HomeMy Public PortalAbout5403 TEMPLE CITY BLVD_Building__ t WORKERS' COMPENSATION DECLARATION
4hereby clRim that I have o ceruiicat�of consent to self AP`PLICATIO.N, FOR BUILDING PERMIT
insure ora certificate of Workers Compensation Insurance
or o certified copy thereof (Sec 3800 Lob C ) COUNTY,OF LOS ANGELES BUILDING AND SAFETY
Policy No I Company
❑ Certified copy is hereby furnished FOR APPLICANT TO FILL IN
ADDRESS a7'/"i' Li+r GT
Certified copy in fled with the county building mspec- BUILDING I -
iron department ADDRESS &M Ig- GI CA 7 o
Date Applicant CITYZIP D LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' ' - No OF BL NEAREST
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS ST DLJ✓a es t
(This section need not be completed if the permit is for one TRACT BLOCK LOT h10 ASSESSOR
hundred dollars ($100)or leu ) MAP BOOL I PAGE PARCH
TELE
I certify that in the performance of the work for which this OWNER NO /
permit is Issued I shall not employ any person in any mannerIAL
ADORFSS / COh1DITIONSp
obec
so m tobecome subject to the Works, 'Compensation Laws U
Date T�.CrL•V—L_Applicant - , ARCHITECT OR ' ZIP TEL O DISTRICT TYPE FIRE D BY O
NOTICE TO APPLICANT If, cher making this Certificate of
Exemption you should become subject to the Workers' ENGINEEADDRESS NO pp T• / ZONEU
Compensation provisions of the Labor Cods, you must forth- ADDRESS � V ^� W
with comply with such provisions or thin permit shall beTEL,
deemed revoked CONTRACTOR r y/� s NO STATISTICAL CLASS
IZ TION APT Z
LICENSED CONTRACTORS DECLARATION - LIC CLASS NO DWELL UNrTS I
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO
(commencing with Section 7000)of Division 3 of the Business and LIC SEWE
/L�s/�P
Professions Code and my license is in full force and effect CITY CLASS SK S/ PG 2 3 v VALDATLpN
50 Fr fJO Of NO OF CHECK `Z A
License Number Lic ClassSIZE L7 STORIES Z FAMILIES ONE vALLrAnoN # • • •i• 23
Contractor Date DESCRIPrION OF WORK NEW ,I 'L!•s\ 8 IS p0O'77z
I am exempt under Sec ADD a 5 TS O
ALTFR ,
B 8P C for this reason REPAIR
Date USE OF (/
EXISTING&DG DEMOI
Signature APPL�I T O /A fig/ FINAL
OWNER BUILDER DECLARATION DATE
1 hereby affirm that I am exempt from the Contractor s License rI
Low for the following reason (Section 7031 5, Business and ADDRESS C/1 V FINAL 3
Professions;Code) PRESENT By
❑ , �
I as owner of the property or my employees with ADDRESS BUILDING 1 41 T ✓ '�•,} • • 6 1 S836
wages as their Bole compensation,will do the work and j �L��`•1\h •
the structure is not intended or offered for sale(Section LOCALITY i J �, ', t J 0 4 1 4"8 8
7041, Business and Professions Code) MOVING TEL �_yl •Vt
171 1, as owner of the property,am exclusively contracting CONTRACTOR NO
with licensed contractor to construct the project (Sec 3 9 6 9 3
iron 70", Business and Professions Code) ADDRESS - # • • • • •'
CONSTRUCTION LENDING AGENCY VU0 YARD HWY I TOTALPROP UNE WIDTH 1 I • 8 3 Q 2 5
1 hereby affirm that there in o construction lending agency for M
RO
the performance of the work for which this permit in issued P - �. ,, `, - `• • 8362 555
(Sec 3D97, Cry C ) SIDE X 0525-88
PL
Lender's Norma
8 ^ LDMA Rei $
• � _
Lender s Address P C Feet �l Permit Fee
1 certify that I have read this application and state that the 4 T4, _ lauance Fee 01 TDMA P/C
9 above Information Is correct I agree to comply with all County Invenigotion Fee '
a here
ordinances s and Stole jaws elotmq MA perm building construction, Total Fee dD $.
and by authorize representativesof this Count'to enter �
%, oZ abovsr- rssntionned property far Inspection pugurrposseie�, N;
' �l//,p 1�(iU.s GLV $O WEW FO!
[RRANATOfIif LANOUAO$
slpiotus,of Apphcont or Apert
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 0508 1112070059
` PHONE (626) 285-0488 ERT
LEGAL ID NO OF CONST BUILDING ADDRESS
TR 11789 LT 5 SQ FT STORIES TYPE I 5403 TEMPLE CITY BL
STRUCTURE 4800 V-B I TEMP CA 917803151
ASSESSOR INFORMATION NUMBER I I NEAREST CROSS STREET
18588-025-005 THOMAS PAGE 597 GRID A4 LOCALITY TEMPLE CITY C
TENAMrr (EXIST BLDG USE REBID USE ZONE R-1 11SSUED ON PROCESSED BY
I EXIST OCC GRP 112/[7/11 SR
IOWNER TEL NO IBLDGS NOW ON LOT VALUATION 1FINAL DATE � I FINAL BY CODE
CHIAO PETER (6 Z6) 285-8270- I 15,470
15403 TEMPLE CITY B6
TEMP 917803151
FEES PAID IDE CRIPTION OF WORK
IREMOVE EXISTING COMP SHINGLES INSTALL DOUBLE LAYER 15 LS FEL
IEEE DESCRIPTION QUANTITY DOM AMOUNT IT AND NEW 20 YEAR SHINGLES
APPLICANT TEL NO
MC FEGGAN, BILL (714) 997-9449- IAA BLDG PERMIT ISSUANCE 27 80 1 '
11212 E ASH AVE AB STATE GREEN BLDG FEE 15470 00 VAL 1 00 (SPECIAL CONDITIONS - 1
IFULLERTON CA 92831 AC STRONG MOTION RBSID 15470 00 VAL 1 60 1
I D2 PERMIT W/O EN-HC 15470 00 VAL 318 30
TOTAL FEES 348 70
ICONTRACTOR TEL NO I IAPPROVALS DATE INSPECTOR SIGNATURE 1
FAIRWEATHER ROOFING INC (714) 997-9449- 1 1
11212 E ASH AVENUE LIC NOTION AND SETBACKS
IFULLERTON CA 92831 770565 C39 • I 1 I [
ISOILS ENGINEER APPROVAL I 1
(ARCHITECT OR ENGINEER TEL NO i FOUNDATION/TRENCH FORMS
1 LIC NO 1 ISIAB/UNDER FLOOR I I
(RAISED FLOOR FRAMING
I I_ I
1MAP NO SEWERMAP BOOR PAGE FIRE ZONE CMP 1 1UNDERFLOOR INSULATION I
1147H269 3 001 I I
I I FLOOR SHEATHING
ING OF FAMILIES DWELLING UNITS APT/COND STAT CLASS I I__I
0 NO 21 1 1ROOF SHEATHING I I
SCHOOL WITHIN HAZARDOUS SHEAR PANELS
(AIR QUA 0
ITY 10000 TE
FEET MATERIALS [
1FRAME INSPECTION 1
I (FIRE SPRINKLER HANGERS 1
1 ' IINSCLATION/WEATHER STRIP[ I
(INTERIOR LATH/DRYWALL
I I (EXTERIOR (ATH I I I
I (RATED FLOOR/CEIL ASSEM I I [
RATED WALL ASSEMBLIES
I I I
RATED SHAFTS/OPENINGS
I I I I I
IT-BAR CEILINGS
ADDITIONAL DATA ON FILE _
L.OT DRAINAGE
IRFPORT ID DPR261 ROUTE TO BS0508 [