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Home My Public Portal About5810 TEMPLE CITY BLVD_Building__ 'WORKERS'COMPENSATION DECLARATION } I�hereby affirm that I have r certificate of consent to self APPLICATION FORBUILDING P E RiM I T insure, ar,a certificate of Workers'Compensation Insurance, or a certified copy thereof'(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY A . Policy No,_ Company ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING ADDRESS ✓ / E]] Certified copy is filed with the county building Inspec- BUILDING tion department. ADDRESS t w ;Date Applicant CIT 1 ZIP LOCALITY] CERTIFICATE OF EXEMPTION FROM-WORKERS'• NO.OF BLDGS. NEAREST COMPENSATION INSURANCE SIZE QF LOT tpp(y :S NOW ON LOT CROSS ST. (This section need not be completed if the permit is for one ASSESSOR hundred dollars($100)or less.) TRACT, (;�( BLOCK LOT NO. MAP BOOK PAGE PARCEL TEL. 1 I certify that in'the performance of the work for which this• OWNER _ n, -� �1�1\ TIO. ` USE/ONI�E//- O. - 'permit is•issued,I shall'not employ a y person in any manner ADDRESSS��(7 �1 �t'.h�i 1T G t- (� �(l� l� SPECIAL pi it CONDITIONS "'so as to become subject to the War rs'Co en atNn aW�S. I !I CO'. CITY '�`�i G�l�. kA ZIP Date Applicaq ARCHITECT'OR EL.' NOTICE TO APPLICANT: If, offer making this Certificate of ENGINEER �NO DISTRICT GROUP TYPE FIRE PRO SSED.BY O Exemptioh, you should become subject to,the Workers' i i�C/' CONST. / SNE w Compensation provisions of the Labor Code, you must forth- ADDRESS (/� b V with comply, with such provisions or this permit shall be. TEL. STATISTICAL CLASSIFICATION APT. CONDO. CO •deemed revoked: CONTRACTOR �_ NO.. 1' Z LICENSED CONTRACTORS DECLARATION . . LIC. CLASS;INC. DWELL. UNITS .a I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. SEWER MAP (commencing with Section 7000)of Division 3 of the Business and 1 LIC. Professions Code,and my license is in full force and effect. CITY I CLASS BI — 'b= SQ.FT. NO.OF NO;OF CHECK o 0 0 V License Number Lic,ClcssSIZE I STORIES ]FAMILIES, FAMILIES ONE .1 1.23-8 VALUATION -0 DESCRIPTION OF WORK'S Int i x\A' - Nom• ® /1 ��' Contractor Date ADD ❑ $ (J ❑I am exempt under Sec. h Cr-,vit'_ ALTER ❑ B.BF.C. for this reason REPAIR ❑ $ Date: . USE OF DEMOL EXISTING BLDG: ❑ Signature APPLICANT TEL. FINAL OWNER-BUILDER DECLARATION PRINT NO. DATE $4; 8•A a I hereby,affirm that I am exempt from the Contractor's License ! # o•0 0 0�o Law for,the following reason (Section 7031.5,.Business and ADDRESS FINAL Professions Code): _ PRESENT- - BY ' A a a2a5,0 ❑ BUILDING 11403 owner of the property, or my employees with ADDRESS r a 0 0 2 8 Jr 0 � Wages as their sole compensation,will do the work and the structure is not intended or offered.for sale(Section. LOCALITY (,�,2 3�8 7 , 7044, Business and Professions Code): ' MOVING • TEL. ' ❑ I,as owner of the property, am exclusively contracting CONTRACTOR NO. with licensed contractors-to construct-the project (Sec- ADDRESS tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY FROW SE�BACK.. YARD HWY TOTAPROPLNE WIDTH I hereby affirm that there is a construction lending agency for FRONT. the performance of the work for which this permit is issued P.L. ' (Sec. 3097, Civ. C.). SIDE PA. I. Lender's Name I i m P.C.Fee$ O LDMA Ref. q r; Lender's Address '�' Permit Fee l O � �p— I certify,that I have this application and state that the Issuance Fee V 'J LDMA°P/C,N R above information is correct; I agree to comply with all County Investigation Fee 0 ordinanc s and State laws relating to building construction, i Total Fee. LDMq Perm. fi and her y authorize representati 'sof this County to enter upon th above-m nW* ied pr e y for inspectionyrpes.� SEE REVERSE FOREXPLANATORY LANGUAGE\ Signature of A plicant or ent .%WORKERS'COMPENSATION DECLARATION : 'herebVaffirm that I have a 4ttificate of consent to self insure,-or�a certificcFe of Workers'Compensation Insurance, APPLICATION F®R BUILDING PERMIT �] or a certif//ied��c��op�yy thereof (Sec. 3800, Lab. l�Gy Corn an S /�—U/V!/ COUNTY OF LOS ANGELES BUILDING AND SAFETY .Policy No p y , ❑ copy Y FOR APPLICANT TO FILL IN BUILDING Certified co is hereby furnished. ADDRESS ✓: Q�e C/, Certified copy is filed with the county building inspec- BUILDING. L� tion department. / ADDRESS��f� ��7��e �l /3L• Date �� Applicant �rr—V�•'L'� CITY 4Ve ZIP LOCALITY g' D&yC I CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT X��`f/ NOF40W ON LOT CROSS ST. !'��/ COMPENSATION INSURANCE (This section need not be completed if the permit is far one TRACT BLOCK LOT NO. ASSESSOR hundred dollars($100)or less.) L�� /meq MAP BOOK PAGE PARCEL OWNER No.�+YJ7`7/ USE ZONE '•' MAP v, r I certify that'in the performance of the work for which this f ° //�,� NO. i permit is issued,I shall not employ any person in any manner ADDRESS.��/d , v',"'�— CSG.1 C�7i SPECIALS so•as to become subject to the Workers'Compensation Laws. CONDITIONS O CITY T ZIP. V Date Applicant [>: + ARCHITECT OR TEL. DISTRICT, GROUP TYPE FIRE CESSED.BY O NOTICE TO APPLICANT: If, after making'this Certificate of ENGINEER NO. �_ Exemption, you should become subject to the Workers' O CONST ZONE ZONE Compensation provisions of the Labor Code, you must forth- ADDRESS Sao �'L V with comply with such provisions or this permit shall be IL TEL. /� j STATISTICAL CLASSIFICATION APT. CONDO. (q deemed revoked. CONTRACTOR �� le NO.��/�p Z j LICENSED CONTRACTORS DECLARATION LIC, . CLASS,NO. �L DWELL. UNITS i I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESSA�®�G /�- / /' NO. �7' SEWER MAP (commencing with Section 7000)of Division 3 of the Business and LIC. Professions Code, and my license is in full force and effect. CITY ' CLASS r VALIDATION SQ.FT. NO.OF NO.OF .CHECK BK. PG. Z� �� / SIZE STORIES FAMILIES ONE j License Number ' Lic.Class �7 / ��1�7j. DESCRIPTION OF WORK' o✓� NEW ❑ VALUATION Contractor Dote ADD $ L� ❑I am exempt under Sec. pill.'j ALTER B.BP.C. for this reason ' I7fC-• '�T REPAIR ❑ s Date: , USE OF 7 97� DEMO' EXISTING BLDG. �7 h� Signature APPLICANT E PRINT —OZ14f �i(/-� NO. FINAL OWNER-BUILDER DECLARATION DATE I hereby affirm that I am exempt from the Contractor's License s�/O aG�-- Law for the following reason (Section 7031.5, Business and' ADDRESS ��,/� FINAL Professions Code): _ PRESENT By NG ❑ I, as owner of the property, or my.employees with ADDRESSSS n wages as their sole compensation,will do the work and r the structure is not intended or offered for sale(Section LOCALITY 7044;Business and Professions Code). MOVING TEL. ❑ I,as owner of the property,am exclusively contracting CONTRACTOR NO. with licensed contractors to construct the project (Sec- ti ADDRESS tion 7044, Business.and Professions Code). { ,7 3 7 R REQUIRED TOTAL SETBACK �' 7�' CONSTRUCTION LENDING AGENCY i SET BACK YARD HWY PROP. LINE WIDTH 1" # m 0 0 0 0,1 1 I hereby affirm that there is a construction lending agency for FRONT ' the performance of-the work for which this permit is issued i P.L. =O 124.88 (Sec. 3097, Ctv. C.). SIDE 5 Lender's Name 1 P.L. `` ° 1-2 4.8 8 c=� $ I. '7 LDMA Ref. R '0 7.0 1 s 8 7 . ; Lender's Address 1 P.C.Fee$ Permit Fee r �O ' I certify that I have read this application.and state that•the I U • �J LDMA P/CN# o ; Issuance Fee • g t above information is correct. I agree to comply with all County Investigation Fee °o ordinances and State laws relating to building construction, Total Fee l/e N ; and hereby authorize representatives of this County to enter �T r�" LDMA Perm. N 1 purposes. upon the above-mentioned property for inspection p P ." SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date y� COUNTY OF LOS ANGELES TEMPLE CITY # 0508 BUILDING PERMIT DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS TENANT IMPROVEMENT BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 BL 0508 1301020046 PHONE: (626) 285-0488 EXT: ILEGAL ID. I NO. OF CONST NEW I BUILDING ADDRESS: 1 ITR: 6561 IT: 593 SQ. FT STORIES TYPE OCCUP GROUPI 5810 TEMPLE CITY BL 1 I (STRUCTURE: 1114 1 V-B B I TEMP CA 917802112 (ASSESSOR INFORMATION NUMBER: I NEAREST CROSS STREET: WORKMAN 18587-018-029 I I THOMAS PAGE: 596 GRID: J3 LOCALITY: TEMPLE CITY CAI I ITENANT: EXIST BLDG USE: COMMS USE ZONE: ISSUED ON: PROCESSED BY: I IDR LIN CHIAO (EXIST OCC GRP: B 103/05/13 SR I (OWNER: TEL. NO: IBLDGS. NOW ON LOT: VALUATION: IFI TE FIN HY: CODE: IHOM ROBERT (626) 383-8166- 1 30,000 1l 15810 TEMPLE CITY HL ITEMPLE CITY CA 91780 I FEES PAID IDEOSCRIPTION OF WORK I I I ITENANT IMPROVEMENT - OPTOMETRY OFFICE I I (FEE DESCRIPTION: QIIANTITY: DOM: AMOUNT:1 I (APPLICANT: TEL. NO: IRUPERT MOK ARCHITECT (909) 468-0099- IA1 PLANCHECK W/EN-HC 30000.00 VAL 525.00 1 I 1829 S. LEMON AVE IAA BLDG PERMIT ISSUANCE 27.80 ISPECIAL CONDITIONS: I IWALNUT CA 91789 AB STATE GREEN BLDG FEE 30000.00 VAL 2.00 I IAE STRONG MOTION OTHER 30000.00 VAL 6.30 I I I _IA2 PERMIT W/ENERGY-HC 30000.00 VAL 617.60 I I (CONTRACTOR: TEL. NO: I TOTAL FEES 1,178.70 (APPROVALS DATE INSPECTOR SIGNATURE 1 IKHANH CONSTRUCTION CO (714) 299-0807- I 112683 PALM VIEW WAY LIC. NO I (LOCATION AND SETBACKS I 1 IRIVERSIDE CA 92503 608313 ISOILS ENGINEER APPROVAL I I I (ARCHITECT OR ENGINEER: TEL. NO: I IFOUNDATION/TRENCH FORMS I I I IRUPERT MOK AND ARCHITECTS (909) 468-0099- I 1 I I I 1829 S LEMON AVE SUITE All-B LIC. NO: I ISLAB/UNDER FLOOR I I I (WALNUT CA 91789 NONE 1 1 1 (RAISED FLOOR FRAMING IMAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CD:P:I (UNDERFLOOR INSULATION I I I I 3 001 I IFLOOR SHEATHING I I I INO. OF FAMILIES: DWELLING UNITS: APT/COND: STAT CLASS: I 0 NO 22 1 IROOF SHEATHING I I I SCHOOL WITHIN HAZARDOUS I (SHEAR PANELS II I (AIR QUALITY: 1000 FEET MATERIALS I NO NO NO i IFRAME INSPECTION I (FIRE SPRINKLER HANGERS I I I I I IINSIILATION/WEATHER STRIP( I I 1 IINTERIOR LATH/DRYWALL olI 1 I EXTERIOR LATH I 1 I (RATED FLOOR/CEIL ASSEM. I I IRATED WALL ASSEMBLIES I I 1 IRATED SHAFTS/OPENINGS I I 1 T-BAR CEILINGS I I I I I I* ADDITIONAL DATA ON FILE ILOT DRAINAGfi I 1 I IREPORT ID: DPR261 ROUTE TO: BS0508 I