HomeMy Public PortalAbout5223 GOLDEN WEST AVE_Building_1/14/2015_L
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COUNTY OF LOS ANGELES
DEPARTMENT OF PUBLIC WORKS
BUILDIIu AND SAFETY / LAND DEVELOPMENT
AL ID:
15693 LT: 2
ESSOR INFORMATION NUMBER:
9-010-002
TEL. NO:
A EMILIO & CAROLINA (626) 780 -5369 -
GOLDEN WEST AV
917803247
.CANT: TEL. NO:
AS OWNER
AS OWNER
OR ENGINEER:
TEL. NO:
LIC. NO
TEL. NO:
LIC. N0:
NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP:
269 3 00
OF FAMILIES: DWELLING UNITS: APT/CONDI STAT CLASS:
0 NO 21
SCHOOL WITHIN HAZARDOUS
QUALITY: 1000 FEET MATERIALS
NO NO - NO
TEMPLE CITY # 0508
9701 LAS TUNAS
TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
NO. OF CONST
SQ. FT STORIES TYPE
STRUCTURE: VN
EXIST BLDG USE: RESID USE ZONE: R-1
EXIST OCC GRP:
BLDGS. NOW ON IAT: VALUATION:
10,000
FEE DESCRIPTION
AA BLDG PERMIT ISSUANCE
AH STATE GREEN BLDG FEE
AC STRONG MOTION RESID
D1 PLANCHECK W/O EN -HC
D2 PERMIT W/O EN -HC
REPORT ID: DPR261
FEES PAID
QUANTITY: DOM: AMOUNT
ROUTE TO: SS0508
BUILDING PERMIT
ALTERATION/REPAIR
BL 0508 1501140021
BUILDING ADDRESS:
5223 GOLDEN WEST AV
TEMP CA 917803247
NEAREST CROSS STREET: OLIVE
THOMAS PAGE: 597 GRID: A4 LOCALITY: TEMPLE CITY, C
ISSUED ON: PROCESSED BY:
01/14/15 SR
FINAL DATE FI AL H CODE:
DESCR PTION OF WORK
DEMO EXISTING CHIMNEY (BRICK), FIT 61WIDE SLIDING DOOR AND
CONCRETE STEPS
SPECIAL CONDITIONS:
APPROVALS DATE INSPECTOR SIGNATURE
LOCATION AND SETBACKS
SOILS ENGINEER APPROVAL r[��
FOUNDATION/TRENCH FORMS
SLAB/UNDER FLOOR
RAISED FLOOR FRAMING
27.80
UNDERFLOOR INSULATION
10000.00
FLOOR SHEATHING
VAL
1.00
I
I
10000.00
I
I
VAL
1.00
FIRE SPRINKLER HANGERS
10000.00
VAL
184.10
10000.00
VAL
216.60
TOTAL FEES
430.50
ROUTE TO: SS0508
BUILDING PERMIT
ALTERATION/REPAIR
BL 0508 1501140021
BUILDING ADDRESS:
5223 GOLDEN WEST AV
TEMP CA 917803247
NEAREST CROSS STREET: OLIVE
THOMAS PAGE: 597 GRID: A4 LOCALITY: TEMPLE CITY, C
ISSUED ON: PROCESSED BY:
01/14/15 SR
FINAL DATE FI AL H CODE:
DESCR PTION OF WORK
DEMO EXISTING CHIMNEY (BRICK), FIT 61WIDE SLIDING DOOR AND
CONCRETE STEPS
SPECIAL CONDITIONS:
APPROVALS DATE INSPECTOR SIGNATURE
LOCATION AND SETBACKS
SOILS ENGINEER APPROVAL r[��
FOUNDATION/TRENCH FORMS
SLAB/UNDER FLOOR
RAISED FLOOR FRAMING
UNDERFLOOR INSULATION
FLOOR SHEATHING
I
400E SHEATHING
I
I
SHEAR PANELS
I
I
FRAME INSPECTION
�l
FIRE SPRINKLER HANGERS
I
LATH/llRYWALL � �
LATH ll�
RATED WALL ASSEMBLIES
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 (J) 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 Contractor pursuant to the Contractors' State License
Law).
(_) I am exemdt 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 if it has not been constructed in its entirety by
licensed contractors. I understand that a copy of the applicable
law, Section 7044 of the Business and Professions Code, is
available upon request when this application is submitted or at
the following Web site: hffo://w .lecinfo.ca.cov/calaw.html.
Date:qq/�/
Signature P party Owwrfbr r Authorized Agent
II
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm under penalty of perjury that I am licensed under
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.
License Class License No.
Date Contractor Signature
WORKERS' COMPENSATION DECLARATION
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.
Policy No.
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' compensation insurance carrier and policy number are:
JOB ADDRESS
LOCALITY
HAZARDOUS MATERIAL DECLARATION
_ Will the applicant or future building occupant handle a hazardous
material or a mixture containing a hazardous material equal to or
greater than the amount specified on the hazardous materials
information guide?
Yes ❑ N o ❑
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 ❑ No ❑
I have read the hazardous materials information guide and the
SCAQMD permitting checklist, I understand my requirements
under the Los Angeles County Code Title 2, Chapter 320
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.
Carrier Policy Number Expiration Date DECLARATION REGARDING CONSTRUCTION LENDING
AGENCY
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 a ree that, if I should become subject to the
workers' corn satin provisions of Section 3700 of the Labor
Code, I sh hwit maty with those provisions
ignature of Applicant 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 at 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
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).
Lender's Name
Lender's Address
By my signature below, I certify to each 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 authorize representatives of this county to enter the
above-id=70w,
rty for inspection purposes.
Signaturener or Authorized Agent
Dille I — I j — I )