HomeMy Public PortalAbout4505 TEMPLE CITY BLVD_Building__ WORKERS COMPENSATION DECLARATION
Thereby affirm that I have r certificate Come of tion in, to ,elf APPLICATION. FOR BUILDING PERMIT
upure, or a certificate of Workers' Compensation Insurance,
or a cenified copy thereof (Sec 3800, Lob C) r -
COUNTY OF LOS ANG6lE5 - BUILDING AND
ISAFE"
Polity No llurn D-�Compony AJURIC_
EJ 'Certified copy Is hereby furnished ///`/�� -FOR APPLICANT TO FILL IN BUILDING
)te` ADDIrEss r
Certified copy is filed with the county building Inspec- BUILDING
RI T i
hon department n/
2 �-c}Z CITY T ZIP I O LOCALm
R'
Date Applicant NO OF BLDG ST ,
CERTIFICATE OF EXEMPTION'FROM W SIZE OF LOT NOW ON LOT ' ' CROSS ST
'COMPENSATION INSURANCE - ASSESSOR
(This section need not be completed If the permit Is foi one TRACT BLOCK LOT NO - - MAP BOOK ,)-r Z PAGE ( pgRCFI Q3
hundred dollars ($100) or less ) OWNER TEL -702`] 115E ZONE t MAP a-lv
I certify that in the performance of the work for which this _ /J _
permit is Issued, I shall not employ any person In any manner ADDRESS rq E /�. / y
GOND TIONS 0.
so as to become subject to the Workers Compensation Lava0
CITY rti ZIP' SA—/ _ _ ._
Date ' Applicant ARCHITECT OR TEL OC
NOTICE TO APPLICANT If, after making this Certificate of ENGINEER NO _ _DISTRICT GROUP NIST _ ,ZONE PROl�SSED BY rO~
Exemption, you should become subject to the WorkersQ' // V
Compensation provisions of the Labor Code you must forth- ADDRESS 1% n --� -•' `3 �L�
with comply with such provlslom or this permit shall be TEL7r4 STATISTICAL CLASSIFICATIAPT CONDO
Z
deemed revoked CONTRACTOR M E NO /O 1 -
LICENSED CONTRACTORS DECLARATION LIC CLASS NO DON WELL UNITS_
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO Z SEWER MAP
(commencing with Section 7000)of Division 3 of the Business _ LIC ,
and Professions Code,and my license is in full force and effect Cin CLAS' BK /-- PG �O�s VALIDATION
License Number A')2?Q4 Z.` Llc Class a SIZE STORIES FAMILIES I ONE
NEW ❑ VALUATION QC
Contractor ,n _Date Jr- 2"'7-ci Z DESCRIPTION OF WORK ,v L $
❑1 am exempt under Sec - ALTER
ADD- ELI pop.� _ � _ _
B 8P C for this reason E REPAIR ❑ $
Date USE OF ," _ _
EXISTING BLDG -DEMOL ❑ 23
Signature APPLICANT TEL FINAL • ,
OWNER43UILDER DECLARATION (PRIM) -rt.L NO' -0Ip DATE ACCT.AT
I hereby affirm that I am exempt from the Contractor s License _ _ _ `�
Law for the following reason (Section 7031 5, Business and ADDRESS FINAL 3307 b2...1
Professions Code) _ _ t4T _ , t - By _ 1
❑ I, as owner of the property, or my employees withDINADDRESS ACCT a T
.r
wogesas their sole compensation willdothewarkand LOCALITY 7 LL�.bJ
the structure is not Intended or offered for sole(Section , 3303
7044, Business and Professions Code ) MOVING TEL ._ , _ -
❑ 1, as owner of the property,am exclusively contracting CONTRACTOR NO 2 ITEMS
with licensed contractors to construct the project (Sec
hon 7044, Business and Professions Code) ADDRESSTOTAL 175.84
CONSTRUCTION LENDING AGENCYSET BACK IRED TOTYARD Ifsvv AL SE pB L(� FROM' Eel -
I NE WIDTH L .84
hereby affirm that there Is o construction lending agency for FRONT ry4Ays�
the performance of the work for which this permit is Issued P IL - - - bFlfg .130
(Sec 3097 Civ C ) SIDE - r
PL
Lender's Name �p OfY L)MA Ref N 8/27/9r:"0001 $727�
PC Fee o2_1 Permit FeePilo.
Lender s Address y 5234 1 AM 9;41
o I certify that I have read this application and state that the Nuance Fes LDMA PTC N
above Information is correct 1 agree to comply with all County Investigation Fee _ p - -
ordinances and State jaws relating to building construction Total Fee /✓� '� LDMA Perm N
< and hereby authorize representatives of this County to enter y -
Y$
upoqAhp above-m�fft)nttigneddp property for Inspection purposes
SEE REVERSE FOR EXPLANATORY joss"
Sigriorore dKApplicant or Agent Date
f
WORKERS COMPENSATION DECLARATION
tinsure
affirm certificate
that I have r certificate of tionconsent to ,elf APPLICATION FOR. BUILDING PERMIT
insure ,or a certifirats of Workers' Compensation Insurance,
or a certified copy thereof (Sec 3800, Lob C )
1lslicy No Company
COUNTY OF LOS ANGELES - - BUILDING AND SAFETY
'
❑
Certified copy is hereby furnished FOR APPLICANT TO FILL IN ppm 5'p
❑ Certified copy Is filed with the county building inspec-
ti
on department ESS swP1C alD
Date Applicant Ta"P\Cr r- GA ZIP g\'l'9'�' LOCALITY
NO OF NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' OF LOT \d C NOW ON LOT \- - CROSS ST
COMPENSATION INSURANCE ,{ M p
(This section need not be completed if the permit is for one T \`Z��{$ BLOCK LOT NO 'Za{ MAPS BOOK' .J pgGP"'� pqQ
hundred dollars ($100)or less )
I comfy that in the performance of the work for which this :R Q 1110 a USE ZOO I NO
MAP
permit s Issued,I shall not employ any Persian in any manner ESS 44 T C 'g�LVD - �' CONSPECDITIONS
a
W as to become subject to the Workers Compensation Laws O
-
CITY ZIP X1'7�1� - - -
Date Applicant IIECi OR TEL
NOTICE TO APPLICANT If, after making this Certificate of NEER L,LA\6 NO DISTRICT GROUP �N$T ZONE
PROCESSED BY OO
Exemption, you should become wblect to the Workers' 1/ G
Compensation provisions of the Labor Code, you must forth- ESS 3 y 9 t
with comply with such provisions or this permit shall be STATISTICAL CIASSIFKATION AP7 CONDO Z
deemed revoked _ TRACTOR Or'1�1 vsi\DV4 NO
LICENSED CONTRACTORS DECLARATION LIC CLASS N0'.�DWEII UNITS_
I hereby affirm that I am licensed under provisions of Chapter 9 ESS _ NOSDNER Map(commencing with Section 7000)of Division 3 of the Business �j qG nG A�(r7a
and Professions Code,and my license is In full force and effect gl( PG g tlAL1BATION
SW 4- OF NO OF6IEIXLicense NumberLic Clap STORIES FAMILIES \ ONE RIPTION OF WORK 1 V . %ii NEW ❑ VALUATION r 1 ITEM_
Contractor Date _ _
❑I am exempt under Sec ,;- oZ SpA ADD ® 4ioPilo.
T(E K ��'fi _ d�
B 8P C for this reason a'L- � � N7FR ❑ ��/SODO �� c�I�C��t��
REPAIR ❑ L 1-O.UI
Date USE OF t - CHAWIG ,11Q
EXISTING BLDG "ewv q , DEMOL ❑
Signature APPLICANT TEL FINAL
(PRINT) Ada\F- NO YY4S' DATE
OWNER-BUILDER DECLARATION I(1 O
I here affirm that I am exempt from the Contractor i License 4'�J�s �6`..4rs C MII.11
Law for the following reason Section 7031 5 Business and aaVD FINAL4 i F
Professions Code)' _ B
BUILDNG
ING L\6pS 'j'� '�JZI Y -
® I, m owner of the property, or my employees with ADDRESS
-
wages as their sole compensation will do the work and LOCALITY - \\ •- a
the structure is not intended or offered for sole(Sectionv' ' ' ► t
7044, Business and Professions Code ) MOVING 1 .• - J"" TFL -
❑ I os owner of the property am exclusively contracting CONTRACTOR 'i NO ` -�+ ,
-- with licensed controctoni to construct the prolect (Sec- i !•-
tion 7044, Business and Professions Code ) ADDRESS t,
CONSTRUCTION LENDING AGENCY
IRED - YARD H1VY AL IXNE FROM. - . ` I 4
I {Yi/ '�.•
O -� f S
hereby affirm that there s BA a construction lending agency for T t -�--- f,
the performance of the work for which this permit is issued PL ' Cly .- i.t F h.•
(Sec 3097 Civ C ) IDE M ?
M. •�.: T.`5
Lend _P
Lender's Name =
F+3 LDMA Ref E "1 N41,PC Fee •� Per $Fee f"/e 667 ►
Lenders Address - .�/- p - -
o I certify that I have read this application and state that the / 6 ce Fee �3'L TDMA P/C 0 t
above info mation is correct I agree to comply with all County Investigation Fee /
ordinances and State laws relating to building construction, Total Fee /Q !O D LDMA Perm It
Q and hereby authorize representatives of this County to enter $
8$ upon 1pe above- ennoned property fes inspection purposes i-• -rc.$ [, uv
Q p r0
7Y1 �•-'i L a-y-9� NERS
E REVERSE FOR EXIT VkNATORY LA0gUfW'F,
F r,_
;.
Sig es re of Applior Agent Dote t ' r -
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 BUILDING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 IAS TUNAS ALTERATION/REPAIR
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 BL 0506 1207120026
PHONE (626) 285-0488 EXT DUPLICATE
)LEGAL ID NO OF CONST BUILDING ADDRESS
ITR 12998 LT 24 BL 001 SQ FT STORIES TYPE 4505 TEMPLE CITY BY,
)STRUCTURE 2300 V-B. TEMP CA 917804234
ASSESSOR INFORMATION NUMBER NEAREST CROSS STREET
18592-001-038 THOMAS PAGE 597 GRID AS LOCALITY TEMPLE CITY C
TENANT IEXIST BLDG USE RESID USE ZONE R-1 ISSUED ON PROCESSED BY
IE%IST OCC GRP 07/16/12 SR
OWNER TEL NO IBLDGS NOW ON LOT VALUATION IF D E F1+nr BY CODE
LEE, BRIAN (626) 215-6870- 1 15,000
14505 TEMPLE CITY BL
TEMP 917809239I FEES PAID IDffcktPTlkON OF WORK
I I R VE ALL LAYERS AND INSTALL COMPOSITION SHINGLE TO BE
FEE DESCRIPTION QUANTITY COM AMOUNT (CHANGED TO LITE WEIGHT TILE
EL
ICANT
PROLROO IF NG CO (213) 663--- 8812- AA BLDG PERMIT ISSUANCE 27 60 I
14219 S ALAMEDA ST AS STATE GREEN BLDG FEE 7500 00 VAL 1 00 (SPECIAL CONDITIONS
1LOS ANGELES CA 90058 IAC STRONG MOTION RESID 7500 00 VAL 0 BO
D2 PERMIT W/O FN-HC 7500 00 VAL 183 00
D2 PERMIT W/O EN-HC 15000 00 VAL 117 60
ICONTRACTOR TEL NO TOTAL FEES 330 20 APP-OVALS DATE INSPECTOR SIGNATURE
IPRO ROOFING CO (213) 663-8812- I
4219 S ALSMEDA ST LIC NO LOCATION AND SETBACKS
)LOS ANGELES, CA 90058 956975C39-
SOILS ENGINEER APPROVAL
(ARCHITECT OR ENGINEER TEL NO 1F0 R9DATION/TRENCH FORMS I
I LIC NO ISLAB/UNDER FLOOR
I
IRAISED FLOOR FRAMING
IMAP NO SEWER MAP BOOK PAGE FIRE ZONE CMP IUI."CERFLOOR INSULATION
I144H269 3 001
FLOOR SHEATHING
IND OF FAMILIES DWELLING UNITS APT/COND STAT CLASS
1 0 NO 21 I_
I I )ROOF SHEATHING I I
I SCHOOL WITHIN HAZARDOUS ISHEAR PANELS
AIR QUALITY 1000 FEET MATERIALS
I
NO NO NO FRAVF INSPECTION
FIRE SPRINKLERHANGERS
I I
)INSULATION/WEATHER STRIP) I
INTLRIOR LATH/DRYWALL
. E%TEPIOR LATH
(RATED FLOOR/CEIL ASSEM
I �
(RATED WALL ASSEMBLIES
IRATFD SHAFTS/OPENINGS
II T-BAA CEILINp9
' )LOT DRAINAGE
(REPORT ID DPR261 ROUTE TO BS0508 I
COUNTY OF LOS 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 1207120026
PHONE (626) 285-0488 EXT r
LEGAL ID NO OF CONSTBUILDING D
ITR 12998 LT 24 BL 001 SQ FT STORIES TYPE 450TEMPLECITY SL
]STRUCTURE 2300 V-B TEMP CA 917804234
A956550R INFORMATION NUMBER NEAREST CROSS STREET
18592-001-038 i THOMAS PAGE 597 GRID AS LOCALITY TEMPLE CITY, Cl
]TENANT IXIST BLDG DSE RESID USE 20NE R-1 ISSUED ON PROCESSED BY
EXIST OCC GRP 07/12/12 SR
OM`6R TEL NO �BLDQS NOW ON LOT VALUATION
)LEE, BRIAN (626) 215-6870- 7,500 1FINAI. (]ATE FINAL BY CODE
14505 TEMPLE CITY BL
]TEMP 917809239I FEES PAID (DESCRIPTION OF WORK
(REMOVE ALL LAYERS AND INSTALL COMPOSITION SHINGLE 1
FEE DESCRIPTION QUANTITY DOM AMOUNT
(APPLICANT TEL NO I
IPRO ROOFING CO (213) 663-8812- AA BLDG PERMIT ISSUANCE 27 80 1
14219 S ALAMEDA ST AB STATE GREEN BLDG FEE 7500 00 VAL 1 00 (SPECIAL CONDITIONS 1
ILOS ANGELES CA 90058 1AC STRONG MOTION RESID 7500 00 VAL 0 BO 1 1
D2 PERMIT W/O EN-HC 7500 00 VAL 183 00
TOTAL FEES 212 60
ONTRACICR TEL
NO IAPPROVALS,, DATE INSPECTOR SIGNATURE
IPRO ROOFING CO (213) 663-8812- I
14219 S ALAMEDA ST LIC NO (LOCATION AND SETBACKS
]LOS ANGELES CA 90058 956975C39-
)SOILS ENGINEER APPROVAL -
)ARCHITECT OR ENGINEER TEL NO t/UNUER
DATION/TRENCH FORMS
LIC NO ] FLOOR
1
1 I
- ]RAISED FLOOR FRAMING
M1AP NO SEWER MAP BOOR PAGE FIRE 7AHE CMP UNDEAFLOOR INSULATION
144H269 3 00
1ND OF MANICIES DWELLING UNITS APT/GOND STAT CLASS ]FLOOR SHEATHING
1 0 NO 21 ]ROOF SHEATHING
SCHOOL WITHIN HAZARDOUS ISHEAR PANELS I
]AIR QUALITY 1000 FEET MATERIALS ( I I
NO NO NO i FRAME INSPECTION
FIRE SPRINKLER HANGERS
INSULATION/WEATHER STRIP
' - I
INTERIOR LATH/DRYWAr.*.
- I
EXTERIOR LATH
RATED FLOOR/CEIL ASSEM
I _ ]
RATED � ASSEMBLIES
I( RATED SHAFTS OPENINGS
T-BAR CEILINGS
I ]LOT DRAINAGE
I 1
]REPORT ID DPR261 ROUTE TO BS0508
1 I I I