HomeMy Public PortalAbout9821 WINDSOR LN_Building__ 'WORKERS' COMPENSATION DECLARATION
1ereinsure bora certificatffirm e of Workers' Compensat on I have a certificate of coeInsuto sel
ran of APPLICATION FOR BUILDING PERMIT
or a certified copy thereof (Sec. 3800, lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. ��� topan°�-U S F&G BUILDING
El Q /
copy y FOR APPLICANT TO FILL IN ADDRESS
Certified co is hereby furnished.
Certified copy is filed with the county building inspec- BUILDING
tion department. ADDRESS
Date 4 23 -8 9 Applic cITYT e m 1 e city zip 91780 LOCALITY
NO. OF BLDGS. o NEAREST.
CERTIFICATE OF EXEMPTION M/0RKF6 SIZE OF LO18 7 0 0 0 NOW ON LOT CROSS ST.
COMPENSATION IN RANCE ASSESSOR
(This section need not be completed if the permit is for one TRACT 4 313 6 BLOCK MAP BOOK PAGE PARCEL
hundred dollars ($100) or less.)
OWNER NO. _ USE ZONE MAP { �
I certify that in the performance of the work for which this � NO. "T-
permit is issued, I shall not employ any person in any manner ADDRESS 1425 Melanie l a n e ^J SPECIAL
�l� CONDITIONS O
so as to become subject to the Workers'Compensation Laws. U
CITY Arcadia ZIP 91006
Date Applicant ARCHITECT OR TEL.
D STRICT GROUP I TYPE FIRE PROCESSED BY
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER Same NO. J l CONST. ZONE
Exemption, you should become subject to the Workers' , O �U
Compensation provisions of the Labor Code, you must forth- ADDRESS
LJ
with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION APT. I CONDO, hZ
deemed revoked. CONTRACTOR S a M E NO. (
LICENSED CONTRACTORS DECLARATION LIC. CLASS N�[_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 LIC. B
and 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 t� Lic. Class SIZE 2 3 0 0 STORIES 2 FAMILIES 1 ONE
VALUATION
Contract v� pFj}e DESCRIPTION OF WORK Single F 1 NEW S11 i
❑1 am exempt under S i
attached 2 c a r ADD ❑ ►
ALTER ❑
B.&P.C. for this reason USE garage . REPAIR ❑ $ g, 400 0
Date' OF
EXISTING BLD DEMOL ❑
Signature APPLICANT
OWNER-BUILDER DECLARATION (PRINFj e o r g e W i e g a n d No 2 8 6-3 6 3 6 FINAL
I hereby affirm that I am exempt from the Contractor's LicenseDATE
Law for the following reason (Section 7031.5, Business and ADDRESS 1425 Melanie Lane Arcadia FINAL
Professions Code): PRESENT By G
ElBUILDING
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, as owner of the property, am exclusively contracting CONTRACTOR NO.
with licensed contractors to construct the project (Sec- ADDRESS (J h
tion 7044, Business and Professions Code.) U
REQUIRED TOTAL SETBACK FROM EXIST. I
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 for which this permit is issued P.L.
(Sec. 3097, Civ. C.). SIDE
BBH Mortgage - I 'i 'r>
Lender's Name -J —�
8383 Wilshire beverly hill P.C. Fee$ Permit Fee LD e ft F•� �I -{ yM
Lender's AddressQ 4 , 41+
° 1 certify that I have read this application and state that theIssuance Fee .510 LDMA P/C a
n
S above information is correct. I agree to comply with all County Investigati ee
R ordinances and State laws relating to building construction, Total FeegFe' '2 !5 ULDMA Perm. a
a and hereby authorize representatives of this County to ent r
upon the above-mentioned ro erty for inspe tion p
p f
SEE REVERSE FOR EXPLANATORY LANGUAGE r+ ,� • •.�, r 00� +
Sign of ALica or nt to e 4`.Q
r,
+
WA
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 1007060009
PHONE: (626) 285-0488 EXT:
ILEGAL ID: I NO. OF CONST I BUILDING ADDRESS: [
ITR: 43136 LT: 1 UN: 12 I SQ. FT STORIES TYPE ] 9821 WINDSOR LN 1
ISTRUCTURE: V-B I TEMP CA 917800000 1
(ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET:
18589-020-090 I I THOMAS PAGE: GRID: LOCALITY: TEMPLE CITY, Cl
(TENANT: 1EXIST BLDG USE: RESID USE ZONE: R-3 [ISSUED ON: PROCESSED BY: [
'JEXIST OCC GRP: 107/06/10 SR 1
(OWNER: TEL. NO: 19LDGS. NOW ON LOT: VALUATION: IFINAL DATE FINAL BY: CODE: ]
(TANG, PATRICK (626) 286-3427- 1 1,500 1 I
19821 WINDSOR LN I I
ITEMP 917803967 1 FEES PAID 1DESCRIPTION OF WORK 1
[ 1 ICHANGE OUT 1 PATIO DOOR SLIDER LIKE FOR LIKE ]
I IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT:( I
]APPLICANT: TEL. NO: 1 I I
IJ RANDALL CONST. (714) 745-7987- 'IAA BLDG PERMIT ISSUANCE 27.80 I [
120891 CATAMARAN LN. IAB STATE GREEN BLDG FEE 1500.00 VAL 1.00 ISPECIAL CONDITIONS: 1
1HUNTINGTON BEACH IAC STRONG MOTION RESID 1500.00 VAL 0.50 [ 1
ID2 PERMIT W/O EN-HC 1500.00 VAL 82.20 ]
I 1 TOTAL FEES 111.50 ] I
ICONTRACTOR: TEL. NO: I (APPROVALS DATE INSPECTOR SIGNATURE [
IJ RANDALL CONSTRUCTION (714) 745-7987- 1 1 I
120891 CATAMARAN LANE LIC. NO ] 1LOCATION AND SETBACKS [ [ I
1HUNTINGTON BEACH, 92646 704087B 1 I I I
[ I ISOILS ENGINEER APPROVAL I I [
1ARCHITECT OR ENGINEER: TEL. NO: - 1 1FOUNDATION/TRENCH FORMS I I I
[ LIC. NO: I (SLAB/UNDER FLOOR ] I [
] �I 1RAISED FLOOR FRAMING I ] [
IMAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP:( 1UNDERFLOOR INSULATION I I I
1144H269 3 001 [_ 1-1 I
I I 1FLOOR SHEATHING I I
INO. OF FAMILIES: DWELLING UNITS: APT/COND: STAT CLASS: I
1 NO 21 1 IROOF SHEATHING 1
1 SCHOOL WITHIN HAZARDOUS ] ISHEAR PANELS I I I
(AIR QUALITY: 1000 FEET MATERIALS ] [ [ I I
1 NO NO NO i 1FRAME INSPECTION I I I
]FIRE SPRINKLER HANGERS 1 [
11NS55ATION/WEATHER STRIP( I [
11NTERIOR LATH/DRYWALL
I I I
] I [EXTERIOR LATH I ] I
I I I
[ I (RATED FLOOR/CEIL ASSEM. I I I
1 1 IRATED WALL ASSEMBLIES 1 [
[ 1 RATED SHAFTS/OPENINGS 1 I [
[ ] 1T-BAR CEILING3
I I I
[ [LOT DRAINAGE I I I
I I I
1 1REPORT ID: DPR261 ROUTE TO: BS0508 ] ] ] I
I