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Home My Public Portal About9477 Blackley St_Building_5/16/2013_COUNTY OF LOS ANGELES DEPARTMENT OF PUBLIC WORKS BUILDING AND SAFETY./ LAND DEVELOPMENT LEGAL ID. ON FILE ASSESSOR INFORMATION NUMBER: 8590-004-014 CHE, CHAY C 4320 GROSSVALE AVE EL MONTE CA 91733 CHAN, SIMON 5338 N BURONT AVE SAN GABRIEL CA 91776 SL BUILDERS 980 ARAGON CIR SUITE 2 VENA PARK CA 90620 OR ENGINEER: TEL. NO: TEL. NO: (626) 318-9839 TEL. NO: (714) 801 -2859 - LIC. NO 982802 TEL. NO: LIC. NO: TEMPLE CITY # 0508 9701 LAS TUNAS TEMPLE CITY CA 91780 PHONE: (626) 285-0488 EXT: NO. OF CONST NEW SQ. FT STORIES TYPE OCCUP GROUP STRUCTURE: 1696 2 V -B R3 GARAGE: . OTHER: 40 1 V -B U EXIST BLDG USE: USE ZONE: EXIST OCC GRP: JBLDGS. NOW ON LOT: VALUATION: 227,940 NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP: 3 001 OF FAMILIES: DWELLING UNITS: APT/COND: STAT CLASS: 0 NO 21 SCHOOL WITHIN HAZARDOUS QUALITY: 1000 FEET MATERIALS NO NO NO I FEES PAID FEE DESCRIPTION: QUANTITY: DOM: AMOUNT 81 PLANCHECK W/ENERGY 227940.00 VAL 1,995.00 AA BLDG PERMIT ISSUANCE 27.80 AB STATE GREEN BLDG FEE 227940.00 VAL 10.00 AC STRONG MOTION REBID 227940.00 VAL 22.80 B2 PERMIT W/ENERGY 227940.00 VAL 2,347.00 08 CERTIF OF OCCUPANCY 101.40 TOTAL FEES 4,504.00 • ADDITIONAL DATA ON FILE ID: DPR261 ROUTE TO: BS0508 BUILDING PERMIT RESIDENTIAL ADD/ALT/REP BL 0508 1302040054 BUILDING ADDRESS: 9477 BLACKLEY ST TEMP CA 917803158 NEAREST CROSS STREET: THOMAS PAGE: 596 GRID: J4 LOCALITY: TEMPLE CITY, C ISSUED ON: PROCESSED BY: 05/16/13 SR F (NNALL DATES FINAL BY: CODE: SCRIP�ON OF WORK �� 1ST: FLOOR INTERIOR REMODEL 1012 SF. AND 571 SF. ADDITION KITCHEN, BEDRM, 1.5 BATHRM, LAUNDRY RM, FAMILY RM. 907 SF. 2ND: FLOOR ADDITION 3 BEDRMS, 2 BATHRMS, PORCH 40 SF. AND SPECIAL CONDITIONS: COVENANT RECORDED LOCATION AND SETBACKS SOILS ENGINEER APPROVAL FOUNDATION/TRENCH FORMS 1 SLAB/UNDER FLOOR RAISED FLOOR FRAMING UNDERFLOOR INSULATION IST LEVEL FLOOR SHEATH j 2ND LEVEL FLOOR SHEATH ROOF SHEATHING FIRE DEPT. FRAME INSPECT BLDG DEPT. FRAME INSPECT SHEAR PANELS INSULATION/WEATHER STRIP INTERIOR LATH/DRYWALL EXTERIOR LATH [OT DRAINAGE SMOKE DETECTION DEVICES ?IRE DEPARTMENT APPROVAL DATE INSPECTOR SIGNATURE VVV I V OWNER -BUILDER DECLARATION LICENSED CONTRACTOR'S DECLARATION JOB ADDRESS 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 Contr<hCtor pursuant.to the Contractors' State License Law). (J 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 whicf] 1 must have resided for at least one year prior) to completiory 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: htto://www.leoinfo.ca.aov/calaw.htmi. Date: Signature of Property Owner or Authorized Agent 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. —ic�ense Class License No. '/+ /7Dater2�_ontractor Signature WORKERS' COMPENSA ON 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: Carder Policy Number Expiration Date Name of Agent Phone Number I certify that, in the performance of the work for which this ermit 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 workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith /com�ply, with those provisions /5�6/hs/7te at of AppIcant 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 appllcati n process. 2orn'Pany lri arae pplicant Sigdature ame Date 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 ❑ No ❑ 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 ❑ Ro ❑ 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 220 Sections 220.100 through 220.140 concerning hazardous material reporting and for obtaining a permit from the SCARMD. 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). 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 owners 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 -identified property for inspection purposes. Signature of arty Owner or Authorized Ag/apt COUNTY OF LOS ANGELES DEPARTMENT OF PUBLIC WORKS BUILDING AND SAFETY ./ LAND DEVELOPMENT LEGAL ID: ON FILE ASSESSOR INFORMATION NUMBER: 8590-004-014 TENANT TEL. NO: CNE, CRAY C 4320 GROSSVALE AVE EL MONTE CA 91733 APPLICANT: TEL. NO: CHAN, SIMON (626) 318-9839 5338 N BURONT AVE SAN GABRIEL CA 91776 ONTRACTOR: TEL. NO: SL BUILDERS (714) 801-2859- 980 ARAGON CIR SUITE 2 LIC. NO DENA PARK CA 90620 982802 OR ENGINEER: TEL. NO: LIC. N0: MAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP: 3 00 N0. OF FAMILIES: DWELLING UNITS: APT/GOND: STAT CLASS: 0 NO 21 1 SCHOOL WITHIN HAZARDOUS AIR QUALITY: 1000 FEET MATERIALS 1 NO NO NO TEMPLE CITY 4800.00 # 0508 BUILDING PERMIT 9701 LAS TUNAS I ) T) SLAB/UNDER FLOOR)1 RESIDENTIAL ADD TEMPLE CITY CA 91780 4800.00 ONDEAFLOOR INSOLATION BL 0508 1302040055 PHONE: (626) 285-0488 EXT: 2ND LEVEL FLOOR SHEATH I 1 VAL NO. OF CONST NEW BUILDING ADDRESS: SQ. FT STORIES TYPE OCCUR GROUP 9477 BLACKLEY ST :UCTURE: 0 2 V -B R3 I TEMP CA 917803158 GARAGE: 60 1 V -B U I NEAREST CROSS STREET: OTHER: I THOMAS PAGE: 596 GRID: J4 LOCALITY: TEMPLE CITY, C '.ST BLDG USE: USE ZONE: ISSUED ON: PROCESSED BY: ST OCC GRP: 105/23/13 SR GS. NOW ON LOT: VALUATION: FINAL BY: CODE: 4,800 1�FjNALD II FEES PAID DESCRIPTION: QUANTITY: UOM PLANCHECK W/O EN -HC 4800.00 SOILS ENGINEER APPROVAL VAL BLDG PERMIT ISSUANCE I ) T) SLAB/UNDER FLOOR)1 STATE GREEN BLDG FEE 4800.00 ONDEAFLOOR INSOLATION VAL STRONG MOTION OTHER 4800.00 2ND LEVEL FLOOR SHEATH I 1 VAL PERMIT W/0 EN -HC 4800.00 FIRE DEPT. FRAME INSPECT VAL TOTAL FEES � ADDITIONAL DATA ON FILE ID: DPR261 ROUTE TO: BS0508 Lj1ID SCRIPTION OF WORK I(E) DETACHED GARAGE TO BE EXPANDED INTO 201X20' INTERIOR AMOUNT:IDIMENSION. (E) ENCLOSED PATIO TO BE REDUCED & CONVERTED BACK 11NTO COVER PATIO 270 SF. (E) WORKSHOP PLUMBING TO REMOVE 112.70 1 27.80 1SPECIAL CONDITIONS: 1.00 1.00 132.60 1 275.10 1APPROVALS DATE INSPECTOR SIGNATURE LOCATION AND SETBACKS SOILS ENGINEER APPROVAL FOUNDATION/TRENCH FORMS' I ) T) SLAB/UNDER FLOOR)1 RAISED FLOOR FRAMING ONDEAFLOOR INSOLATION 1ST LEVEL FLOOR SHEATH 2ND LEVEL FLOOR SHEATH I 1 200E SHEATHING FIRE DEPT. FRAME INSPECT 1 3LDG DEPT. FRAME INSPEC) SHEAR PANELS CNSULATION/WEATHER STRIP INTERIOR LATH/DRYWALL 3XTERIOR LATH AT DRAINAGE iMOKE DETECTION DEVICES SIRE DEPARTMENT APPROVAL I 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 U 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 Contr9 or pursuanL.to the Contractors' State License Law). UI 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 prior) to 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: htto://www.iecinfo.ca.aov/calaw.html. Date: Signature of Property Owner or Authorized Agent 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. d - License Class � License No.ON/ / 820 O' Z ontractor 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: Carder Policy Number Expiration Date 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 workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions ,,--� �^ �� 05.2 •/ a% Sim ure oft 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. �C (,'H5l�1A) LA 84 Applicant Pnnt arae) nt Signature Company Name Date JOBADDRESS' ' 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 220 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 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 -identified property for inspection purposes. Signature o rop�ner or.A Agent ate, S•Z"�./� r _ COUNTY OF LOS ANGELES TEMPLE CITY # 0508 DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS BUILDING AND SAFETY '/ LAND De VELOPMENT TEMPLE CITY CA 91780 PHONE: (626) 285-0488 EXT: LEGAL ID: NO. OF CONST NEW ON FILE SQ. FT STORIES TYPE OCCUR GROUP STRUCTURE: 1052 2 V-B R-3 ASSESSOR INFORMATION NUMBER: GARAGE: 8590-004-014 OTHER: TENANT: USE ZONE: R-1 OWNER: TEL. NO: JBLDGS. NOW ON LOT: VALUATION: CHE, CRAY C - 141,389 4320 GROSSVALE AVE EL MONTE CA 91733 FEES PAID FEE DESCRIPTION: QUANTITY: DOW: RMOUNT:j APPLICANT: TEL. NO: LAM, CHSUNG (714) 801-2859- JAA BLDG PERMIT ISSUANCE 27.80 6980 ARAGON CIR p2 JAB STATE GREEN BLDG FEE 141389.00 VAL 6.00 BUENA PARK CA 90620 JAC STRONG MOTION RESID 141389.00 VAL 14.10 IB1 PLANCHECK W/ENERGY 141389.00 VAL 1,464.20 IB2 PERMIT W/ENERGY 141389.00 VAL 1,722.60 CONTRACTOR: TEL. NO: TOTAL FEES 3,234.70 CSL BUILDERS (714) 801-2859- 6980 ARAGON CIR SUITE 2 LIC. NO BUENA PARK CA 90620 982602 ARCHITECT OR ENGINEER: TEL. N0: LIC. NO MAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP: 3 01 NO. OF FAMILIES: DWELLING UNITS: APT/COND: STAT CLASS: 1 NO 01 SCHOOL WITHIN HAZARDOUS AIR QUALITY: 1000 FEET MATERIALS NO NO NO ID: DPR261 ROUTE TO: BS0508 BUILDING PERMIT NEW RESIDENTIAL BL 0508 1308140019 BUILDING ADDRESS: 9477 BLACKLEY ST TEMP CA 917803158 NEAREST CROSS STREET: THOMAS PAGE: 596 GRID: J4 LOCALITY: TEMPLE CITY, C ISSUED ON: PROCESSED BY: 08/14/13 SR FINAL DATE FINAL BY: CODE: r§r-v14 DE CRIPTZON OF WORK DEMOLISH EXISTING DAMAGED WALLS & REBUILD IN SAME LOCATION TO SUPPORT NEW 2 -STORY SFD TOTAL 4 BEDROOMS 3 BATHROOMS AND POWDER SEE ALSO BL 1302040054 SPECIAL CONDITIONS: FIRE SPRINKLERS REQUIRED APPROVALS DATE INSPECTOR SIGNATURE LOCATION AND SETBACKS SOILS ENGINEER APPROVAL FOUNDATION/TRENCH FORMS SLAB/UNDER FLOOR RAISED FLOOR FRAMING EVEL FLOOR SHEATH SHEATHING BLDG DEPT. FRAME INSPECTS SHEAR PANELS INSULATION/WEATHER STRIP INTERIOR LATH/DRYWALL I EXTERIOR LATH LOT DRAINAGE SMOKE DETECTION DEVICES FIRE DEPARTMENT APPROVAL I I 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 1, 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 Contr'agtor pursuant.to the Contractors' State License Law). ' (_) 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 p6orl to 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: hftD://www.leoinfo.ca.00v/calaw.htmi. Date: Signature of Property Owner or Authorized Agent 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. lcense Class _F License No. S Z g d 2 Date �aontractor Signature WORKERS' COMPE ON 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 -AIsurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My Keromge� nsatipn ins ��//ce tamer �d policy are: /Carrier !t ''! Polic�um� F�cpiration Date 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 workers' c�n provisions o Section 3700 of the Labor Code, I shall fo comply with those provisions oe rialure of Applicant Date v 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 IJOB ADDRESS I 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 220 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). 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 -identified property for inspection purposes. Signatur Prope wltier or Authorized A COUNTY OF LOS ANGELES DEPARTMENT OF �'USIJC WORKS BUILDING AND SAFETY / LAND DEVELOPMENT LEGAL ID: ON FILE ASSESSOR INFORMATION NUMBER: B590-004-014 TENANT: 3WNER: TEL. NO: CHS, CRAY C - 4320 GROSSVALE AVE EL MONTE CA 91733 APPLICANT: TEL. NO: HO, JENNY (626) 308-9155- 320 W CLARY AVE SAN GABRIEL CA 91776 CONTRACTOR: TEL. NO: A H ACCORD GROUP INC (626) 308-9155- 320 W CLARY AVENUE LIC. NO SAN GABRIEL CA 91776 757675 ARCHITECT OR ENGINEER: TEL. NO: LIC. NO: MAP 140: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP: 00 NO. OF FAMILIES: DWELLING UNITS: APP/COND: STAT CLASS: NO 20 SCHOOL WITHIN HAZARDOUS AIR QUALITY: 1000 FEET MATERIALS NO NO NO TEMPLE CITY # 0508 BUILDING PERMIT 9701 LAS TUNAS FIRE SPRINKLER TEMPLE CITY CA 91780 BL 0508 1311050099 PHONE: (626) 285-0488 EXT: NUMBER OF ADDED/RELOCATED BUILDING ADDRESS: SQ. FT SPRINKLER HEADS 22 9477 BLACKLEY ST STRUCTURE: 2748 TEMP CA 917803158 NEAREST CROSS STREET: THOMAS PAGE: 596 GRID: J4 LOCALITY: TEMPLE CITY, EXIST BLDG USE: JISSUED ON: PROCESSED BY: EXIST OCC GRP: 11/05/13 SR ( BLDGS. NOW ON IAT: VALUATION: FINAL DATE FINAL BY: CODE: 3,900q / FEES PAID D IPTIONOF WORK NEW FIRE SPRINKLER SYSTEMS FEE DESCRIPTION: QUANTITY: DOM: AMOUNT: AA BLDG PERMIT ISSUANCE 27.80 AB STATE GREEN BLDG FEE 3900.00 VAL 1.00 SPECIAL CONDITIONS: DO FIRE SPRINKLER PC 3900.00 VAL 98.40 D2 PERMIT W/O EN -HC 3900.00 VAL 115.80 TOTAL FEES 243.00 (APPROVALS DATE INSPECTOR SIGNATURE ID: DPR261 ROUTE TO: BS0508 7IRE DEPARTMENT 7IRE SPRINKLER H 7IRE DEPARTMENT OWNER -BUILDER DECLARATION LICENSED CONTRACTOR'S DECLARATION I JOB ADDRESS 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 U 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). 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 pricrito 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: httD://www.leainfo.ca.aov/calaw.html. Date: Signature of Property Owner or Authorized Agent 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 Clasgi6 License No. -7 � 7 4PT- ,—,Date I i -t 1 Contractor Signature - 1� WORKERS'COMPENSA D ON WANING: 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 c Tier and olic umbe are .�..� h12D(, az I Career Pdlicy Number Ex iratior Date 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 workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions T 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 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 ❑ No ❑ 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 requirements under the Los Angeles County Code Title 2, Chapter 220' 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). 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 owners 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 -identified property for inspection purposes. Signature of Property Owner or Authorized Agent