HomeMy Public PortalAbout5816 TEMPLE CITY BLVD_Building__ WORKERS'COMPENSATION DECLARATION CJ 3
hereby affirm that I have certificate of consent to self APPLICATION, FOR -L4.L D I N G P E RM I T
insure, or a certificate of Workers'Compensation Insurance,
or a certified copy thereof(Sec. 3800,Lob. C.) I
COUNTY OF LOS ANGELES j' Ba LDING AND SAFETY
PPolicy NoWP-83-446 mpany. Fremont Indemnity .
Certified co is hereby furnished. BUILDING
copy Y FOR APPLICANT TO FILL IN - ADDRESS �
�.❑X Certified copy is filed with the county building inspec- BUILDING Ia
tion department. ADDRESS 5816 Temple City Blvd, LOCALITY
NEAEST
Date 7/1/ Applicant Virgin Roof Co. CITY Te le Cit ZIP 91780 CROSS
83sT.
CERTIFICATE OF EXEMPTION FROM WORKERS' 11 NO.OF BLDGS. ASSESSOR
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP'BOOK PAGE PARCEL
(This section need not be completed if the permit.is for one USE ZONE MAP'
hundred dollars($100)or less.) TRACT BLOCK LOT NO. j{ NO.
TEL. SPECIAL IL
I certify that in the performance of the work for which this OWNER• NO. a V.-,2 CONDITIONS 0
P employ permit is issued, I shall not em to an erson in an manner CONSTZONE
DISTRICT .GROUP TYPE FIRE P OCESSED BY
any Y .
so as to become subject to the Workers'Compensation Laws. ADDRESS 5816 Temple City Blvd•
IM
CITY Temple City ZIP 91780 neo 0
Date Applicant ; ARCHITECT OR TEL. STATiSTICAI C SIFICATION PT. CONDO.
V
NOTICE TO APPLICANT: If, after.making this Certificate of ENGINEER = NO. CLASS NO. DWELL.UNITS a
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- ADDRESS SEWER MAP W
with comply with such provisions or this permit shall be EL' I z
deemed revoked. CONTRACTORVir. in Roof CO .. ... NO. 287-0507 ( BK. PG, VALIDATION.
LICENSED CONTRACTORS DECLARATION LIC.
I hereby affirm that I'am licensed under provisions of Chapter 9 ADDRESS P. 0, BOX J No. 160650 VALUATION
(commencing with Section 7000)of Division 3 of the Business and Ba .91778 LIC.
Professions Code,and my license is in full force and effect.. CITY CLASS C39 $; 4000.00'
160650
SQ.FT. NO.OF NO.OF CHECK r
License Number Lic.Class C39 ' SIZE STORIES FAMILIES ONE
Contractor Virgin Roef ['n -Date. 7/.1 183 DESCRIPTION.OF WORK ' Re—roof With NEW. I�.
❑I am exempt under Sec. 30# 15# -and gravel. ADD ❑ .
ALTER ❑> -FINAL �r�p- {?� •
B.BP.C. for this reason REPAIR DATE U
USE OF
Date: EXISTING BLDG. DENIOL ❑ FINAL
By _
Signature APPLICANT TEL.
-OWNER-BUILDER DECLARATION PRINT NO. 9 8 2'A
I hereby affirm that I am exempt from the Contractor's License
Law for the.following reason (Section 7031.5, Business and ADDRESS # 0 0 0 0 0
(Professions Code): PR E NG 2 - 6863
1, as owner of the property, or my employees with ADDRESSSS 0
i wages as their sale compensation;will.do the work and LOCALITY i ° ° °'6 8 6,'�
the,structure is not intended or offered for sale(Section
7044, Business and Professions Code). MOVING TEL.
❑ CONTRACTOR NO. 0 7.27-83
I,as owner of the property,am•exclusively contracfing '
with licensed contractors to construct the project (Sec- ADDRESS +
'tion 7044, Business-and Professions-Code). I
REQUIRED TOTAL SETBACK FROM EXIST. .
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP.LINE WIDTH
I hereby affirm that there is a construction lending agency for .FRONT
the performance.of the work foe which this permit is issued P.L. �.
(Sec.3097,Civ. C.). SIDE
a Lender's.Name -
P.C.Fee$ ' ' Permit Fee
Lender's Address
I certify that I have read this application and state that the Issuance Fee lO O
;obove information is correct. I agree to comply with,all County Investigation Fee
ordinances and State laws relating to building construction, Total Fee
and hereby authorize represent tives of this County to enter
up the above-mention pro for inspection purposes. i
JA�AT �C�j-� �;' SEE REVERSE FOR EXPLANATORY LANGUAGE +'
nature of Applicant or ent . Date ®s
.1•
t 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 0903300040
PHONE: (626) 285-0488 EXT:
ILEGAL ID: I NO. OF CONST I BUILDING ADDRESS: 1
ITR: 6561 LT: 591 I SQ. FT STORIES TYPE I 5816 TEMPLE CITY BL
ISTRUCTURE: V-B I TEMP CA 917802112 I
(ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET: LAS TUNAS
18587-018-027 I I THOMAS PAGE: 596 GRID: J3 LOCALITY: TEMPLE CITY, Cl
ITENANT: IEXIST BLDG USE: COMME USE ZONE: C-3 (ISSUED ON: PROCESSED BY:
IEXIST OCC GRP: 103/30/09 SR
(OWNER: TEL. NO: IBLDGS. NOW ON LOT: VALUATION: [FINAL DATECODE: I
1SHAWJOHN L;JOANNA TRS SHAW TRUST (626) 286-3710- 1 10,000 1I
6453 LIVIA AV Expigni:
ITEMP 917801330 1 FEES PAID IDESCRIPTION OF WORK I
IREPLACE 6 WINDOWS, REMOVE PLANTER, REPLACE WITH STONE FACIA I
I [FEE DESCRIPTION: QUANTITY: UOM: AMOUNT:1 I
[APPLICANT: TEL. NO: I I I
ISAME AS OWNER - IAA BLDG PERMIT ISSUANCE 27.75 1 I
I IAB STATE GREEN BLDG FEE 10000.00 VAL 1.00 SPECIAL CONDITIONS: 1
I 1AE STRONG MOTION OTHER 10000.00 VAL 2.10 1
D2 PERMIT W/0 EN-HC 10000.00 VAL 216.60
I [ TOTAL FEES 247.45 [ I
ICONTRACTOR: TEL. NO: I [APPROVALS DATE INSPECTOR SIGNATURE
ISAME AS OWNER - 1 I I
I LIC. NO 1 [LOCATION AND SETBACKS I I I
ISOILS ENGINEER APPROVAL [ I I
1ARCHITECT OR ENGINEER: TEL. NO: - 1 1FOUNDATION/TRENCH FORMS I I
LIC. NO: I (SLAB/UNDER FLOOR I I [
IRAISED FLOOR FRAMING 1 1 I
MAPNO: SEWER MAP BOOK: PAGE: FIRE ZONE. CMOOI (UNDERFLOOR INSULATION I I I
I I I
IFLOOR SHEATHING
INO. OF FAMILIES: DWELLING UNITS: APT/COND: STAT CLASS: I I I I I
NO 22 1 IROOF SHEATHING I I I
SCHOOL WITHIN HAZARDOUS 1 ISHEAR PANELS I I I
(AIR QUALITY: 1000 FEET MATERIALS I II I I
1 NO NO NO 1 IFRAME INSPECTION 1 1
IREQUIRED TOTAL SETBACK FROM EXIST [ IFIRE SPRINKLER HANGERS I
ISET BACK YARD: HWY: PROP LINE: WIDTH:
IFRONT PL- 1 [INSULATION/WEATHER STRIP( I I
SIDE PL- I I I I I
NTERIOR LATH/DRYWALL I I I
1 1 1EXTERIOR LATH
1 [ IRATED FLOOR/CEIL ASSEM.
I (RATED WALL ASSEMBLIES I I 1
1 I RATED SHAFTS/OPENINGS 1 1 [
I IT-BAR CEILINGS I I
I 1 I
I [LOT DRAINAGE I I I
I I
1 (REPORT ID: DPR261 ROUTE TO: BS0508 1 I I I