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Home My Public Portal About5907 TEMPLE CITY BLVD_Building__ WORKERS'COMPENSATION DECLARATION I 'gereby affirm that I have a certificate of consent to self ® `� y ` insure, or a certificate of Workers'Compensation Insurance, I ® C9 ® ®I PERMIT or certified copy thereof(Sec. 3800, C.) i COUNTY OF LOS ANGELES BUILDING AND SAFETY j otic No.f S� Company ;,.:.:•... .. . ,' I Certified copy is hereby furnished BUILDING P ❑ •„�Y OR APPLICANT TO FILL IN ADDRESS •^!/ Certified copy is filed with the county buillinspec- BUILDIN tion department. ADDRE LOCALITY ,S , NEAREST Date Applicant ! CITY (�' ZIP CROSS ST. CERTIFICATE OF EXEMPTION FROM WORKERS' I. 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 ESPECIAL hundred dollars ($100)or less.) TRACT BLOCK LOT NO. 7 b TEL. G-� ' •I certify that in the performance of the work for which this OWNER ,!^ - NO. ITIONS t: permit is issued, Lshall not employ any person in any manner DISTRICT GROUP. TYPE FIRE PROCESSED BY 0 so as to become subject to the Workers'Compensation Laws. ADDRESS CONST. ZONE V 104. IV 3 � Ed Date Applicant CITY ZIP STATISTICAL CLASSIFICATION APT. CONDO. NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL. _ 'Exemption, you should become subject to -the Workers' ENGINEER NO. CLASS NO. WELL. UNITS Compensation provisions of the Labor Code, you must forth- -ADDRESS SEWER MAP y with comply with such provisions'or this permit shall be }deemed revoked. • CONTRACTOR ,i NO. BK. LPG, r VALIDATION — LICENSED CONTRACTORS DECLARATION J LIC• I hereby affirm that I am licensed under,provisions of Chapter 9 ADDRESS Q� i2�t � - NO. VALUA ION (commencing with Section 7000)of Division 3 of the Business and L LIC. D% Professions Code,-and my license is in full force and effect. CITY � L /OG' - CLASS .�'"' $ 0 � / SQ. Ft. NO.OF NO.OF CHECK ;r...- License Numbe r Lic.Class / SIZE STORIES FAMILIES ONE �r DESCRIPTION OF WORK NEW ❑. $ Contractor A')� �'/ �C3 Date � - I ADD ❑I am exempt under Sec. ALTER FINAL+ 1 .. B.BP.C. for this reason REPAIR ElDATE / Date: USE OF DEMOL FINAL EXISTING BLDG. ❑ By C -4 Signature APPLICANT TEL. OWNER-BUILDER DECLARATION PRINT NO. I hereby affirm that I am exempt from the Contractor's License D l_ !/ Law for the following reason (Section 7031.5, Business and ADDRESS Professions Code): PRESENT E] BUILDING I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and the structure is not intended or offered for sale(Section LOCALITY 7044, Business and Professions Code). MOVING TEL. I ❑ 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 REQUIRED TOTAL SETBACK FROM EXIST. YARD HWY- SET BACK PROP. LINE WIDTH (( 5 ITA 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. Set. 3097,Civ. C.). SIDE• ff o o a o a 1 `a Lender's Name ' ° ' - 2 0 0 4 0.5'0' P.C. Fee$ Permit Fee o o (! c z Lender's'Address Q J C�0' r I certify th(it I have read this application and state that.the Issuance Fee d ,�� 2. 1 5—R J above informbtion is correct:I agree to comply.•with-all CovntY i Investigatian':Fee; ordinances and�State;ldvirs relctin to'btYildiii .constructtori; and hereby authorize represetitativ sof this County to'enter _ upon the ov , rhentione ro rt for-•inspection'purposes. N:. SEE.REVERSE FOR EXPLANATORY LANGUAGE es Signature of Arppliffnt or Agent - - - APPLICATION FOR BUILDING PERMIT � s _+ COUNTY OF LOS ANGELES BUILDING AND SAFETY FOR APPLICANT TO FILL IN BUILDING DDRESS WORKER'S COMPENSATION DECLARATION Cf' I hereby affirm that I have a certificate of consent to self insure, BUILDING ADDRESS 59 -7 TQM t- Cf-F+ Y &v.or a certificate of Workers'Compensation Insurance,or a certified CITY ZIP copy thereof(Sec.3800,Lab.C.) TE M P LE LOCALITY Policy No. CompanySIZE OF LOT NO. oz- El Certified copy is hereby furnished. OF BLDGS. ON LOT NEAREST CROSS ST. ❑ Certified copy is filed with the count building Inspection TRACT/4_G / BLOCK LOT NO. y 9 P ca 43 USE ZONE MAP NO, �D department. �- Date-Applicant 435— ASSESSOR MAP BOOK PAGE PARCEL PP 005,97 014 00// � � SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' NER TEL,NO, COMPENSATION INSURANCE (K Gs l/ 'AP N =-� C'(�' ` 21'3 &S l^23& WITHIN 1000 FT.OF SCHOOL? YES NO (This section need not be completed if the permit is for one hundred At�Z4 /y , LA K L A V F-. 102- DISTRICT GROUP TYPE CONST.' FIRE ZONE PROCESSED BY dollars($100)or less.) CITY ZIP ry '` I certify that in the performance of the work for which this permit PRS Pt D r-14 R 'C 1 0 1 ` ,�tl "-02 I/ Is issued, I shall not employ any person in any manner so as to ARCHITECT OR ENGINEER TEL NOr! become subject to the Workers'Compensation Laws. f D A Q LAR , LI3 J p O 7 TS I STATISTICAL CLASSIFICATION APT CONDO Date Applicant ADDRESS CLASS NO.1-0/ DWELL UNITS NOTICE TO APPLICANT. If, after making this Certificate of 52 F_ F- AV. *204- REQUIRED TOTAL SETBACK FROM EXIST Exemption, you should become subject to the Workers' CONTRACTOR TEL NO. SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code,you must forthwith WA FRONT comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC.NO. PL LICENSED CONTRACTORS DECLARATION CITY LIC.CLASS PIL G 1 hereby affirm that I am licensed under provisions of Chapter 9 SEWER MAP `'^°' c.I (commencing with Section 7000)of Division 3 of the Business and SO.FT.SIZE NO.OF STORES NO.OF FAMILIES 1 L? r , Professions Code,and my license is in full force and effect. 3S x 40 NEW ❑ BK PG � c_ License Number Lic.Class DESCRIPTION OF WORK ADD ❑ VALUATION ® _ Lvu E U jL Rai FO K , Contractor Date ALTER ❑ rTI.r. ,a ❑ I am exempt under Sec. REPAIR ❑ $ /'�4, p D e , e'0 B.BP.C.for this reason DEMOL ❑ LDMAP/C q �~� L USE OF EXISTING BLDQ. Date: C F F I c)= Sid{?14 E URM V T}:kt_ •�2 G -9 Signature APPLICANT(PRINT) TEL NO. 77r" ❑ I, as owner of the property, or my employees with wages as LDMA Penn 1) Z �. _i=� ^•�y; their sole compensation,will do the work and the structure is ADDRESS not intended or offered for sale (Section 7044, Business and FINAL DATEa o Professions Code.) 12`31`1WILLTHEAPPLICANTOR FUTUREBUILDING OCCUPANTHANDLEAHAZARDOUS MATERIAL I, as owner of the r0 8 OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN a I+ C• p p rt% am exclusively contracting with THE AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY � j +I�'IJIi t I.ti I •i i L,= L Ilcensed contractors to construct the project (Section 7044, YES❑ NO❑ mv; z Business and Professions Code.) ANt '` :r WILL THE INTENDED USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING OCCUPANT REOUIREA PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FORGUIDELINES 4theI hereby affirm that there is a construction lending agency for YES❑ NO❑ .74- the performance of the work for which this permit is issued(SBC. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMO 3097,CIV.C.). PERMITTING CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE,TITLE2,CHAPTER 220SECTIONS220.100THROUGH 220.140 CONCERNING O Lender's Name HAZARDOUS MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD. 0 Lender's Address OMEN oRaeevr 0 1 certify that I have read this application and state that the above information is correct. I agree to comply with all county RC.FEE p D/ PERMIT FEE ordinances and State laws relating to building construction,and d 'oma herejq authorize representatives of this County to enter upon lofO ISSUANCE FEE /3' the ve- t' ad pr pe f ri ion purpos ,� INVESTIGATION FEE TOTAL FEE -IF-d WAp .AgW SEE REVERSE FOR EXPLANATORY LANGUAGE If APPLICATION FOR BUILDING PERMIT 4 COUNTY OF LOS ANGELES BUILDING AND SAFETY `• WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDI G DRESS BUILDwG AODREss D I hereby affirm that I have a certificate of consent to self insure, 590 T L c 1$�( &V or a certificate of Wbrkere'Comperlsetlon Insurance,or a certified copy thereof(Sec.3800,Lab.C.) CITY. rel L� LP LOCALITY Policy Na Company SIZE OF LOT' NO.OF BLDGS. ON LOT I R4,6- ❑ Certified copy is hereby fumished. NEAREST CROSS ST. 13Certified copy is filed with the county building Inspection �.-� BLOCK LOT No. department. USE USE ZONE MAP NO. _ Date Applicant ASSESSOR MAP BOOK PAGE PARCEL I 9'J q Q `,4 ® ®} SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' t 9VYNG /3�i\l�R 3NDC�8I—23(o YES No COMPENSATION INSURANCE DR WITHIN 7000 FT.OF SCHOOL? (TMs section need not be completed 9 the permit Is for one hundred K E 7 1 V 02 DISTRICT' GROUP TYPE CONST' FIREZONE PRocEssED BY dollars($100)or less) CITY ZIP I certify that in the performance of the work for which this permit �i4Sl��W A `�I I O I ��' �►/ Is Issued. I shall not employ any person in any manner so as to ARCHITECTS ENGINEER TEL NOr become subject to the Workers'Compensation Laws (Z IRR 2a3 71S I STATISTICAL CLASSIFICATION APT CONDO Data Applicant ADDRESS CLASS NO. DWELL UNITS APPLICANT.TO APPLICANIf, after making this Certificate of S2 1= AV. *204- REOUIRED TOTALsETBACKFROM EXIST Exemption, you should become subject to the Workers' CONTRACTOR s TEL NO. SETBACK YARD FIVYY PROP UNE WIDTH ADDRESS LIC NO. Compensation provisions of the Labor Code,you must forthwith WFRONT comply with such provisions or this permit shall be deemed revoked. PL LICENSED CONTRACTORS DECLARATION CITY LID.CLASS PL E , I hereby affirm that I am licensed udder provisions of Chapter 9 SEWER MAP 'J (commencing with Section 7000)of Division S of the Business and 80 FT SIZE NO.OF STORES NO.OF FAMILIES Professions Code,and my license is in full force and effect. 3S-,c4-0 1 NEW ❑ BK PG u 7 DESCRIPTION OF WORK VALUATION License Number Lia Class E t1 Q� r ADD ❑ I 4 Contractor - Date ALTER ❑ i%a ❑ I am exempt under Sec. REPAIR ❑ $ /e¢ ®® , L� 3K. B.SP.C.for this reason USE OF EMS TING DEMOL 13LOMA P/q 0 L 1;• NI' • TING B OFFICE 'STORE E •URM Salt;!- 320.9-Z Signature APPLICANT(PRINT) TEL NO. LOMA Perm 0 CHER 131,as owner of the property,or my employees with wages as Z (+ Gt`r their sole compensation,will do the work and the structure is ADDRESS ' O ►�,I'� It7t • not Intended or offered for sale(Section 7044, Business and FINALtNi,'da /• / R Q Professions Code.) MLLTHEaRICANTORFUTUREBUILDINOOCUWHANAHZ �aD"E I, as owner of the Propertyem Exclusively contracting h THAMITN THEOUNTSS IREDONHE HAZARDOUS MATERIALS MIMONGUI !• f/ FINAL BVI ; 1.301111G iIG,IJ1 5/3015; licensed contractors to construct the project.(Section 7044, YES❑ No❑ s Business and Professions Code.) l c! iil ' 4 WILL THE INTENDED USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING THESOUTH CONSTRUCTION LENDING AGENCY �RRa RRa QUALITY MANAGEMENTPERMRis�CT(SCAQR,uDM))SEE�IrnNG CHECKLIST �B Z.) DEUN�ES[3 13 Jam" 1 hereby affirm that there Is a constnlction lending agency for YES❑ NO [� the performance Of the work for which this permit is issued(Sea 3097,CIV.C.). I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMrTING CHECKLISL I UNDERSTAND MY REOUIREMENTs UNDER THE LOS ANGELES Lenders Name COUNTYCODMTTTLEZ,CHAPTER2 0SEanONSM100THR000H2.Z0.14000NCERNING HAZARDOUS MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCACMD. Lenders Address owRmanAGOr 'o 1 certify that I have read this application and state that the above PC FEE ®® PERMIT FEE Information is correct. 1 agree to comply with all county ordinances and State laws relating to building construction,and d hereft authorize representatives of this County to ender upon ISSUANCE FEE the Zed pn,ape f r I p on pujM, m INVESTIGATION FEE TOTAL FEE �Jgry a sAprd dYi O ^'V 80 REVERSE FOR EXPLANATORY LANGUAGE.