HomeMy Public PortalAbout5411 TEMPLE CITY BLVD_Building__ - WORKERS COMPENSATION DECLARATION ' `T G �f
nsu�e,yor c c�ifcateo Workers„Compensation Insuro e, - APPLICATION FOR BUILDING PERMIT iLl4
or o certified%cCQ/py thereof (Sec 3830,LLob
�kCC ) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No 2 35/ Company c)I M l� f�"� BUILDING
Certified copy in hereby furnished FOR APPLICANT TO FILL IN
ADDRESS �a
Certified copy is filed with the county budding mspec- BUILDING /�� �/ o, I' or
ho de menr ADDRESS PCA �W LOCALITY i -
/rl A- NEAREST -
Data Pf!/ YAppl Kant OTY ZIP �r� '�/ CROSS ST
RT KATE OF EXEMPTION FROM WORKERS' - SIZE OF LOT NOW NO F BLD v MAP BOOK PAGE PARCEL
ASSESSOR
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one I - USE ZONE MA
hundred dollars ($100)w 67
less ) TRACE BLOCK - LOT NO NO 0<5
W RASTMI- TEL 28'7 �/ SPEGAL , }
I certify that in the performance of the work for which this OWNER NO LC! !� CONDITIONS d
permit n issued, 1 shall not employ any person In any manner I - DISTRICT GROUP TYPE FIRE 55ED By O
so os to become subject to the Workers Compensation Lows ADDRESS C• CONST ZONE de
- J 0 3de
Date Appltcont CITYZIP
OR ZIP TEL - STATISTICAL CLA IFKATION 'A. O
NOTICE TO APPIL If, after making this Certificate of - tJ
Exemption you should become subject to the Workers ENGINEER NO
CLASS NO _DWELL UNITS_
Compensation provisions of the Labor Code, you must forthADDRESS SEWER MAP 2
with comply with such provisions or this permit shall be 1 -. _
deemed revoked CONTRACTOR-wPf WSTOM NO>7Rf BK PG VALIDATION
LICENSED CONTRACTORS DECLARATIONLK
I hereby offum that I am licensed under provisions of Chapter 9 ADDRESS NO VALUAT -
(commerwng with Section 7000)of Divr on 3 of the Business andUC - '
Professions Code, and my license is "T""
In full force and effect CITY ck "T- MSB $NW1 LJ ,
rt-45—OF NO
ECK
License Nu LK Class SIZE��� STORIE)�S—� yy FAMR ES ^SONE .
Contractor Dote lY l DESCRIPTION OF WORK CMtW NEW S 1
I am exempt under Sec `UJ8IMP ADO
MAL
CSE ALTER ❑ lill
DATE (J�
B 8P C for this reason v�•s(„� �` �5'��'+f' REPAIR ❑
Date EXISTIINGSLDG S<{— �7 3Q/%o OEMOL ❑ By �—( _� - - • �
Signature APPLKANT TEL r� 8 4 2 3 4
OWNER-BUILDER DECLARATION �INi tv0
I hereby affirm that I am exempt from the Contractor's License , LL^-' 4 .t• • • 2 3
Law for the following reason (Section 7031 S, Business and /
Professions Code) WER� {/l( 2,•'• 27 63
property, or my employees 1, as owner of the P yees with BUILDING 'wages, ADDRESwages,as thou sole compensation,will do the work and • • ' 2 7 6 36
. the structure Is not intended w offered for sale(Section ., LOCALITY -
7044, Business and Professions Code) MOVING TEL 1 21 .7-82
E] 1, as ct r of the property, am exclusively contracting CONTRACTOR NO
with licensed contractors to construct the project (Sec ADDRESS 2 8 4 2 4 A
tion 7044, Business and Professions Code)
' CONSTRUCTION LENDING AGENCY MAO YARD NWv TOTAL ETBAu FROM WIDTHX ��• • • • •
I hereby affirm that there Iso construction lending agencyfw FROM -
the performance of the work for which this permit Is issued P L Pilo 2'-'- 3 0,0
ZSec 3097 Civ C ) SIDE • • • 4 3 0 0 v
s PL
Lender it Name / ` 121 .7-82
Lender s Address P C Fee i --2- v 63 Permit Fee f Q'
I certify that I have recd thin application and state that the Issuonce Fee GJ .
above infornotion Is correct I agree to comply with all County I ;"gatwn Fee
ordinances and State jaws relating to building consitmOmn, Total Fee Q b
or4Areloy authorize representatives of this County to enter
M
bio s- a toned property for 1�tipu se! -
^ 17
EEE REV@i!EG EXPLANATORY LANGUAGE
Signature of Applicant w Agent
COUNTY OF LOS ANGELES TEMPLE CITY � _�/f 0508 BUILDING PERMIT
DEPARTMENT OF PUBLIC WORKS 9071 LAS TUNAS RESIDENTIAL ADD/ALT/REP
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA BL 0508 9807270013
PHONE (818) 285-0488 ENT
LEGAL ID NO OF CONST NEW BUILDING ADDRESS
TR 11789 LT 6 SO FT STORIES TYPE OCCUP GROUP 5411 TEMPLE CITY BL
STRUCTURE 20 1 VN R3 TEMP CA 917803151
ASSESSOR INFORMATION NUMBER GARAGE NEAREST CROSS STREET OLIVE
8588-025-006 OTHER THOMAS PAGE 597 GRID A4 LOCALITY TEMPLE CITY
TENANT EXIST BLDG USE USE ZONE ISSUED ON F'Ructstitu UT LXPIRES ON
EXIST OCC GRP 07/27/98 UT 07/27/99
OWNER TEL NO BLOGS NOW ON LOT VALUAT I ON FINAL DA BY CODE
CHWA DAVID K,LAI K - 1 3,000
5411 TEMPLE CITY BL
TEMP 917803151 FEES PAID DMTMUN OF WORK
TEAR OFF PLYWOOD REPLACED WITH GAF 25 YR SHINGLES 20 SO FT
APPLICANT --Tn—wcF— FEE DESCRIPTION QUANTITY UOM AMOUNT
i
J L ROOFING CO - AA BLDG PERMIT ISSUANCE 27 75
AC STRONG MOTION,RESID-- 3000 00 VAL 0 50 SPECIAL CONDITIONS
D2 PERMIT W/OIEN-HC 3000 00 VAL 99 00
/5 PNGELEeOTAJFEES\ 12725
CONTRACTOR TEL NO APPROVALS DATE INSPECTOR SIGNATURE
J L ROOFING CO (909) 465-1100-
12927 E. ROBIN LANE LIC NO ///JJJLOCATION AND SETBACKS
CHINO, CA 91710 594429C39 \
ARCHITECT OR ENGINEER TEL NO FOUNDATIUM/TRENCH FORMS
LIC N0 ,111)71SLAB/UNDER FLOOR
MY NO SEWER NO B= PAGE
3 101 JU MIST LE
� TV \� NJ
NO OF FAMILIES DWELLING LIMITS APT/CUNL) STAT CLASS
No 21 \ /I U°
J rEl lh
ROOF SHFATH;NGAIR QUALITY ITY 100N00 FEET MATERIALS A � Il-vi
REQUIRED IUIAL SETBACK FROM EXISTBLDG DEPT FRAME iNgM,b
SET BACK YARD HWY PROP LINE WIDTH SerVICQ
`67�C C t�O`
FRONT PL- Thi/ SHEAR PANELS
SIDE PL-
REPORT ID DPR261 ROUTE TO BS0508