HomeMy Public PortalAbout5120 TEMPLE CITY BLVD_Building__ WORKERS' COMPENSATION DECLARATION
hereby affirm that I have certificate of consent to =elf _ 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 'Company
❑ Certified copy is hereby furnished FOR APPLICANT TO FILL IN BUIWIN C
❑ Certified copy a flied with the county building mspac- AI�5Ns 5/2C) %=.fA1�LE ADDRESSG- 8L 1
• tion department %¢ 16
CITY 72ii9rf'1GE C17-Y ZIP /780 LOCALITY i
Date Applicant NO GF& - CROSS Lr9 RC75A - --
CERTIFICATE OF EXEMPTION FROM WORKERS Sig OF lOT NOW ON LOT •
COMPENSATION INSURANCE ,p pp PSSESSOR p p 1
-(This section need not be completed if the permit is for one---- TRACT /,rj 8 &IX7C LOT NO t7 MAP 8001( p O PAGE O/ J pgRCELO2O
hundred dollars ($,00) or less ) - L
OWNED VAj USE ZONE MAP
I certify that in the performance of the work for which this 'c
permit is issued, I shall not employ any person in any manner ADDRESS S/.ZO�MPLF CITY 491 SPEOA
�- TIONS d
so as to become subject to the Workers' Compensation Laws O
, , CITYTBS'" c1//'Y cq zip -W700 V ,
Date Applicant ARCHITECT OR TELIY
NOTICE TO APPLICANT If, after making this Certificate of - ENGINEER _ NO DISTRICT GROUP TYPE - IRE PROCE BV Q
ZONE
Exemption, you should become subject to the WorkersCsQQ �� � .s7
Compensation provisions of the Labor Code, you must forth- ADDRESS
with comply with such provisions or, this permit shall be TEL STATISTICAL CL4SSIF TION API CO Z
deemed revoked CONTRACTOR NO ,
LICENSED CONTRACTORS DECLARATION UC CLASS
NO DWELL UNITS—
I hereby affirm that I am licensed under provisions of Chapter 9 _ ADDRESS NO
(commencing with Section 70DO)of Division 3 of the Business LIC SEWER MAP t
and Professions Code,and my license is in full force and effect CITY CUSS BK PG VALIDATION
SQ FT�.,� NO OF NO OF I CHECK
License Number Lic Class SIZF's>T�L STORIES FAMILIR `�� ONE
_ VALUATION ,
t Contractor Dote DESCRIPTION OF WORKC#OPW4d A 57-IA( NEW ❑
ElI am exempt under Sec WnD JoynolysM ADD
I❑l ► _
9 ALTER
B'8P C for this reason REPAIR ❑ S -
Date USE OF _
EXISTING BLDG D ����j�/��/� .�o ntM ❑
Signature APPLICANT
F4MIItO #4%V4 IZW t p/-oS 177 S
OWNER-BUILDER DECLARATION _ DATE
FINAL
I hereby affirm that I g r exempt from the Contractor's License ADDRESSS/�AWAef C17Y BL
Low for the following reason (Section 7031 5, Business and FINAL UJ
Professions Code) M _ - - - f"
BUILDING
® I, as owner of the property, or my employees with ADDRESS , -t- t •*
wages as their sole compensation,will do the work and - '- - -
the structure is not intended or offered far sale(Section LOCALITY 711r il:.:_
7041, Business and Professions Code ) MOVING TEL , 1 iTchl,=
L ❑ 1 as owner of the property, am exclusively contracting CONTRACTOR NO
with licensed contractors to construct the project (Sec- - ADDRESS TOTAL AL I I� 82
tion 7044, Business and Professions Code ) E WID
_
REQUI D TOTAL SETBACK FROM L.HE I
CONSTRUCTION LENDING AGENCY SET BA YARD HWY p N
I hereby affirm that there is a construction lending agency for FRONT _ _ CHANE (IAL
the performance of the work for which this Permit is issued P L - -
(Sec 3097, Civ C ) SIDE
PL
r
Lender s Name UI 1_�l-I_171_1 11•_1/ 71
8 - r vdwp TDMA Ref •
Lender sAddress
PC Fee S Perms Fee 015t.
�/
I certify that I have read this appb /� q
k/• IS and state that the luuance Fee O` LDMA P/C 0
above Information is correct I agree to comply with all County Invenigonon Fee - _
ordinances and State laws-relating to building construction Total Fee 3 L)MA Perm N
and h y authorize representatives of this County to enter
upo above-mento ed property for inspection purposes
p
k — UE EEVEIOE FOR EXPLANATORY LANGUAGE
Sgnature of AppLcont a Agent Date
APPLICATION FOR BUILDING PERMIT t � .
COUNTY OF LOS ANALES BUILDING AND SAFETY
WORKER S COMPENSATION DECLARATIONe FOR APPLICANT
/T!O FILL IN I' BUILDIN ADD♦3 ss
I hereby affirm that I have a certificate of consent to self Insure S/ZEJ.�I'IK- LC
or a cerufcate of ftrkers Canpensabori Insurance s a certified �Y/
copy thereof Sec 800 b C) ///LLQ----r�� CIT LP
yygg ( ` OCA RY
Polioy TJd CornPerN SIZE O LOT NO OF BLDGS NOW ON LOT
�❑ Certified copy is hereby furnished NEAREST CROSS ST
❑ Certified copy is filedwdh the count building inspection TRACT BLOCK LOT NO
de/partm9M USE ZONE MAP NO
-_ DBte�L�[2 Applicant ASSE R MAP_ K 000E
5'•g Q SPECIAL CONDfTION9
CERTIFICATE OF EXEMPTION FROM WORKERS, TEL No
COMPENSATION INSURANCE ee r�e S ' / 7 7Q VATMN 1000 FT of SCHOOL' YES No
(That section need not be completed if the permit Is for one hundred ESS
DISTRICT GROUP TYPE CONS FIRE ZONE PROCESSED BY
dollars (Stoo) or less) CITY ZIP `
I certify that in the performance of the work for which this permitx�I
s Issued I shall not employ any person In any manner so as to
become subject to the Workers Compensation Laws ARCHITECT OR ENGINEER TEL NO
smnsrlcAL I APT coNDo
Date Applicant ADDRESS CLASS NO DWELL UNITS
NOTICE TO APPLIC4NT If after making this Certificate Of REWIRED TOTAL SETBACK FROM EXIST {
Exemption you should become subject to the Workers CONTRACTOR^Q STEL NO SET BACK YARD HWY PROP UNE WIDTH
nsr
Compeation provisions of the Labor Code must forthwith T ROOF �(�4
FRONT
comply with such provisions or this permit shall be deemed revoked gppgESS LIC NO PLr-
LICENSED CONTRACTORS DECLARATION 670&98 NDE
V LIC CLASS C`J PL
nssu
I hereby affirm that I am licensed urderprovns of Chapter 9 SEWER MAP
(canmencug with Section 7000)of Divswn 3 of the Business and SO FT SIZE NO OF STOFV NO OF FAMILIES
Professions Code and my Ixxmse Is In full force and effect NEW ❑ BK PG d
/ License Number 69 7B b T V L,c CIa99 C -- S '? TION OF VAR ADD ❑ VALUATION ' 0
a/ Contracts �. Date G _7, ALTER ❑ $
cc
j(
REPAIR ❑ �
❑ I am exempt under Sec $ F
BEPC for this reason DEMOL ❑
LOW P/C• W
Date LASE o Ex'SJ D BLDG URM ❑ 1Q.
Sgnalum APPLICANT(PFII T) TEL NO LDMA Perm• t*XT A Z
EII as owner of the property s my employees wdli wages as .fl - /G re =O 37M - 133.511
them sole compensation will do the work and the structures ADDRESS F
not Intended or Offered for sale (Section 7044 Business and 4w /77 X1.%9 % /O/ FINAL DATE Q 1 ITEMS
Professions Code) vnu TIS APPuuxr OR FurLrE eU. O occurNT HArpLE A HAZARoous MATERAL ZZ C
❑ 89 owner of itK; property em exclusively, LIX1fraLling VAIN oRAy�ry.���p��"µ�pgijs M�ATE�nws uFp wnpi ou�iOEEATFa Ttwl TRE FINAL BY ' TLITtB. 133 -50
licensed contractors to construct the project (section 7044 Yes❑ NOBS CHECK IF,.50
Business and Professions Cade)
1YLL TIE IKOURE USE OF THE aUlaJNa BY THE MWLXwNr OR FROM T BU SOUTH
f L1Al1T .00
OCCUPANT REGI TY A PERMIT FOR C TFrCr(CTgN In EE PERMITT FROM THE 9WTH �Plv///. )� NTI'CTVL
CONSTRUCTION LENDING AGENCY OUDE NR ouwTv MMNGEMENT usTRlcr IscAOMm see PERMmnNG clECKusr FOR O/�F4..��Y, /
ouoeuNEs
I hereby affirm that there is a construction larding agency for �s❑ No 0�,
N the performance of the work for which this penlnt is*sued(Sec 171}00-+)001 6/16/93
m 3097 Civ C) ca�aKLJSF IuoEl ur REQUIRE W2 20 100r TS U R��GO-ES COUWY GO EE
N 2 20 140
Lenders Name WTERVLS REECkLAP�PORmG MI)FORROBTAiMNG APERMi FROM THESCAOvO O HAZARpOUS 0279 1 T91 8:25
Lenders Address r
o w+cn w.¢wr
I certify that I have read this application and state under penalty
g of perjury that the above Information is correct Iagree n PC FEE PERMR FEE
o comply n, wllh all county ortllnences and State Paws relating to bulldog 7 R
Construction and hereby authorize representatives of this County ISSUANCE FEE
^ s Pon the above,m--enntioned P Fly for impact"purposes
(
INVESTIGATION FEE TOTAL FEE
..ria MVoru¢. !6 rau r ,
' SEE REVERSE FOR EXPLANATORY LANGUAGE
COUNTY OF LOS ANGELES - TEMPLE CITY N 0508 BUILDING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 IAS TUNAS ALTERATION/REPAIR
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 BL 0508 0706150026
PHONE (626) 285-0488 EXT
LEGAL ID NO OF CONST I BUILDING ADDRESS
1TR89-013-020
15683 LT 98 9Q FT STORIES TYPE 1 5120 TEMPLE CITY BL
STRUCTURE VN I TEMP CA 917803831
SESSOR INFORMATION NUMBER I NEAREST CROSS STRHSP LA ROSA I THOMAS PAGE 597 GRID A4 LOCALITY TEMPLE CITY, CI
1
TENANT EXIST BLDG USE RESID USE ZONE R-1 JISSUED ON PROCESSED BY E%PIRES ON
EXIST OCC GRP _ _ 06/15/07 - _- - --SR- - 06/09/08 -
OWNER
6/09/08 -OWNER TEL NO BLDGS NOW ON IAT VALUATION IFJNAL DA BY CODE 1
HERNANDEZ RAMIRO CO TR HERNANDEZ TR (626) 285-1978- 1,200 (l//1L/-
15120 TEMPLE CITY BL
TEMP 917803831 FEES PAID DESCR IPTI OF WORK
REPLACE 3 WINDOWS (SAME SIZE)
IFEE DESCRIPTION QUANTITY DOM AMOUNT
(APPLICANT TEL NO 1' 1
15AME AS OWNER - AA BLDG PERMIT ISSUANCE 27 75
AC STRONG MOTION RHSID 1200 00 VAL 0 50 SPECIAL CONDITIONS
D2 PERMIT W/O EN-HC 1200 00 VAL 82 20
TOTAL FEES 110 45
i
1CONTRACT0R TEL NO APPROVALS DATE INSPECTOR SIGNATURE 1
SAME A9 0WNER LIC NO LOCATION AND SETBACKS I I
SOILS3ENGINEER APPROVAL I I
ARCHITECT OR ENGINEER TEL NO IFOUNDATION/TRENCH FORKS
LIC NO SLAB/UNDER FLOOR I 1
I
RAISED FLOOR FRAMING I
1
MAP NO SEWER MAP BOOR PAGE FIRE ZONE CMUNDERFIAOR INSULATION 1 I
144X2693 O1 FLOOR'SHEATHING
1NO OF FAMILIES DWELLING UNITS APT/CONO STAT CLASS
I NO 21 1 ROOF SHEATHING
SCHOOL WITHIN HAZARDOUS SHEAR PANELS
AIR QUALITY 1000 FEET MATERIALS 1 '
NO NO NO 1 IFNxmS INSPECTION
I
REQUIRED TOTAL SETBACK FROM EXIST IFIRE 9PRINKLER HANGERS 1
SET BACK YARD HWY PROP LINE WIDTH
MONT PL- (INSULATION/WEATHER STRIP I --
SIDE PL-
INTERIOR IATH/DRYWALL
I
H%TERIOR LATH 1
RATED FLOOR/CEIL ASSEM
1
RATED,WALL A55910LIE5
RATED SHAFTS/OPENINGS I I
I
T-BAR CEILINGS
LOT DRAINAGE
I
1REPORT ID DPR261 ROUTE TO 890508
I