HomeMy Public PortalAbout5011 SERENO DR_Building__ • 140RKERS COMPENSATION DECLARATION
h�eliy affirm certificate
that 1 have r cs' Come of consent to self - APPLICATION FOR BUILDING' PERMIT
M1aure ora certificate of Workers' Compensation Insurance
or a certified copy thereof (Sec 38DO Lab C )
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No Company
Certified copy is hereby fumnhed FOR APPLICANT TO FILL IN BUILDING /
Certified copy its filed wish the county budding mADDREADDRESSapec BUILDING
hon department _ ADDRESS
Date Applicant CITY ZIP / 120 LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT 6 A NOW ON'LOT R ST
COMPENSATION INSURANCE
(This section need not be completed if the permit Is for one TRACT &OCIL LOT NO MAP BOOK ASSESSORl�-•--_ PAGE PARCEL
hundred dollen($10D)w less )
TEL MAP -
I certify that in the performance of the work for which this OWNER NO NO },
permit Is Issued i shall not employ any person in any manner , SPECIAL
� D_
w as to become subleo to the Work Compenwt & 5907113 8
Date —��yy CRY ZIPApp /
NOTICE TO APPLICANT If, after making th rtiflc of ARCHITECT N� DISTRICT UP TYPE R BY O
Exemption, you should become subject the Worken' CONST ZONE
Compensation provisions of the Labor Cod ou must forth ADDRESS Sct v W
with comply with such provisions w this permit shall beL STATISTICAL CASSIN TION APT CONDO
N
deemed revoked CONTRACTOR Z
LICENSED CONTRACTORS DECLARATION / LIC QA.SS NO DWELL UNITS_
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS V NO
(commencing with Section 70DO)of Division 3 of the Business ad UC SEWER MAP
Professions Code, and my license Is in full force and effect CRY CUSS VALIDATION
SO FT NO OF NO OF CHECK SK PIG
License Number Uc CI - SIZE STORIES / F (LIES / ONE
VALUATION
NEW
t Date DESCAIPfION OF WORK - ADO
I am exempt under Sec ALTER
B 8P C for this reasonREPAIR i ;29 0 Q 9 A
Date P.7(ISIE TING BLDG DEMOL # • • • • • 1
Signature APPLICANT _ TEL FIN �O I • 1 06,1 3 1
OWNER-BUILDER DECLARATION PRINT NO ' DA
I hereby affirm that I am exempt from the Contrxtw s License
Law for the following reason (Section 7031 3 Business and ADDRESS RN • • 1 061135
Professions Code) _ BUIL •'
IL7-77�L( ADDRESS '•
I, as owner of the property, or my employees with ADDRESSESS Z � 0 0 OI't 8 8
-
wages as their sole compensation,will do the work and � •
the structure is not intended or offered for sole(Section LOCALITY
70", Business and Professions Code) MOVING TEL `
I, as owner of the properly, am exclusively contracting CONTRACTOR NO `
with licensed controcion to construct the prolect (Sec- ADDRESS 1
tion 70" Business and Professions Code)
CONSTRUCTION LENDING AGENCY SET BA YARD HWY TO PROP UNE 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 �i'
(Sec 3097 Civ C ) SIDE
PL
Lender s Nome `Ref I
8
PC Fee S Permit For 1 ^
Lender's Address
1 certify that I have read this application and state that the hsinnce Fee V IDAsn PiC�� `• ` 1 r_ `` ��
above information is coned I agree to can with all County Invepigation Fee
$ ordinances and State lawrelating to budding construction Tool Fee V TDMA P
s erm 1 I
R and hereby authorize representatives of the County to enter ,
upon t e above- nt id pr arty for inspection purposes - `
N �� J •� ° '
=aM RfVEIR FOR EXPLAEIATOIY LANGUA6[
+grin App ant w Agent \
1 '
MINTY OF LOS ANGELES TEMPLE CITY 0 0508 BUILDING PERMIT
DEPARTMENT OF PIALIC WORKS 9701 LAS TUNAS ALTERATION/REPAIR
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 BL 0508 0411290051
PHONE. (626) 285-0488 EXT
LEGAL ID NO OF CDNST BUILDING ADDRE55
ON FILE SO FT STORIES TYPE 5011 SERENO DR
STRUCTURE 400 VN TEMP CA 917803038 _
ASSESSOR INFORMATION NUMBER NEAREST CROSS STREET ACASO
5388-016-003 THOMAS PAGE 596 GRID: H5 LOCALITY: TEMPLE CITY, C
TENANT EXIST BLDG USE RESID USE ZONE K-I ISSPJFD ON PROCESSED BY EXPIRES ON
EXIST OCC GRP 11/29/04 JK 11/24/05
OLEUNG WNER TEL. NO: BLDGS NOW ON LOT: VALI ON FI BY-. CODE
PING K,LOUISE S (818) 286-2883- 1,000 —
6203 CLOVERLY AV
TEMP 917801602 FEES WID I TON OF WOR
T OFF AND REROOF COMPOSITION SHINGLES GARAGE ONLY
FEE DESCRIPTION QUANTITY U01: AMOUNT:
APPLICANT: TEL NO- I
SAME AS OWNER - AA BLDG PERMIT ISSUANCE 27 75
AC STRONG MOTION RESID 1000.00 VAL 0 50 SPECIAL CONDITIONS
D2 PERMIT W/O EM-HC 1000 00 VAL 65.40
FR IRV WORK W/O PERMIT 128 50 DOL 128 50
TOTAL FEES 222 15
CONTRACTOR. TEL NO APPROVALS ----DATE INSPRTff-9rMUMT--
SAME AS OWNER - -
LIC NO LOCATION AND SETBACKS
SPOILS ENGINEER APPRNA7
ARCHITECT OR ENGINEER No. FOUNDATION/TRENCH FDMW-
LIC NO SLAB/UNDER FLOOR
RAISED FLOOR FRAMING
MAP NO: SEWER MAP BOOK PAGE FIRE ZONE cw LINDERFLOOR INSULATION
XX 3 01
-=INU-GMS APT/COND STAT CLASS
_ FLOOR SHEATHING
NO OF FAMILIES I
NO 21
---CHWE-9MIN HAZARDOUS
AIR QUALITY 1000 FEET MATERIALS
NO NO NO FRAME INSPECTION 2_
rrffE-MNILLt:R HANGERS
SET BACK YARD HWY PROP LINE WIDTH
/;Z/ tr
FRONT PL- --�,{a�` TLU R«, 1�
HEATHER STRIP; —
SIDE PL- Y
INTERIOR LATH/DRYWALC---
EXTERIOR LATH
RATED WALL ASSEMBLIEr--
RATED SHAFTS/OPENINGS
T-BAR CEILINGS
LOT DRAINAGE
REPORT ID DPR261 ROUTE TO. BS0508