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HomeMy Public PortalAbout5821 TEMPLE CITY BLVD_Building__ WORKERS'COMPENSATION DECLARATION ' �. •ly I hereby affirm that I have a certificate of consent to self A P P L I CATION ' FOR BUILDING PERMIT insure;Jp'r a certificate of Workers'Compensation Insurance,. :,,-or-d cettified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAF TY Company Policy No. Certified'copy is hereby.furnished. BUILDING FOR APPLICANT TO FILL IN ADDRESS ❑ Certified copy is filed with the county building inspec- BUILDING ( L tion department. ADDRESS L7 /6I 1. Date Applicant CITY7, Le, L. ZIP ? LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS'• NO.OF BLDGS. NEAREST . COMPENSATION INSURANCE SIZE OF LOT dS / 5_ NOW ON LOT CROSS ST. PARCEL (This section need not be completed if the permit is forane ASSESSOR- • hundred dollars($100)or leTRACT BLOCK LOT NO. MAP BOOK" PAGE ss+J I certify that in the performance of the work for which this OTEL OV.3 WNER 1✓ A) NO. x213^ // USE ZONE MAP 5-D- permit is issued, I shall not employ any person in any manner c- SPECIAL so as to become subject to the\Wor�ompeaws. ADDRESS .S� —/7 SD A✓ CONDITIONS O/1 Date ApplicantCITY CA- ZIP /NOTICE .O APPLICANT:�If, after of ARCHITECT OR /r TEL. DISTRICT UP TYPE FIRE P7ED BY O Exemption, you should become "subject to the Workers' ENGINEER L)1'2� NO. / CONST.. ZONE Compensation provisions of the Labor Code, you must forth- 01 ADDRESS (e 3 S �fS C'F �� IvG�Dt�e+ U�0[ VJ� LL with comply. with such provisions or this permit shall beTEC1. M deemed revoked.. CONTRACTOR ti S! NO. STATISTICAL CLAS I�q,TION APT. CONDO. C0 LICENSED CONTRACTORS DECLARATION LIC. CLASS NO.' DWELL. UNITS- 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 LIC, Professions Code,and my license is in full force and effect. CITY ' CLASS BK PG VALIDATION SQ:FT. NO.OF NO.OF CHECK ' License Number Lic.Class SIZE S,f STORIES FAMILIES' ONE VALUATION Contractor Date DESCRIPTION OF WORK- SI I A) __&)5 NEW 2] 0� ❑ "". ❑ I am exempt under Sec. ADD. $ (/e/[:] 2 9 9 2'9'A ALTER B.BP.C. for this reason USE OF REPAIR ❑ $ o 0 0 0 Date: EXISTING BLDG. D ❑ 'To-e 3 7 5 0 Signature APPLICANT TEL*/8 FINAL OWNER-BUILDER DECLARATION PRINT ) L4 .� NO. -uza DATE '��`� o o 0 3 7.5 0 5 I hereby affirm-that I am exempt from the Contractor's License ,Q Law for the following reason,(Section 7031.5, Business and , ADDRESS St a I TIm f?L-Gi /J� FI 062.0-88 Professions Code): PRESENT b ❑ I, as owner of the property, or my employees with ADDRESS. aa / L wages as their sole compensation,will do the work and LOCALITY T� the structure is not intended or offered for sale(Section 7044, Business and Professions Code). MOVING TEL. 1, as owner of the property,am exclusively contracting CONTRACTOR NO. i with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). REQUIRED TOTAL SETBACK �• CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP.LINE WIDTH I hereby affirm that there is a construction lending agency for FRONT X10 0 7 A the performance of the work for which this permit is issued P.L. (Sec. 3097, Civ. C.). SIDE P.L. #'o j0:0,0 o}� Lender's Name LDMA Ref. p „( o o t!J.A 5 0 m P.C.Fee$ 3 sd Permit Fee Lender's Address s o,0 4 a 5 0 53 0 1 certify that I have read this application and state that the Issuance Fee LDMA P/C N g above Information is correct. I agree to comply with all County Investigation Fee 0 8 8 9 ordinances and State laws relating to building construction, Total Fee LDMA perm,. $ and hereb authorize representatives of this County to enter S. upon th ove- ned property for inspection urp ses. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date APPLICATION FOR BUILDING PERMIT COUNTY OF LOS ANGELES BUILDING AND SAFETY l JBUILDING ADDRESS WORKER'S' OMPENSATION DECLARATIONI.heFOR APPLICANT TO FILL IN r BUILDING ADDRESS orcert affirm that I a certificate of sent to self Insure, t EAl?i.E6r � -�-► or a certificate of Worke Compeneatio nsurance,or a certified CITY ZIP r copy thereof(Sec.3800,Lab. .) LC GL7-d CA- '91-7630 LOCALITY / Policy No. - Ompany.STRr'E FUN/ SIZE OF LOT r NO.OF BLDGS.NOW ON LOT ❑ Certified copy is here umish Ll s NEAREsS cROss f Certified copy I led with t e co iiding inspection TRACT- BLOCK LOT NO. �/If �^ N department.' I �j USE ZONE MAP NO. �L,� G�FIG ASSESSOR MAP BOOK PAGE PARCEL /� •/ .0- Date Date `g Applicant7.2 Loa /) SPECIAL CONDITIONS 0. CE TIFICATE OF EXEM ION FROM WORKERS' R -T S A A� z 7�826 (moi YES NO COMPENSATIO INSURANCE WITHIN 1000 FT.OF SCHOOL? ADDRESS (This section need not be completed if the permit is for one hundred J,j OO 1-b M11-L, RD DISTRICT GROUP TYPE CONST' FIRE ZONE PROCESSED BY dollars($ or less.) CITY :.ZIP I certify that in the performance of the work for which this'permit S N M PAJ.NO 0 J Is Issued, I shall not employ any arson in ny manner so as to ARCHITECT OR ENGINEER TEL.NO. Ig become Q s��ubbj�jectt to the WOrkere'CO pensatiD , I S CEG N&A-r , 1 y 9-q s STATISTICAL CLASSIFICATION APT CONDO Date! `1JL_AppliCant ADDRESS' CLASS NO. In DWELL UNITS b O S E AVS AsA4� c.�l' 9110 NOTICE TO APPLICANT: If, of r making this Certificate.of � REQUIRED TOTAL SETBACK FROM EXIST Exemption, you should beco subject to the Workers' I CONTRACTOR TEL No. ) n /' S SET BACK YARD HWY PROP LINE WIDTH Compensation provislom of the•La or Code,you must forthwith PAG 1 G I� .S UGTr z 9 FRONT comply with such provisions or this permit shall be deemedTevoked. : -ADDRESS ^ LIC.NO. PR L i l 5 LOw&IL Az mo R. 3 1 Ll Iq I SIDE G}. LICENSED CONTRACTORS DECLARATION CITY LIC.CLASS PO IM " ` — I hereby affirm that I am licensed under provisions of Chapter 9 El. 7e Co. 9173 G10 SEINER MAP (commencing.with Section 7000)of Division 3 of the Business and SQ FT,SIZE NO.OF STORES NO.OF FAMILIESll 9=Professions Code,and my license Is in full force and effect. I N 10. NEW ❑ BK L PG A , License Number y gqy(2 t Li,.Class c-10 - DESSCRI rI,ON OF WOS igE AM In 0� ADD ® VALUATION CO) Contractor T- IIA S 1G O Data -*- + -2f •a�J ' ALTER ❑ $ 74 0 z _ZIf_ 5?1 DRS 0EPICEAdd P4 mok REPAIR ❑ _ ❑ $ I am exempt urid•er Sec. B.8',PIC.for this reason 1 f>N C� 11?pR o y"Ewa%S DEMOL Q USE OF EXISTING BLDG. C AC-Atr7^� LDMA P/C# Date: WI t O!c.4 t 4 r C't URM. ❑ Signature APPLICANT(PRINT) TEL NO. 1 LDMA Perm# ❑ I,as owner of the ro y 1111-R Teo E L! A 7 4 "Z y Z ' Z p pertA or m employees with wages as ( O s their sole compensation,Will do the work and the structure is ADDRESS - ACCI=- not Intended or offered for sale (Section 7044, Business and (,S© OL-AO N IMI- P6. S'iw Al R,/Nb FI �JATE Q ���� - � Professions Code.) WILLTHEAPPLICANTOR FUTURE BUILDING OCCUPANTHANDLEA HAZARDOUS MATERIAL '�� l 0 1s OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN T"' ® 1, as owner of the property, am exclusively contracting with THE AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY `J =j EMM licensed contractors to construct the project.(Section 7044, YES❑ NO 19 Business and Professions Code.) i \ TOITAL 30 1 m 3 WILL THE INTENDED USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING t OCCUPANT REOUIREA PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THESOUTH CHECK (• 17 CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST s � I FOR GUIDELINES. I hereby affirm that there is a construction lending agency for YES 11NO® CHANGE GO the performance Of the work for which this permit Is Issued(Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SOAQMD _ 3087,Civ.C.). PERMITTING QHECKUST I U ERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES i ? COUNTYCOD TITLE2,C SECTIONS22DAIXITHROUGH 22D.140 CONCERNING r Lender's Name HAZARDOUS TERIALS R RTI AND FOR OBTAINING A PERMIT FROM THESCAOMD. I VI II i�)— �� 9/ 5/90 ' Lenders Address ,a,OR,G 27 113 1 All 1 o' I certify that I have read this applicatlon and State that the above PC.FEE pERMI information is correct. I agree to comply with all county �G `3 ordinances and State laws relating to building construction,and �J d here authorize resentatives of this County to enter upon ISSUANCE F thea mentionrty for inspection purposes. D 8 m `.4?J INVESTIGATION FEE T.OTAIqFEE/ / r 8hamm IAppllu„t arApenl Dab SEE REVERSE FOR EXPLANATORY LANGUAGE.- , :w�. k'• APPLICATION FOR BUILDING PERMIT ti COUNTY OF LOS ANGELES BUILDING AND SAFETY FOR APPLICANT TO FILL IN WORKER'S COMPENSATION DECLARATION 1 Bul I �rZR I"hereby affirm that 1 have a certificate of consent to.self Insure, BUILDING ADDRESS l_ j� or a certificate of Workers'Compensation Insurance,or a certified !v G copy thereof(Sec.3800,Lab.C.) O o&i^ �,J ZI �O LOCALI Policy No. Company gIZ�OFF T ��L NO.OF B GS.NOW ON LOT " ❑ Certified copy is hereby furnished. j5 X �� NEA M ❑ Certified copy is filed with the county building Inspection TRACT BLOCK LOT NO department.' USE ZONE MAP NO60 . /J ASSESSOR MAP BOOK PAGEQ PARCEL. 41651 Date Applicant I JS ✓ SPECIAL CONDITIONS I CERTIFICATE OF EXEMPTION FROM WORKERS' 2 En M I�• TEL S YES NO COMPENSATION INSURANCE WITHIN 1000 FT.OF SCHOOL? A RESS (This section need not be completed if the permit Is for one hundred VAT T GROUP TYPE CONST' FIRE ZONE ESSED BY dollars($100)or less.) CI ZIPI certify that In.the performance of the work for which this permit 9'6is issued, I shall not employ any person In any manner so as to CHIT. ORE GIN E g`^become subject to the Workers'Compensation Laws. f��CJV CAL CLASSIFICATION APT CO O Date ApplicantKESS , CLASS NO. DWELL UNITS - Q ` V .. NOTICE TO APPLICANT: If, after making this Certificate of REWIRED TOTAL SETBACK FROM EXIST Exemption, you should become subject to the Workers' CONTRACTOR TEL NO. SETBACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code,you must forthwith FRONT comply with such provisions or this permit shall be deemed'revoked. .. ADDRESS LIC.NO. PL LICENSED CONTRACTORS DECLARATION CITY • LIC.CLASS SIDE C PL Q I hereby affirm that I am licensed under provisions of Chapter 9 SEWER MAP v (commencing with Section 7000)of Division 3 of the Business and So.FT. IZE NO,.,OF STORES NO.OF FAMILIES m Professions Code,and my license is in full force and effect. Q� ------�' N ❑ BK PG License Number Lia.'Class V DESCRIPTION OF WORK ADD ❑ VALUATION Contrector Date ,.` U J L CJ ALTER ❑ �� 23 CSO .. _ _ .......... ❑ I am exempt under Sea REPAIR ❑ $ ACCT°s BARC.for this reason DEMOL ❑ LDMA P/ # D 3307186.47 Date: U E OF EXISTING BLL 'URM. ❑ 1 1.TEt S Signature APP ICANT(PRNY2 .�� T N �� .. LOMA Pen,# ❑ I, as owner of the property, or my•employees with wages es (/J�� Z: TOTAL 186.47 . �. Pd ga�y'L9- . S (/(/F AV 3o�J 0*0 FINAL DATE a CHECK. lOQ 47 ,96 their sole compensation,will do the work and the structure,is ° not intended or offered for sale (Section 7044, Business and d , Professions Code.) CHANGE .10 WILLTHEAPPUCANTOR FUTURE BUILDING OCCUPANTHANDLEA HAZARDOUS MATERIAL 7- 5" OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EOUAL TO OR GREATER THAN ❑ 1, as owner of the property, am.exclusively-contracting with THE AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY j licensed contractors to construct the project.(Section 7044, YES 1:1No❑ Business and Professions Code.) QQQQ—QQQ 5i �1 I9Q WILL THE INTENDED USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING" ' OCCUPANT REOUIREA PERMIT FOR CONSTRUCTION OR MODIFICATION FROMTHESOUTH CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT ISCAOMD)SEE PERMITTING CHECKLIST Qa q ° 7 11 1 AM 7°57 FOR GUIDELINES. I hereby affirm that there is a construction lending agency for YES❑ NO❑ the performance of the work for which this permit is issued(Sec. ,)y,„I I HAVE READ THE HAZARDOUS MATERIALS INFORMATION '' E�WD THE• L••.1 S•�• 3097,CIV.C.). HAVE CHECKLIST.I UNDERSTAND MY REOUIREMENT3 EQIE LAS 1 Q COUNTY CODE,TITLE2•CHAPTER 220 SECTIONS 220.100THR_ 14000 •„� ",� �3 Lender's Name HAZARDOUS MATERIALS REPORTING AND FOR Car. INGAP 11 THE br CT1 yp 'Lenders Address OMMORAGM C=I� I-1 o' I certify that I have read this application and state that the above en information is correct. I agree to comply with all county P.C.FEE ! PER IT E ordinances and State laws relating to building construction,and ° d' hereby authorize representatives Of this County to enter upon �` ISSUANCE FEES the above-mentioned property for inspection purposes. / INVESTIGATION FEE TO-TA E SEE REVERSE FOR EXPLANATORYQ&- GE