HomeMy Public PortalAbout9932-9934 WOODRUFF AVE_Building__ WORKERS'COMPENSATION DECLARATION-04•1
hereby affirm that I have a certificate of consent to self APPLICATION FOR BUILDING PERM
. insure,or a certificate of Workers'Compenstion Insurance,or
a certlfiopy thereof(Sec. 3800, Lab. C. r� I COUNTY OF LOS ANGELES BUILDING AND SAFETY
Po O �3 Companyb
❑ Certified copy is hereby"furn ished. FOR APPLICANT ILL IN 6 d ,m�� BUILDING Q c
ADDRESS.Rq d Zy
Certified copy is filed with the county building ins c- BUILDING(M P - G
,1XJ\ tion department. ADDRESS 1�/?—� LOCALITY r(.
NEARE
ate/D —,ff?—Applicant CITY �- L'�'�'` ZIP CROSS ST. RV L,0 L vz�
JC CERTIFICATE OF EXEMPTI ROM WORKERS' NO.OF BLDGS. ASSESSOR
COMPENSATION SURANCE SIZE OF LOT d NOW ON LOT MAP BOOK ' PAGE PARCEL
(This section need no('be completed if the permit is for one �j USE ZONE MAP
hundred dollars,($100)or less.) BLOCK LOT NO. NO. v V
OWNER L SAAk /JC�v, TEL. /' �7`7 SPECIAL >-
�4Q Z
I certify that in the performance of the work for which this NO /. CONDITIONS aO
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permit is issued, I shall not employ any person in any manner ADDRES gZ(r•' ie [� DISTRICT GROUCONST.TYPE FIRE ZONE
PROCESSED BY
so as to become subject to the Workers'Compensation Laws. ` 2S
Date Applicant CITY ZIP f/72 72 STATISTICAL CLASSIFICATION APT. CONDO.
NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL. �� LU
U
Exemption, you should become subject to the Workers' ENGINEER NO CLASS NO. WELL. UNITS '2'
Compensation provisions of the Labor Code, you must forth-
ADDRESS SEWER MAP ig
with comply with such provisions or this permit shall be p '
deemed revoked. CONTRACTOR De _Nly-- O BK. PG, VALIDATION
LICENSED CONTRACTORS DECLARATION LIC.
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS. w ILIQ/ NO. VALUATIO
(commencing with Section 7000)of Division 3'of the Business and ..fir LIC. _
tl
Professions Code, and my license is in full force and effect. CITY /eCLASS $ O�
SQ. NO.OF NO.OF CHECK
License Number Lic.Class SIZE STORIES FAMILIES ONE
Contractor-" la +�`�eiPy yDafe /U`� ��� D CRIPTION OF WORK 92N* NEW
❑ I am exempt from the licensing requirements as I am a _ !—�,_ ADD
licensed architect or a registered professional engineer sZY
ALTER E] FINAL
acting in my professional capacity (Section 7051, !�0 - REPAIR E] DATE,.--<
Business and Professions Code). E OF
E TING BLDG. DEMOL ❑ B,,"AL j� � _ -�,•'
Lic.or Reg.No. Date' - t APPLICANTTEL.7 �,7 Y )
OWNER-BUILDER DECLARATION (PRINT) flAr1 N a
I hereby..affirm that I am exempt from the Contractor's License r •r / ^� r wad a
Law for the following reason (Section 7031.5, Business and ADDRESSr7�Z�" /L'�i I C �I , r S.f �� z 6 5 8,5 A
Professions Code): PRESENT
El 1, -
0 0 0 0 0
I, as owner of The property, or my employees with ADDRESS
wages as their sole compensation,will do the work and LOCALITY - 2 ° 2 7.5
the structure is not intended or offered for sale(Section Q
7044, Business and Professions Code). MOVING TEL.
❑ I, as.owner of the property, am exclusively contracting CONTRACTOR NO. �" ° ° 8.2 7 5 0 60
with licensed contractors to construct the project (Sec- ADDRESS f �, —$2
tion 7044, Business and Professions Code).
REQUIRED TOTAL SETBACK FROM EXIST. /
CONSTRUCTION LENDING AGENCY SET BACK YARD Hwy PROP. LINE WIDTH
I hereby affirm that there is a construction lending agency for FRONT
the performance of the work for which this permit is issued P.L. -70 D ;
(Sec. 3097, Civ. C.). SIDE
P.L. ,
Lender's Name ./ ,f
_
P.C. Fee$ S.] e��/ Permit Fee
Lender's AddressCO' IF
I certify that I have read this application and state that the Issuance Fee
above information is correct. I agree to comply with all County Investigation FeeO }
ordinances and State laws relating to building construction, Total Fee
and hereby authorize representativ of this County to enter
upon bov -me Toned pr per for inspection ur oses.
1
/ ? SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent balel ®s
,
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 1501050015
PHONE: (626) 285-0488 EXT:
LEGAL ID: N0. OF CONST BUILDING ADDRESS:
IBK: 154 PG: 12 PC: 2 SQ. FT STORIES TYPE 9932 WOODRUFF AV
ISTRUCTURE: 3800 V-B TEMP CA 917801729
ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET:
18587-031-024
I i THOMAS PAGE: 597 GRID: A2 LOCALITY: TEMPLE CITY CAI
TENANT: EXIST BLDG USE: RESID USE ZONE: R-1 [ISSLED ON: PROCESSED BY:
1EXIST OCC GRP: 101/05/15 SR 1
(OWNER: TEL. NO: IBLDGS. NOW ON IAT: VALUATION: IFINAL DATE FI BY: CODE:
1WING FAI NG (626) 823-2668- 1 12,500 I
9932 WOODRUFF AV <J
1TEMP 917801729 FEES PAID ID SC. IPTION OF WORK
ITEAR-OFF AND REROOF WITH 30 L COMPO SHINGLES
I IFEE DESCRIPTION: QUANTITY: DOM: AMOUNT:
APPLICANT: TEL. NO: I I I
ROGER, LI (626) 378-8031- IAA BLDG PERMIT ISSUANCE 27.80 [_
12702 DENTON AVENUE IAB STATE GREEN BLDG FEE 12500.00 VAL 1.00 [SPECIAL CONDITIONS:
ISAN GABRIEL CA 91770 :AC STRONG MOTION RESID 12500.00 VAL 1.30
ID2 PERMIT W/O EN-HC 12500.00 VAL 267.00
TOTAL FEES 297.10
CONTRACTOR: TEL. NO: ; (APPROVALS DATE INSPECTOR SIGNATURE
ROGER LI CONSTRUCTION, INC. (626) 378-8031-
I2702 DENTON AVE LIC. NO ILOCAiION AND SETBACKS I I I
IROSEMEAD, CA 91770 962953 I I I 1 I
[ 1SOILS ENGINEER APPROVAL
I �
1ARCHITECT OR ENGINEER: TEL. NO: - 1 IFOUN-DATION/TRENCH FORMS I I I
1 LIC. NO: 1 1SLAB/UNDER FLOOR I I
(RAISED FLOOR FRAMING
I I �
(MAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP:( IUNDErcFLOOR INSULATION I I II I I
3 001 11-1
FLOOR SHEATHING I I [
INO. OF FAMILIES: DWELLING UNITS: APT/GOND: STAT CLASS: I I I I I
1 NO 21 I [ROOF SHEATHING I 1
I SCHOOL WITHIN HAZARDOUS ISHEAR PANELS [
[AIR QUALITY: 1000 FEET MATERIALS I [
1 NO NO NO IFRAME INSPECTION I [
� [ I
1 I 1FIRE SPRINKLER HANGERS I [
I I I
1 [ [INSULATION/WEATHER STRIP[ [ I
1 11NTERIO /DRYWALL
[ 1 1EXTERIOR LATH I [ [
1 I IRATED FLOOR/CEIL ASSEM. I I [
[ IRATF.D WALL ASSEMBLIES [ [ [
IRATED SHAFTS/OPENINGS
_ I 1
1 I IT-BAR CEILINGS [
1 I
ILOT DRAINAGE [
I
1 REPORT ID: DPR261 ROUTE TO: BS0508