The URL can be used to link to this page

Home My Public Portal About5555 1/2 SANTA ANITA AVE_Building__ WORKERSG COMPENSATIODI DECLARATION hereby affirm that I'havecertificate of consent to self APPLICATION FOR BUILDING PERMIT insure, or a-certificate of Workers'Compensation Insurance, or a certified copy thereof(Sec. 3800, Lob. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. WWZ00'%0Company C7[fi//U ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING ' ADDRESS CJ Er Certified copy is filed with the county building inspec- BUILDING j 7/z S" UAV tion department. ` ADDRESS Date �lrp rme+" Applicant CITY Temp 1 e Ci t y ZIP 917 LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. NEAREST COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS ST. Vak ASSESSOR (This section need not be completed if the permit is for one hundred dollars ($100)or less.) TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL TEL.576=8737 I No. USE ONE MAP � I certify that in the performance of the work for which this OWNER J.E. Plount & Co. � NO. ��7-7 y permit is issued, I shall not employ any person in any manner SPECIAL D. so as to become subject to the Workers'Compensation Laws. ADDRESS CONDITIONS V Date Applicant CITYSan. GnbritalZIPQ1:7:76 ad NOTICE TO`APPLICANT: If, after making this Certificate of ARCHITECT OR EL• DISTRICT G OUP TYPE FIRE P ESSED BY V g ENGINEER Neil Esurki NO. 576-7456, CONS . ZONE Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- ADDRESS �� v _—�) y with comply-with such provisions or this permit shall be TEL. i STATISTICAL CLASSIFIPATION APT. ONDO. Z deemed revoked.. CONTRACTOR same as owner NO. �J LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. DWELL. UNITS�L L I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. I 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.Te A PG 6S6 VALIDATION SQ. NO. IE 2 FA OF CHECK License Number Lic.Class SIZE STORIES FAMILIES ONE VALUATION DESCRIPTION Contractor �! L �!/f/� jJ Vd pO}e DESCRIPTION OF WORK NEW $ igloo 9 4 3-3 4 A ❑ single family detached ADD ❑ , # o a o a 2 3 I am exempt under Sec. ALTER - 62730 p B.&P.C. for this reason condominium.--F- 000 4/'(t C- REPAIR ❑ $ 0 3 3 USE OF 7 8 8 v U Date' EXISTING BLDG. DEMOL ❑ g APPLICANT John Plount No 576-8737 Si nature FINAL OWNER-BUILDER DECLARATION DATE, I hereby affirm that I am exempt from the Contractor's License 217 W. Las Tunas Dr.. San Gabriel Law for the following reason (Section 7031.5, Business and ADDRESS Fl?%VZ7 Professions Code): PRESENT B ❑ 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. with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). ;2 5 0 IL 0 A REQUIRED TOTAL SETBACK FROM T. CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH #,0 0 0 0 0 1 hereby affirm that there is a construction lending agency for FRONT • the performance of the work for which this permit is issued P.L. ~ - 748.50 (Sec. 3097, Civ. C.). SIDE .i_� a P.L. O o 74a50 = Lender's Name LDMA Rgf.•#. P.C. Fee$ Permit Fee 07. 1 5-86 Lender's Address r I certify that I have read this application and state that the Issuance Fee ! ��S V 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 ,S6 LDMA Perm. # t, and hereby authorize representatives of this County to enter 5 upon thq above-mentione property for inspection purposes. _ SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of pplicant or Agent Date pvt S,!WORKERS•.COMPENSATIOL1 DECLARATION it hprebj,aftrm that I have a certificate of consent to self � APPLICATION FOR BUILDING PERMIT 1, or or a,certificate of Workers'Compensation Insurance, or a certifigd copy thereof 4sec. 3800, Lab. C.), �JZP03 � COUNTY OF LOS ANGELES BUILDING ANDS FETY Policy No/ Company DING Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILADDRESS Oft�+� UW 24> Certified copy is filed with the county building inspec- BUILDING tion department. " ADDRS 5555 Santa Anita Ave. - P.� i Date Applicant CITY Temple City zip 91780 LOCALITY CERTIFICATE OF EXEMPTION FROM WORKE S' NO.OF BLDGS. NEAREST Ila COMPENSATION INSURANCE SIZE of LOT NOW ON LOT CROSS ST. (This section need not be completed if the permit is for one }4319 ASSESSOR hundred dollars($100)or less.) TRACT, BLOCK LOT NO. � MAP BOOK PAGE PARCEL j J.E. Pl ount & Co. TEL. US ZON MAP `-� I certify that in the performance of the work for which this OWNER N057 — NO. / d permit is issued, I shall not employ any person in any manner 217 W. Las Tunas Dr. SPECIAL so as to become subject to the Workers'Compensation Laws. ADDRESS CONDITIONS O 1 V Date Applicant CITY. San Gabriel ZIP 91776 ®s NOTICE TO APPLICANT: If, after making this-Certificate of ARCHITECT ORTEL• DISTRICT OUP TYPE FIRE PROC SED BY V ENGINEER Neil Es rk NO-576—7 — CONST. ZONE Exemption, you should become subject to the Workers' �� `/ W Compensation provisions of the Labor Code, you must forth- ADDRESS :J V IL with comply with such provisions or this permit shall be TEL. STATISTICAL CLASS ICATION APT. CO DO. deemed revoked. CONTRACTOR same as owner NO. J / LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. DWELL. UNITSIJ— 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 e ff ect. CITY CLASS BK PG B VALIDATION Z/{✓ ' Lic.Class ' �% SFT. NO. FAMILIES OF CHECK �lf' License Number SIZE 1613 STORIES 2 � FAMILIES ONE • VALUATION NEW # Contractor�•Gr �dGA/ C pate DESCRIPTION OF WORK ADD $ 9,9 ( 0 6035 ALTER ❑ I am exempt under Sec. single family detached ❑ , o a 6 3.5' • cr. t B.BP.C. for this reason condominium.l,}- �/,�(J� 42M z- REPAIR ❑ $ 0 a3 1 —86 Date: USE OF,: 1 0DEMOL EXISTING BLDG. APPLICANT TEL. Signature PRINT John Plount NO. FINAL OWNER-BUILDER DECLARATIONDATE !G� I hereby affirm that I am exempt from the Contractor's License ADDRESS 217 W. Las Tunas DP.. San Gabriel Law for the following reason (Section 7031.5, Business and FI N Professions Code): PRESENT B BUILDING I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and LOCALITY ' I the structure is not intended or offered for sale(Section -2 5 0 3j,9 A 7044, Business and Professions Code). MOVING, -TEL. ❑ CONTRACTOR NO. I, as owner of the property,am exclusively contracting # 0 0 0 0 0 with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). 1 - 721.50 REQUIRED TOTAL SETBACK FRO ST. CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP.LINE WIDTH ,]2 �,5 C cz I hereby affirm that there is a construction lending agency for FRONT 0 0 the performance of the work for which this permit is issued P.L. (Sec. 3097, Civ. C.). SIDE , s:�•. 0;7, 15-86 g P.L. e` Lender's Name I O LDMA Ref.,# P.C.Fee$ r 3.� Permit Fee l t Lender's Address r I certify that I have read this application and state that the i 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, I Total Fee and hereby authorize representatives of this County to enter LDMA Perm.# 5 upon the above-mentione property for inspection purposes. j _ / J SEE REVERSE FOR EXPLANATORY LANGUAGE D Signature of plicant or Agent Date t