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Home My Public Portal About5551-5551 1/2 SANTA ANITA AVE_Building__ ,WORKERS!COMPENSATION DECLARATION cl • •1 herody offir,►n that I have a certificate of consent to self ® � I�� ®� L�I L®I N G PERMIT c insure; or a,cerfificate of Workers'Compensation Insurance, P`� ICU or a certified'c�op'y thereof(Sec. 3800, Lob. C.) Policy No.ed �" he=QCompany /3#60 � s . COUNTY OF LOS ANGELES BUILDING AND PARTY ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING ADDRESS Certified copy is filed with the county building inspec- . BUILDING tion departtment. ti ADDRESS 5551 Santa Anita Ave. Date o� Applicant Fle� CITY Temple City ZIP 91780 LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. NEAREST COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS ST. (This section need not be completed if the permit is for one TRACT 44319 BLOCK LOT NO. ASSESSOR hundred dollars ($100)or less.) MAP BOOK PAGE PARCEL OWNER J•E• Plount & Co. No. 576-8737 USE ONE MAP7-1 I certify that in the performance of the work for which this NO. I permit is issued, I shall not employ any person in any mannerADDRESS 217 WLas Tunas Dr. �� SPECIAL W.so as to become subject to the Workers'Compensation Laws. CONDITIONS O0 c1rY San Gambriel ZIP 91776 U Date Applicant ARCHITECT OR TELA 0 NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER Neil Esurlci NO 576-7456 DISTRICT GROUP TYPE FIRE PROC SED BY Exemption, you should become subject to the Workers' CONST NE i. V/ � esa Compensation provisions of the Labor Code, you must forth- ADDRESS S`Ux� CAN with comply with such provisions or this permit shall be TEL. STATISTICAL CLAS IFI TON APT. NDO. deemed revoked. CONTRACTOR NO. LICENSED CONTRACTORS DECLARATION LIC, CLASS NO. WELL. UNITS �f I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. SEWER MAP (commencing with Section 7000)of Division 3 of the Business and LIC. Professions Code, and my license is in full force and effect. CITY CLASS B PG �.•� VALIDATION �fl zo Lic.Class / SO. FT. 1417 NO.OF NO.OF CHECK License Number SIZE STORIES FAMILIES ONE o Q ��'�� VALUATION Contractor T11 r�W�lr Date DESCRIPTION OF WORK NEW f!r/ single ami y etac a ADD ❑ $ 7715 o 5 5&4 5 C6 ❑I am exempt under Sec. ALTER [-] ® 3.31 —86 condominium�4GS'. g. REPAIR ❑ O B.BP.C. for this reason $ Date: USE OF ff DEMOL EXISTING BLDG. E] APPLICANT TEL. Signature PRINT John Plount NO 576-8737 FINAL OWNER-BUILDER DECLARATION DATE 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): PRESENT B F-11,I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and the structure is not intended or offered for sale(Section LOCALITY 7044, Business and Professions Code). MOVING TEL. ❑ I, as owner of the property,am exclusively contracting CONTRACTOR NO. 5 0 5 A with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). # 0 0 0 o a 1 CONSTRUCTION LENDING AGENCY OM EXIST. SETBACK YARD HWY TOTAPROP. LINE FR WIDTH I hereby affirm that there is a construction lending agency for FRONT 1 - 667.50 the performance of the work for which this permit is issued P.L. (Sec. 3097, Civ. C.). SIDE o o 6 6 7 5 0u s g P.L. i Lender's Name fit LDLPerm. # 0 715-86 P.C. Fee$ r S Permit Fee n r Lender's Address I certify that I have read this application and state that the Issuance Fee r LD0010 above information is correct. I agree to comply with all County Investigation Fee ordinances and State laws relating to building construction, Total Fee LD and hereby authorize representatives of this County to enter upon the above-mention d property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature o Applicant or Agent Date t WORKERS'COMPENSATION DECLARATION •1 hereby offirtn that I have a certificate of consent to selfO insure;`or a-certificate of Workers'Compensation Insurance, A P P L I C A`�I�O N F BUILDING PERMIT or a.certified copy thereof(Sec. 3800, Lab. C.) �.t ��a C►�S • COUNTY OF LOS ANGELES BUILDING AND AFETY Policy N Z9a6oCompany ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS / ADDRESS UWA Certified copy is filed with the county building inspec- BUILDING tion department. ADDRESS 5551 1/2 Santa Anita Avenue Date D` Applicant t�z CITY Temple Cit ZIP LOCALITY CERTIFICATE OF EXEMPTION FROM WORKL�S' NO.OF BLDGS. NEAREST COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS ST. U'L (This section need not be completed if the permit is for one 44319 . ASSESSOR hundred dollars ($100)or less.) TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL TEL. US ZONE MAP I certify that in the performance of the work for which this OWNER J.E. NO. — � � NO. 1,50-2-77 >. permit is issued, I shall not employ any person in any manner 217 W. Las Tunas Dr.. SPECIAL IL so as to become subject to the Workers'Compensation Laws. ADDRESS CONDITIONS V Date Applicant CITY San Gabriel zip 91776 Id NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL. — DISTRICT GROUP TYPE FIRE PRO SED BY Exemption, you should become subject to the Workers' ENGINEER Neil Esurki NO• �` p� CONST. / ZONE U Compensation provisions of the Labor Code, you must forth- 'ADDRESS �/�l V J4 IL IL with comply with such provisions or this permit shall be deemed revoked. Same as owner TEL. STATISTICAL CLASS� C�ITION APT. 17NDO. CONTRACTOR NO. cc LICENSED CONTRACTORS DECLARATION LIC, CLASS NO. DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. SEWER MAP (commencing with Section 7000)of Division 3 of the Business and LIC. Professions Code, and my license is in full force and effect. CITY CLASS BK $-sv VALIDATION ��jj SIZES 1735 STORIES 2 FAMILNO-OF NO.OIES CO EK License Number �•�S�Z�ao Lic.Class _ VALUATION �)�] Contractor T.e•t&*--r Date DESCRIPTION OF WORK NEW nj ADD $ oo 9 4 3 3 0 A ❑I am exempt under Sec. single family detached ❑ 1011. ALTER ❑ # 0 0 o a '2 3 B.&P.C. for this reason condominium rG REPAIR ❑ $ 1 USE OF Date: EXISTING BLDG. DEMOL ❑ I ° 6 3 3 0 5 Signature APPLICANT TEL. ° ° 6330560 g PRINT John Plount NO. FINAL OWNER-BUILDER DECLARATIONDATE O 3 I hereby affirm that I am exempt from the Contractor's License ADDRESS 217 W. Las Tunas, San Gabriel FI L Law for the following reason (Section 7031.5, Business and '1 Professions Code): PRESENT B 11 1,I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and ' the structure is not intended or offered for sale(Section LOCALITY 7044, Business and Professions Code). MOVING TEL. 0 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 FROM CONSTRUCTION LENDING AGENCY SET BACK YARD HY PROP. LINE WIDTH W5 Q 3.6 A 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. # 0 0 0 0 0 (Sec. 3097, Civ. C.). SIDE P.L. I ° 755,25 Lender's Name /) LDMA Ref. # ' P.C. Fee$ 3 3 t W Permit Fee o ° 7 5 5 2 5 rSt Lender's Address / I certify that I have read this application and state that the Issuance Fee ( 0 rs� LDMA P/C# pool ], 15-86u�-$6 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. # I and hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature ofpplicont or Agent Date Oo WORKERS'COMPENSATION DECLARATION I hereby affirm that I have certificate of consent to self L I CAT 'BUILDING" insure, or a certificate of Workers'Compensation Insurance, or a certified copy thereof(Sec. 3800, Lob. CC..,) �® COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No ,f7J—v Company BUILDING n ❑ Certified copy is hereby furnished. FOR APPLICANT ATO FILL IN ADDRESS Certified copy is filed with the county building inspec- BUILDING X+,(�/ P tion,clep rtment. ADDRESS J.s Nt 7T Date da 3a r Applicant 64ZEAi dS/U•S ',CITY (tel 4a ZIP LOCALITY AU CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. t.i 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 11 TEL. USE ZONE MAP OWNER T TEL' -74- 7 NO. 1 certify that in the performance of the work for which this �� permit is issued, I shall not employ any person in any manneryy1� SPECIAL so as to become subject to the Workers'Compensation Laws. ADDRESS+02/7 ")" d. CONDITIONS 0 Date Applicant �7 CITY ZIP NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PR SED Y ENGINEER NO. + /)� CONST. ZONE Exemption, you should become subject to the Workers' l� (f 9� Compensatin provisions of the Labor Code, you must forth- :.ADDRESS with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSI CATION APT.,o g deemed revoked. CONTRACTOR No. 77.3 '. �.r LICENSED CONTRACTORS DECLARATION LIC, CLASS NO. DWELL.UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS 3 ,NO. 0 , is" SEWER MAP (commencing with Section 7000)of Division 3 of the Business and /p LIC. Professions Code,and my license is in full force and effect. CITY C�6� CLASS C^o-1 BK VALIDATION ��/y Q SQ.FT. NO.OF / NO.OF CHECK . License Number ` 0 rI S Lic.Class C ��, SIZE STORIES ` FAMILIES / ONE /� �e rte,I q // VALUATION Contractor &JfZ4/ �AdS Date fay �/�`� DESCRIPTION OF WORK E A NEW ❑` $ ❑ scve4 ADD I am exempt under Sec. C ALTER B.&P.C. for this reason �` B REPAIR ❑.' $ Date: USE OF .f DEMOL EXISTING BLDG. 4C�/ 3,..: Signature APPLICANT TEL. FINAL OWNER-BUILDER DECLARATION PRINT 6 NO. JDATE 6/U I hereby affirm that I am exempt from the Contractor's License C ADDRESS �.3 r !Yi'i Law for the following reason (Section 7031.5, Business and /A/ FIN 41 Professions Code): PRE ENT By tIIXP BUILDING ❑ I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and LOCALITY �,�_,�,Q, g r/ p z�S, o 3 5 a 0 A the structure is not intended or offered for sale Section ,a 7044, Business and Professions Code). MOVING TEL. �wJZ ¢ # 0 0 0 0 0 ❑ I, as owner of the property,am exclusively contracting CONTRACTOR NO. a with licensed contractors to construct the project (Sec- ADDRESS rO tion 7044, Business and Professions Code). REQUIRED TOTAL F SETBACK O 10 0 6 Q 5 0 CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP.LINE WIDTH I hereby affirm that there is a construction lending agency for FRONT o 0 o 6 Q 5 0 5 the performance of the work for which this permit is issued P.L. (Sec. 3097, Civ. C.). j. SIDE 1203-85P.L. B e Lender's Name qr.% LDMA Ref. q Lender's Address J P.C.Fee$ Permit Fee 5 ✓✓ - >> r r I certify that I have read this application and state that the Issuance Fee `0•J O LDMA P/C#f 1001 3 above information is correct. I agree to comply with all County Investigation Fee 9 ordinances and State laws relating to building construction, Total Fee (/• LDMA Perm.#i and hereby authorize representatives of this County to enter ': upon t above-mentioned property for inspection urposes. M SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date A ' WORKERS'COMPENSATION DECLARATION hereby affirm fI have certificate of consent to self APPLICATION FOR 13U I L®I N G PERMIT � insure, or a certificate of Workers'Compensation Insurance, or a certified copy thereof (Sec. 3800, Lab. C.) �� COUNTY OF LOS ANGELES BUILDING AND SAFETY PolicyNo f Company ElCertified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING Iva f�/} a�1j�/4(J ADDRESS 1f Certified copy is filed with the county building inspec- BUILDING ,{ )Y.2 `nJ LA tion department. //,p��- ADDRESS .d Y.2 Date b t�� Applicantyv�/r/ It W CITY ^ lam/ ZIP LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. NEAREST Q COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT r CROSS ST. (This section need not be completed if the permit is for one ASSESSOR hundred dollars($100)or less.) TRACT Q!_BLOCK LOT NO. MAP BOOK PAGE PARCEL �• F /"�D JJ-W - NOS7la--b,3 7 USE ZONE MAP I certify that in the performance of the work for which this OWNER j ''{(� Tom/ NO. 9L permit is issued, I shall not employ any person in any manner ;ADDRESS o?�7SPECIAL 4.4-,3 J ,3 0A • Iv '" CONDITIONS so as to become subject to the Workers'Compensation Laws. /� / 0 CITY S/T/�d 64 - zip 9177Z Date Applicant O NOTICE TO APPLICANT: If, after makingthis Certificate of ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY ENGINEER NO. CONST. ZONE ti Exemption, you should become subject to the Workers' G� D,� Compensation provisions of the Labor Code, you must forth- ADDRESS /� /� t/ y with comply with such provisions or this permit shall be CONTRACTOR (� ,f. NO. -S7� STATISTICAL CLASSIFI TO APT. ' APT. CO deemed revoked. LICENSED CONTRACTORS DECLARATION L`S /�� ) LIC. �� .�� CLASS NO. DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS �7.7 (,v.(, 0 (Z NO. SEWER MAP (commencing with Section 7000)of Division 3 of the Business and LIC, Professions Code, and my license is in full force and effect. "CITY 6f�fw 19 CLASS BK VALIDATION License Number oW 2�`r -AlSIZE STORIIES FAMILILIES CHECK Lic.Class C � 1 � E� �� /a 3 ` NEW VALUATION Contractor 'r' Date DESCRIPTION OF WORK _ ADD ❑`• $ -7 I am exempt under Sec. — re- P�� ALTER pill B.&P.C. for this reason REPAIR ❑ $ USE OF 9 3 5 a 2 A Date: EXISTING BLDG. DEMOL ,� U�-G�jf/� Signature APPLICANT QA' /� TEL. pp FINA g (PRINT) /�G aao.S• NO. f9� 07�S OWNER-BUILDER DECLARATION DATE "- # 0 0 0 0 0 1 1 hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and ADDRESS C14 .vim' FI 1 - - 60.50 Professions Code): PRESENT ; By A F1 I, 0 0 o 6 Q 5 0 5 I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and LOCALITY 1203-85 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 SETT BACK YARD HWY TOTAPROP.L NEFR M 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 m P.L. <_ Lender's Name 5D ,to LDMA Ref. # S P.C. Fee$ Permit Fee (J Lender's Address 1 certify that I have read this application and state that the Issuance Fee lf/''� 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 V V.IS LDMA perm. # b and hereby authorize representatives of this County to enter 9 upon the above-mentioned property for inspection pur oses. ,lA - �A-Gca f•�c-�S, �/4 0 SEE REVERSE FOR EXPLANATORY LANGUAGE n ' Signature of Applicant or Agent Date 0