HomeMy Public PortalAbout5021 CAMELLIA AVE_Building_3/1/2016_COUNTY OF LOS ANGELES
DEPARTMENT OF PUBLIC WORKS
BUILDING AND SAFETY / LAND DEVELOPMENT
LEGAL ID:
TR: 14467 IT: 30
ASSESSOR INFORMATION NUMBER:
6589-014-017
fokh,I A
OWNER: TEL. NO:
KONOSKE ROGER J;SHARON E
5021 CAMELLIA AV
TEMP 917803854
APPLICANT:
TEL.
NO:
HERNANDEZ, NORA
(213) 479-5765-
1128 N MONTEREY ST
1
ALHAMBRA CA 91801
1
I
CONTRACTOR:
TEL.
NO: 1
SANZ CONSTRUCTION INC.
(626)
926-4935- 1
2724 W MAIN ST
LIC. NO 1
ALHAMBRA CA 91801
896113
ARCHITECT OR ENGINEER: TEL. NO:
LIC. NO
4AP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP:
3 001
1
40. OF FAMILIES: DWELLING UNITS: APT/COND: STAT CLASS:
NO 21
SCHOOL WITHIN HAZARDOUS
SIR QUALITY: 1000 FEET MATERIALS
NO NO NO
?ERMIT EXPIRES 180 DAYS IF
L) WORK DOES NOT COMMENCE, OR
?) WORK IS SUSPENDED OR ABANDONED, OR
3) FAILS TO OBTAIN CODE REQUIRED INSPECTION
TEMPLE CITY # 0508 BUILDING PERMIT
9701 LAS TUNAS ALTERATION/REPAIR
TEMPLE CITY CA 91780 BL 0508 1603010101
PHONE: (626) 285-0488 EXT:
NO. OF CONST BUILDING ADDRESS:
SQ. FT STORIES TYPE 5021 CAMELLIA AV
STRUCTURE: 1800 V -B TEMP CA 917803854
NEAREST CROSS STREET:
THOMAS PAGE: 597 GRID: A4 LOCALITY: TEMPLE CITY
EXIST BLDG USE: REBID USE ZONE: R-1 ISSUED ON: PROCESSED BY:
EXIST OCC GRP: 103/01/16 SR
BIGGS. NOW ON LOT: VALUATION:FINAL PATE FIN::AyyJ,,, BY: CODE:
9,500 3 (71/r/h /• f
FEES PAID DESCR P N OF WORK
IRE -ROOF 1800 SQ.FT. (HOUSE ONLY) AND SHEATHING - INCLUDING
FEE DESCRIPTION: QUANTITY: DOM: AMOUNT:ITEAR OFF COMPOSITION SHINGLES
AA BLDG PERMIT ISSUANCE 34.40 '
AB STATE GREEN BLDG FEE 9500.00 VAL 1.00 JSPECIAL CONDITIONS:
AC STRONG MOTION REBID 9500.00 VAL 1.20
D2 PERMIT W/O EN -HC 9500.00 VAL 270.40 1
TOTAL FEES 307.00 1
(APPROVALS DATE INSPECTOR SIGNATURE
(LOCATION AND SETBACKS
(SOILS ENGINEER APPROVAL
I
(FOUNDATION/TRENCH FORMS
(SLAB/UNDER FLOOR
ID: DPR261 ROUTE TO: BS0508
UNDERFLOOR INSULATION
FLOOR SHEATHING
ROOF SHEATHING
SHEAR PANELS
FRAME INSPECTION
FIRE SPRINKLER HANGERS
INSULATION/WEATHER STRIP
INTERIOR LATH/DRYWALL
EXTERIOR LATH
RATED FLOOR/CEIL ASSEM.
RATED SHAFTS/OPENINGS
T -BAR CEILINGS
LOT DRAINAGE
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from
the Contractors' State License Law for the reason(s) indicated
below by the checkmark(s) I have placed next to the applicable
item(s) (Section 7031.5, Business and Professions Code): Any
city or county that requires a permit to construct, alter, improve,
demolish, or repair any structure, prior to its issuance, also
requires the applicant for the permit to file a signed statement
that he or she is licensed pursuant to the provisions of the
Contractors' State License Law (Chapter 9 (commencing with
Section 7000) of Division 3 of the Business and Professions
Code) or that he or she is exempt from licensure and the basis
for the alleged exemption. Any violation of Section 7031.5 by
any applicant for a permit subjects the applicant to a civil
penalty of not more than five hundred dollars ($500).):
U I, as owner of the property, or my employees with wages as
their sole compensation, will do (✓) all of or (_) portions of the
work, and the structure is not intended or offered for sale
(Section 7044, Business and Professions Code: The
Contractors' State License Law does not apply to an owner of
property who, through employees' or personal effort, builds or
improves the property, provided that the improvements are not
intended or offered for sale. If, however, the building or
improvement is sold within one year of completion, the Owner -
Builder will have the burden of proving that it was not built or
improved for the purpose of sale.).
U I, as owner of the property, am exclusively contracting with
licensed Contractors to construct the project (Section 7044,
Business and Professions Code: The Contractors' State License
Law does not apply to an owner of property who builds or
improves thereon, and who contracts for the projects with a
licensed Contrba for pursuant.to the Contractors' State License
Law).
U I am exempt from licensure under the Contractors' State
License Law for the following,reason:
By my signature below I acknowledge that, except for my
personal residence in which I must have resided for at least
one year priorlto completion of the improvements covered by
this permit, I cannot legally sell a structure that I have built as an
owner -builder fl it has not been constructed in its entirety by
licensed contractors. 1 understand that a copy of the applicable
law, Section 7044 ofthe Business and Professions Code, is
available upon request when this application is submitted or at
the following Web site: hltD://www.lecinfo.ca.cov/calaw.html.
Date:
Signature of Property Owner or Authorized Agent
LICENSED CONTRACTOR'S DECLARATION JOB ADDRESS
I hereby affirm under penalty of perjury that I am licensed under LOCALITY
provisions of Chapter 9 (commencing with Section 7000) of
Division 3 of the Business and Professions Code, and my
//license is in full force and effect. HAZARDOUS MATERIAL DECLARATION
4ucense Class License N r+ ' Will the applicant or future building occupant handle a hazardous
//�� material or a mixture containing a hazardous material equal to or
DateontractorSignatur greater than the amount specified on the hazardous materials
information guide?
WORKERS'COMPENSATIO ACLARATION Yes ❑ No ❑
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION
COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN
EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO
ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION
TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED
FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND
ATTORNEY'S FEES.
I hereby affirm under penalty of perjury one of the following
declarations:
I have and will maintain a certificate of consent to self -
insure for workers' compensation, issued by the Director of
Industrial Relations as provided for by Section 3700 of the
Labor Code, for the performance of the work for which this permit
is issued.
Py No.
Z
I have and will maintain workers' compensation
insurance, as required by Section 3700 of the Labor Code, for
the performance of the work for which this permit is issued. My
workers' MZ en 4 0 insumn�eQc�Qi �i policy nvi
r
Carder Policy lumber /Y Expiration bate
Name of Agent Phone Number
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 become subject to the workers' compensation laws of
California, and agree that, if I should become subject to the
work! compensation provisions of Section 3700 of the Labor
�gd, I hall if with compl with those provisions
/l �// Y
ure Apphc'an "� Date
LOBBYIST ORDINANCE CERTIFICATION
Complete this section for permits in
Unincorporated Los Angeles County only
This is to certify that I, as permit applicant, am familiar with the
requirements of Los Angeles County Code Chapter 2.160 et seq.,
(relating to the Los Angeles County Lobbyist Ordinance) and that
all persons acting on behalf of myself complied and will continue
to comply therewith through the application process.
Applicant (Print Name) Applicant Signature
Company Name Date
Will the intended use of the building by the applicant or future
building occupant require a permit for construction or
modification from the South Coast Air Quality Management
District (SCAQMD)? See permitting checklist for guidelines.
Yes ❑ N o ❑ i
I have read the hazardous materials information guide and the
SCAQMD permitting checklist, I understand my requiremnts
under the Los Angeles County Code Title 2, Chapter ;0'
Sections 220.100 through 220.140 concerning hazardous
material reporting and for obtaining a permit from the SCAQMD.
ASBESTOS NOTIFICATION
❑ Notification letter sent to AQMD and/or EPA
❑ I declare that notification of asbestos removal is not
applicable to addressed project.
DECLARATION REGARDING CONSTRUCTION LENDING
AGENCY
I hereby affirm under penalty of perjury that there is a
Construction lending agency for the performance of the work for
which this permit is issued (Section 3097, Civil Code).
Lenders Name
Lenders Address
By my signature below, I certify to leach of the following:
I am the property owner or authorized to act on the
property owner's behalf.
I have read this application and the information I have
provided is correct.
I agree to comply with all applicable city and county
ordinances and state laws relating to building
construction.
I auth ' e representatives o county to enter the
abov -id ntified property for insp tion purposes.
Sig atu of Pr wnor thorized Agent
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