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Home My Public Portal About5234 VILLAGE CIRCLE DR_Building__ WORKERS'COMPENSATION DECLARATION i J U 60 U hereby affirm that I have certificate of consent to self j APPLICATION FOR �UILDING P E RM I T insure, or a certificate of Workers'Compensation Insurance, or a certified copy thereof(Sec. 3800, Lab. C.) Policy No.IV83-2251�6,r,panyFremont Indemnity COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING ADDRESS ® Certified copy is filed with the county building inspec- BUILDING oe tion department. ADDRESS 5234 Village Circle Dr. LOCALITY NEAREST Date 11/8183 Applicant Virgin Roof CO- CITY Temple CityZIP CROSS ST. CERTIFICATE OF EXEMPTION FROM WORKERS' 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 y USE ZONE MAP hundred dollars($100)or less.) I TRACT BLOCK LOT NO. NO. d TEL. / SPECIAL > I certify that in the performance of the work for which this OWNER Jim Goddard NO. r CONDITIONS 9L permit is issued,I shall not employ any person in any manner = STRICT GROUP TYPE FIRE PROCESSED BY V so as to become subject to the Workers'Compensation Laws. ADDRESS P 0 BOX 1384 CONST. ZONE E9L Date Applicant CITY Arcadia ZIP STATISTI�CLA SIFI TION PT. looriDo.- TEL.NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR UU ENGINEER NO. CLASS NO. DWELL. UNITS LU Exemption, you should become subject to the Workers' I M Compensation provisions-of the Labor Code, you must forth- I ADDRESS SEWER MAP with comply with such provisions or this permit shall be deemed revoked. I TEL' BK. FG VALIDATION CONTRACTOR V NO. — LICENSED CONTRACTORS DECLARATION LIC. t° I hereby affirm that I am licensed under provisions of Chapter 9 1 ADDRESS P. 0. BOX J NO. 160600 VALUATION (commencing with Section 7000)of Division 3 of the Business and LIC. Professions Code, and my license is in full force and effect. I CITY San Gabriel CLASS C39 $8825.00 , SQ.FT. NO.OF NO.OF CHECK SIZE STORIES FAMILIES ONE License Number Lic.Class I - Contractor Date I DESCRIPTION OF WORK Re-roof Vwith FTX NEW ❑ . I am exempt under Sec. lass C Medium shakes. 34 S S ADD ❑ ALTER ❑ FINAL B.BP.C. for this reasonDATE s REPAIR USE OF Date: ❑; FINAL DEMOL i EXISTING BLDG. By Signature APPLICANT TEL. OWNER-BUILDER DECLARATION PRINT Vir in ROOF CO NO.287-0507 I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and ADDRESS P 0 Box J San Gabrial c) 1> Professions Code): PRESENT ❑ BUILDING I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and r G�S 9 4 the structure is not intended or offered for sale(Section LOCALITY 7044, Business and Professions Code). MOVING TEL. I,as owner of the property,am-exclusively contracting CONTRACTOR NO. a} a o o:o u 1 with licensed contractors to construct the project (Sec- ADDRESS 2 1 1 5.50 tion 7044, Business and Professions Code). REQUIRED TOTAL SETBACK FROM EXIST. r c s CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH o � 1 1 � " 0 I hereby affirm that there is a construction lending agency for FRONT the performance of the work for which this permit is issued j P.L. j I. 1 7'_8 3 tSec. 3097, Civ. C.). l SIPE FD P.L. a Lender's Name I 105 00 P.C.Fee$ Permit Fee • - Lender's Address r I certify that I have read this application and state that the Issuance Fee 10.50 above information is correct. I agree to comply with.all CountyI Investigation Fee ordinances and State laws relating to building construction, Total Fee 115.50 and h Deby authorize representativ sof this County to enter upo he above-mentioned ape rt r inspection purposes. o s SEE REVERSE FOR EXPLANATORY LANGUAGE Sig c ure of Applicant or Agen Date I ®s APPLICATION FOR BUILDING PERMIT COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS - — Ihereby affirm that I have a certificate of consent to self insure, BUILDING ADDRESSSt�_ �*ne . or a certificate of Workers'Compensation Insurance,or a certified V111ftSet Gicele ZIP copy thereof(Sec.3800,Lab.C.) LOCAL Policy No. 625246 _Company s .)ri3zc ?U19 r v -T�rr>� S'Alw&e GityNO.OF BLoDftg.NOW ON LOT n❑ Certified copy is hereby furnished. NEAREST CROSS ST. �R Certified copy is filed with the county building inspection TRACT BLOCK LOT NO. USE ZONE MAP NO. `aft°department. ASSESSOR MAP BOOK PAGE PARCEL Date 11�f6 9i Applicant____ _— SPECIAL CONDITIONS OWNER TEL.NO. CERTIFICATE OF EXEMPTION FROM WORKERS' YES NO COMPENSATION INSURANCE 3 WITHIN 1000 FT.OF SCHOOL? ADDRESS (This section need not be completed if the permit is for one hundred 275 Court k;034:1-3aa DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY dollars($100)or less.) CITY ZIP I certify that in the performance of the work for which this permit , ; ✓ is issued, I shall not employ any person in any manner so as to ARCHITECT OR ENGINEER T L.NO. become subject to the Workers'Compensation Laws. STATISTICAL CLASSIFICATION APT CONDO Date Applicant ADDRESS CLASS NO. DWELL UNITS NOTICE TO APPLICANT: If, after making this Certificate of 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 'a1148 '' FRONT comply with such provisions or this permit shall be deemed revoked. ADDRESS o. P L �- a SIDE U LICENSED CONTRACTORS DECLARATION CITY I PL W I hereby affirm that I am licensed under provisions of Chapter 9 SEWER MAP —� (commencing with Section 7000)of Division 3 of the Business and SO. T NO.OF FAMIL LL_ Professions Code,and my license is in full force and effect. ' � ) NEW ❑ BK PG r DESCRIPTION OF WORK ADD ❑ VALUATION License Number 4447 Lic.Class�C39 tr Contractor a t=om+ s,�,9` ALTER4 - � rip CAI ShgkotREPAIR W ip 1 ires 5-3i^94 ElI am exemp gdc�"S'R B.BP.C.for this reason DEMOL ❑ LDMA P/C# USE OF EXISTING BLDG. Date: URM ❑ Signature APPLICANT(PRINT) TEL NO. LDMA Perm a ❑ I, as owner of the property, or my employees with wages as p their sole compensation, will do the work and the structure is ADDRESS l`_ not intended or offered for sale (Section 7044, Business andloll ig III FINAL DATE y Professions Code. IO f WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL J OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN El 1, as owner of the property, am exclusively contracting With THE AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY � licensed contractors to construct the project (Section 7044, YES❑ NO❑ 2 Business and Professions Code.) t _�°. �^-'•' WILL THE INTENDED USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING OCCUPANT REQUIRE A PERM IT FOR CON ST RU CTI ON OR MODIFICATION FROM THE SOUTH {2,•1.1�.j. ° CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST i NRlA 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 HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD 3097,Civ.C.). PERMITTING CHECKLIST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES m COUNTY CODE,TITLE 2,CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING fyr t I Lender's Name HAZARDOUS MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD. I aLender's Address—____ O NERD AGENT 0 0 1 certify that I have read this application and state that the above Q information is correct. I agree to comply with all county P.C.FEE PERMIT FEE ordinances and State laws relating to building construction,and a hereby authorize representatives of this County to enter upon ISSUANCE FEE the above-mentioned property for inspection purposes. a INVESTIGATION FEE TOTAL FEE Sgnelef APph.nf or Agent Defo _ SEE REVERSE FOR EXPLANATORY LANGUAGE 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 0112180009 PHONE: (626) 285-0488 EXT: LEGAL ID: - NO. OF CONST BUILDIIUG_�WRESS:i TR: 29602 LT: 1 UN: 50 SQ. FT STORIES TYPE I 5234 VILLAGE CIRCLE DR STRUCTURE: VN TEMP CA 917803357 ASSESSOR 0 NEAREST CROSS STREET: BALDWIN 8585-001-117 THOMAS PAGE: 597 GRID: 64 LOCALITY: TEMPLE CITY • I •S S - D S5 - EXIST OCC GRP: 2/18/01 JK 06/16/02 OWNER: TEL. NO: BL GS. NOW ON 0 VALUATION: f NAL DATE FINAL BY: CODE: BAKER ARLENE N TR ARLENE M BAKER TR - 7,000 O , 5234 VILLAGE CIRCLE TEMP 917803357 p (MSCRIPT0rOFOOF HOUSE & GARAGE; APPLY 1/2 CDX & 30YR CAL SHAKE FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: APPLICANT: NO: I DOUG DEARDEN (626) 287-0669- AA BLDG PERMIT ISSUANCE 27.75 4251 BALDWIN AVE AC STRONG MOTION RESID 7000.00 VAL 0.70 SPECIAL CONDITIONS: EL MONTE D2 PERMIT W/0 N=HC'nn��70Q0.00 VAL 166.20 — GrETO '�FIEE 194.65 CONTRACTOR, TEL. NO: ®� APPROVALS , DATE INSPECTOR SIGNATURE WEATHERITE ROOFING (626) 287-0669- 4251 BALDWIN AVE LIC. .� `� 1iOCATION AND SETBACKS �- ELMONTE CA 91731 HI6 i•/ 4� MOILS ENGINEER APPROVAL ARCHITECT R R: TEL. N : O Rbc O�N/TREWCI.ro S LIC. N0: I --- ' SLAB UNDER FLOOR. RAI-SED FOO F G �. MAP 0: SEWER MAP B00 PAGE: FIRE ONE: CMP. �J I UNDERFLOOR INSULATION X 3 �01 L I. -,IJ VO�U U�LJ LOO SHEATHING 0. OF FAMILIES: DWE G U S: P CO : STAT CLASSF ----NO 21 ROOF SHEATHING 7` WITHINSCHOOL '` r' S PANELS 5 / AIR QUALITY: 1000 FEET MATERIALS ,� � NO NO NO ." FRAME INSPECTIONf \ i REQUIREDTOTAL SETBACK R EXIST Ilip FIRE SPRINKLER NG SET BACK YARD: HWY: PROP LINE: WIDTH: /% FRONT L- C Servic- �h�� INSULATION/WEATHER STRIP INTERIOR /DR EXTERIOR LATH RAT5Di - S RATED WALL ASSEMBLIES I � SHAFT976-MR-G-r— f-BAR CEILINGS * ADDITIONAL.DATA ON"FILE REPORT' !D: DPR26f ROUTE TO: 13S0508 I I