HomeMy Public PortalAbout5260 SERENO DR_Building__ e WORKERS COMPENSATION DECLARATION
hereby affirm that I have certificate of consent to self
insure FOR BUILDING PERMIT
surd or a ceMif¢ate of Workers Compensation Insurance, - APPLICATION
a certified copy thereof (Sec 3800, Lab C) _ t
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No Company '
❑ Certified copy is hereby furnished FOR APPLICANT TO FILL IN plp� vJ'V 40
❑ Certified copy Is filed with the county building inspec- TNG '5-Z/ d
LIATFON
hon department '0'�R
Date Applicant CI ZIP ! f%/'� LOCALITY
• _ NO OF& - NEAREST
CERTIFICATE,OF EXEMPTION FROM WORKERS r SIZE OF LOT NOW ON LOT CROSS ST
COMPENSATION INSURANCE _ _ AZESSOR
�/ O /,
(This section need not be completed If the permit is for one TRACT BLOCK LOT NO (� AMP BOOK �J O __ PAGE 10/ P RCEL
hundred dollar (5100) or leu ) 11 TEL z USE ZONE MAP
OWNER V Li 'Np 7
, I certify that in the,performance of the work for which this {� }
permit is Issued, I shall not employ any person In any manner `s ADDRESS - ��
SPECIAL , O
J so as to b orae subject to the Work m neati CONDITIONS
/ ZIP %/00 7 U
Dale Applicant ARCHITECT ',.A L�-' TEL K
NOTI E TO APPLICANT If, after th ertfkote of X4ENGINEER yr`Tj L - pp DI GROUP TYPE FIRE PROCESSED BY O
Exemption, you should become subject to the Worker L .1 �O p 5 NST ✓ �E 0
Compensation provisions of the Labor Code, you must forth- ADDRESS L�IJ O
with comply with such provisions or this permit shall be TEL STATISTICAL CLASSIFICATION APT CONDO N
�1 n 2
deemed revoked - CONTRACTOR LIC CLASS NO�DWEII UNITS
LICENSED CONTRACTORS DECLARATION ADDRESS NO
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000)of Durston 3 of the Business UC SEWER A4IP ^
and Professions Code,and my license is in full force and effect CIN CLASS g pG O� VALIDATION
SO yrJ��J,?� NO OF /J ,, NO OF CHECK
License Number Lic ClassSIZE //% STORIES (/ FAMILIES ONE rt�f T.r
Contractor Dote-
e2 OF WORK NEW Vµ
❑ am exempt under Sec �: L.j P• AW ❑
B BP C for this reason 4 ALTER 1:1 _
REPAIR ❑ s II21rlL itfl�-USE OF
.i•_
EXISTING BLDG DEMOL ❑ QQWn IAEL-K
Signature (� APPLICANT _ _ TEL .0 L 1-f'rl�It.� ,I1{7
OWNER-BUILDER DECLARATION ,u (PRINT) NO flNAI DATE-
I hereby affirm that I am exempt from the Contractor s License - --- - -
Low for the following reason (Section 7031 5, Business and ADDRESS FINAL �'--I/'_
Professions Code) - T _ _ _ BY
1•-
❑ I, oa owner of the property, or my employees with BADDRESSS
wages as their sole compensation,will do the work and r'"+
the structure is not Intended or offered far sale(Section LOCALITY
g7(/7044, Business and Professions Code ) A10VING TEL 9 I J t . 7 - 1759.70
LJ I, as owner of the property, am exclusively contracting CONTRACTOR NO I er v�fa L a,l `„'v r�i 1 17 ^
with licensed contractor to construct the project (Sec- D 1•
hon 7044, Business and Professions Code ) ADDRESS -EXIST _ -{{ S C 1 TOTAL 17 9.71{
CONSTRUCTION LENDING AGENCY REQUIRED YARD HWY AL k pep' F� L 't (,WC( 1759.70
' I hereby affirm that there n a construction larding agency for FRONT
the performance of the work for which this permit uIssued - P L v t (� .01I
(Sec 3097 Civ C) SIDE - _ _
Lender's Nome PL
`, LDMA Ref a \' 7N"• tr; 0000-M01 4/29/93
_ - PC Fee: 7ou�•a- Perms Fee 9451 1 Ali10:(K
Lender s Address _ �O - I
o I certify that I have read this application and state that the luiwiice Fe •GS LDMA P/C
above information s correct I agree to comply with all County Investigation Fee _ �y _
ordinances and State jaws relating to budding construction, Total Fe.// -/Vi 0 LDMA Perm Y
and hereby authorize representatives of this County to enter _ _ -
upon d e ov me rte ro rty for inspection Our7s
i
SEN REVERSE FOR EXPI/LNATOIIY LANGUAGE _
6/4w.r.of Applicant or Agent Dais
' COUNTY OF LOS ANGELES TEMPLE CITY K 0508 BUILDING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ALTERATION/REPAIR
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 BL 0508 1006140023
PHONE (626) 285-0488 EXT
LEGAL ID NO OF CONST BUILDING ADDRESS
ITR 45808 LT 1 UN 3 SQ FT STORIES TYPE 5260 SERENO DR
STRUCTURE 2500 V-B TEMP CA 917803058
ASSESSOR INFORMATION NUMBER NEAREST CROSS STREET
5388-010-051 THOMAS PAGE 596 GRID H4 LOCALITY TEMPLE CITY, CI
TENANT EXIST BLDG USE REBID USE ZONE R-2 ISSUED ON PROCESSED BY
EXIST OCC GRP - 06/14/10 _ SR _
(OWNER TEL NO JBLIX75 NOW ON LOT VALUATION F BY CODE
JiANO WEI-CH[Ri (626) 286-8342- 14 500 '/` ^�
15260 SERENO DR
ITEMP 917803058 FEES PAID DESCRIPTION OF NORK
IRE ROOF-TILE ROOF (1) REMOVE OLD TILE (2) TO COVER ROOFING
FEE DESCRIPTION QUANTITY DOM
AMOUNT
FELT (3) TO COVER OLD TILE BACK
APPLICANT TEL NO
YOUNG, KIM (323) 264-8050- IAA BLDG PERMIT ISSUANCE 27 75 1
1541 LOMA VERDE ST AB STATE GREEN BLDG FEE 14500 00 VAL 1 00 SPECIAL CONDITIONS
MONTEREY PARK 91754 - IAC STRONG MOTION RESID 14500 00 VAL 1 45
D2 PERMIT W/O EN-HC 14500 00 VAL 300 60 W �m x
TOTAL FEES 330 80 , , oO
itAO V N
l15
NTRACTOR TEL NO APPROVALS DATE I 9 A SIGNATURE
LODMA
CAP CONSTRUCTION INC (323) 264-8050-
41 MA VERDE STREET LIC NO (LOCATION AND SETBACKS
NTEREY PARK CA 91754 807380 C39
SOILS ENGINEER APPROVAL
I
ARCHITECT OR ENGINEER TEL NO IFOUNTDATION/TRENCH FORMS
1
LIC NO SIAB/UNDER FLUOR
RAISED FLOOR FRAMING
1
MAP NO SEWER MAP BOOK PAGE FIRE ZONE CMP (UNDERFLOOR INSULATION
147H265 3 00 1 1 _
(FIR SHEATHING I
ING OF FAMILIES DWELLING UNITS APT/GOND STAT CLASS
INO 21 ROOF SHEATHING
SCHOOL WITHIN HAZARDOUS SHEAR PANELS
AIR QUALITY 1000 FEET MATERIALS
NO NO NO IFRAME INSPECTION
(FIRE SPRINKLER HANGERS
' (INSULATION/WEATHER STRIP
INTERIOR IATH/DRYWALL
EXTERIOR LATH
7
RATED FLOOR/CEIL ASSEM
RATED WALL ASSEMBLIES
RATED SHAFTS OPENINGS
T-BAR CEILINGS
LOT DRAINAGE
(REPORT ID DPR261 ROUTE TO BS0508