 19 0 NOW ON LOT CROSS ST.
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if the permit is for one 7RACf G 1 BLOCK LOT NO. MAP BOOK PAGE PARCEL
hundred dollars ($100)or less.) �• * TEL
OWNER 2 0040 f'v(L) NO• ,M_ 3(a USE ZONE OP .i'y�
I certify that in the performance of the work for which this SPECIAL }
permit is issued, I shall not employ any person in any manner ADDRESS , W /SIH CONDITIONS- n.
so as to become subject to the Workers' mponsatipp Laws. O
CIN
U
ZIP / e}
4Date 2 Applic nt ARCHITECT TEL.
NOTICE TO APPLICANT: If, er maki t is C ificate ENGINEER NO DISTRICT I GROUP TYPE FIRE PROCESSED BY O
Exemption, you should become sub ect to the Workers' i9y CONST../ ZONE
Compensation provisions of the Labor Code, you must forth- ADDRESS 5 ' 0� � t/ `✓L a
with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION APT. CONDO. N
deemed revoked. CONTRACTOR NO. Z
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. 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 � LIC SEWER MAP
and Professions Code,and my license is in full force and effect. CITY CLASS BK PG J VALIDATION
SQ. FT. NO. OF NO. OF CHECK
License Number Lic. Class SIZE Qp STORIES FAMILIES Z ONE
VALUATION
Contractor Date DESCRIPTION OF WORK NEW ❑
Elam exempt under Sec. �� /�c��ry w y ADD ,
ALTER ❑
B.&P.C. for this reasona . o urn! 9 REPAIR ❑ $
Date: USE OF
EXISTING BLDG. DEMOL ❑
Signature APPLICANT � p TEL•(PRINT) lG� /L /C&CL NO.cQ.�o"y' FINA
(o
OWNER-BUILDER DECLARATION DATE
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and ADDRESS v` G✓J41"11F ` FINAL 1
o essions Code): PRESENT By
I, as owner of the property, or my employees with ADDRIESS ACCTa4
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section LOCALITY , 3M7 78.00
7044, Business and Professions Code.) MOVING TEL. ITEM❑ I, as owner of the property,am exclusively contracting CONTRACTOR NO. 1 ITEMS
r with licensed contractors to construct the project (Sec- ADDRESS
T4TI!L78.11310
tion 7044, Business and Professions Code.) ` � Q0
REQUIRED YARD HWY TOTAL SETBACK FROM EXIST. lain
CONSTRUCTION LENDING AGENCY SET BACK PROP. LINE WIDTH
I hereby affirm that there is a construction lending agency for FRONT. `CHANGE o
the performance of the work for which this permit is.issued P.L.
00
(Sec. 3097, Civ. C.). SIDE
P.L.
Lender's Name _ A000-0001 7/21/89
3 /y •' LDMA Ref. q
Lender's Address P.C. Fee$ permit Fee C/ , 4597 1 tt/LLQ $o�`i
AM t o
I certify that I have read this application and state that the Issuance Fe 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 G/t/ LDMA Perm. #
anoth .,e-mention
uthorize representativ s of this County to enter
upgrope for inspection purposes.
,Z-2 SEE REVERSE FOR EXPLANATORY LANGUAGE
Sign re f A 1 ant or Agent —+ Date
` COUNTY OF IAS 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 0704100046
PHONE: (626) 285-0488 EXT:
ILENO. OF CONST BUILDING ADDRESS:
ITR:656AL 1 IT: 32 UN: .002 SQ. FT STORIES TYPE 6017 ROWLAND AV
(STRUCTURE: VN TEMP CA 917801721
ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET:
15385-028-009 I THOMAS PAGE: 597 GRID: A2 LOCALITY: TEMPLE CITY, Cl
ITENANT: EXIST BLDG USE: RESID USE ZONE: R-1 IISSUED ON: PROCESSED BY: EXPIRES ON:
I
I (EXIST OCC GRP: 104/10/07 JK 04/04/08
I I
(OWNER: TEL. NO: IBLDGS. NOW ON LOT: VALUATION: IFINAL DA [� BY: CODE: I
LAM, LAI LIN (626) 286-1813- 1 7,500 1 ���Inl 1
6017 ROWLAND AV I 1 TEaaQ���ou u u LJ
ITEMP 917801721 I FEES PAID IDESCRIPTION OF WORK 1
ICHANGE OUT 25 WINDOWS (SAME SIZE) I
IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT:( I
(APPLICANT: TEL. NO: I I
ISAME AS OWNER - IAA BLDG PERMIT ISSUANCE 27.75 I I
I IAC STRONG MOTION RESID 7500.00 VAL 0.75 ISPECIAL CONDITIONS:
ID2 PERMIT W/O EN-HC 7500.00 VAL 183.00 I
FR INV WORK W/O PERMIT 257.00 DOL 257.00 I
TOTAL FEES 468.50 I 1
(CONTRACTOR: TEL. NO: I (APPROVALS DATE INSPECTOR SIGNATURE
ISAMB AS OWNERLIC NO I ILOCATION AND SETBACKS I I I
ISOIPS ENGINEER APPROVAL I I 1
(ARCHITECT OR ENGINEER: TEL. NO: I (FOUNDATION/TRENCH FORMS I I I
LIC. NO: �I (SLAB/UNDER FLOOR I I I
(RAISED FLOOR FRAMING I I 1
IMP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP:( I I I 1
UNDfiRFLOOR INSULATION
JISOH269 3 Oil I 1 1 1
(FLOOR SHEATHING I 1 1
INO. OF FAMILIES: DWELLING UNITS: APT/COND: STAT CLASS: I 1 I I I
NO 21 I IROOF SHEATHING I 1 1
1 SCHOOL WITHIN HAZARDOUS I ISHEAR PANELS I I I
(AIR QUALITY: 1000 FEET MATERIALS I I I I 1
NO NO NO IFRAME INSPECTION I 1
IREQUIRED TOTAL SETBACK FROM EXIST I (FIRE SPRINKLER HANGERS I I
ISET BACK YARD: HWY: PROP LINE: WIDTH: I 1 1 1 1
IFRONT PL- I IINSULATION/WEATHER STRIP( 1 1
SIDE PL- 1
IINTERIOR LATH/DRYWALL I 1 1
(EXTERIOR LATH
1 1 1
I
(RATED FLOOR/CEIL ASSEM. I 1 1
1
(RATED WALL ASSEMBLIES I I 1
(RATED SHAFTS/OPENINGS I I
1
IT-BAR CEILINGS I 1
1
1 (IAT DRAINAGE I I 1
(REPORT ID: DPR261 ROUTE TO: BS0508
I I I I I I