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HomeMy Public PortalAbout9707 BLACKLEY ST_Building__ APPLICATION FOR BUILDING-PERMIT F.OR APPLICANT TO FILL IN (Print or type only) EIRLID IIJ(. COUNTY'OF LOS ANGELES ADDRESS 22 D 7 G DEPARTMENT. OF COUNTY ENGINEER CITY ,t _` - ZIP 91 Z11 gp BUILDING AND SAFETY DIVISION �-I NO.OF BLDGS. BUILDING q SIZE OF LOT _77 X O�y NOW ON LOT ADDRESS '1707 0 Je- TRACT BLOCK LOT NO LOCALITY e M eC T y+ f TEL ^ NEAREST /� ' OWNER L/OIL 11 F— s NO. e� ;• 00 CROSS ST. cr- e(e - - dip - ASSESSOR ADDRESS g-70:7 MAP BOOK PAGE PARCEL ' /� "2172o -7(� DISTRICT GROUP- TYPE FIRE- PROCESSED BY CITY e („n j ZIP / / 3 CONST. ZONE ARCHITECT R TEL. �% O8 ENGINEERNO• -- _ _ _ STATISTICAL CLASSIFICATION SE R MAp ADDRESS CLASS NO. ', _DWELL,UNITS �PG_ O�aJYI NO, USE. ZONE MAP �� 6 CONTRACTOR LIC. ��„� NO.- - ADDRESS - NO. SPECIAL LIC. CONDITIONS CITY CLASS ROAD DEPARTMENT APPROVAL REQUIRED YES❑ NO ❑ CONSTRUCTION LENDER NAME AND BRANCH LOG.SETBACK FROM >. FRONT PROP,LINE OF (STREET)CITY a C:)ADDRESS _ HIGHWAY + YARD TOTAL SETBACK FROM TYPE OF EXISTING CJ SQ. FT NO. OF NO. OF- " CHECK 1 FRONT PROP. LINE HIGHWAY WIDTH SIZE STORIES FAMILIES ONE O + 20 = L ,9 �� U DESCRIPTION OF WORK NEW 1:1O a- ADD ❑ BLDG.SETBACK FROM ' N S E PROP. LINE OF (STREET) Z 2' aCie. ALTER _ TOTAL SETBACK FROM TYPE OF EXISTING In HIGHWAY + YARD - SIDE PROP. LINE HIGHWAY WIDTH REPAIR❑ USE OF + _ EXISTING BLDG, I^�S c'�Qy1l L� DEMOL ❑ APIT)N1T� NEOLae ` CORNER CUTOFF YES ❑ NO PRN ❑ (SIGNATURE) 1` / G7lo IN OPEN SPACE YES ❑ NO BY (R NT) ❑ IN COASTAL ZONE - YES ❑ NO ❑ - VALUATION1+Q r ©O CATEGORICAL EXEMPTION YES❑ NO ❑ 'A 1 HEREBY ACKNOW EDGE THAT I HAVE READ THIS APPLICATION ENVIRONMENTAL AND STATE THAT THE ABOVE IS CORRECT AND,AGREE TO COMPLY- IMPACT EXEMPTION'DECLARATION SIGNED (DATE) WITH ALL ORDINANCES AND LAWS REGULATING BUILDING CON- STRUCTION. I CERTIFY THAT IN DOING THE WORK AUTHORIZED IMPACT REPORT PROCESSED (DATE) HEREBY I WILL NOT EMPLOY ANY PERSON IN VIOLATION OF THE LABOR CODE OF T STATE OF CALIFORNIA IN RELATING TO WORKMEN'S COMPE SA ION INSURANCE SIGNATURE OF PERMITTEE_ - ADDRESS D e- //�� .FINAL B•Y CITY NOLO 00 DATEQ � � /1,1/�E CHECKS PA P:17'A13LE N FEE % FEE �-. e� HARVEY T. BCHECKS COUNTY ENGINEER > PLAN CHECK VALIDATION CK M o CASH" _ PERMIT VALIDAi N CK N+O CASH ! ('^ 17.3571 J113 1 -D5 ,G ON 76A638A CE#803 12/72 . .. '" 76A638A CE #803 31-69 .. ,APPLICATION FOR BUILDING PER rIT COUNTY­OF LADS ANGELES BUILDING 9;,d�. DEPARTMENT OF COUNTY ENGINEER ADDRESS • BUILDING AND SAFETY DIVISION LOCALITY / JOHN A. LAMBIE, COUNTY ENGINEER COLEMAN W. JENKINS, SUPT OF BUILDING NEAREST CROSS ST. - FOR APPLICANT,TO FILL IN DISTRICT NO GR 7YPE�c uss.: P o r (PRINT OR TYPE ONLY) 0 V BUILDING ��` STATISTICAL CLA SI (CATION SEWER MAP a ADDRESS /-r�.K.LE - CLASS NO. DWELL.UNITS. BI( PG LOT NO. �,�BLOCK USE ZONE MAP �J� N0. (J 7 " TRACT / SPECIAL N0. OF B DGS. } CONDITIONS SIZE OF LOT - NOW ON LOT f ,. USE OF EXISTING BLDG. �C I et4� BLDG. SETBACK FROM TEL. p S FRONT PROP. LINE OF (STREET) OWNER ) - N0. p�O�O/ �� TYPE OF EXISTING SETBACK HIGHWAY + - YARD = TOTAL ADDRESS O .tt it I-E '<_r, HIGHWAY WIDTH FROM C.L. "• CITY ! K �1 �V + ® O BLDG.S TBACK FROM ARCHITECT OR TEL. SIDE PROP. LINE OF (STREET) ENGINEER -, � N0. TYPE OF EXISTING SETBACK HIGHWAY '+ YARD'' = TOTAL ADDRESS HIGHWAY WIDTH FROM C.L. - TEL. _ CONTRACTOR E NO. - + - ADDRESS LIC. CORNER CUTOFF YES.,•❑ NO ❑ 0 LIC. i �. O i=. N ` p[ rADDRESS CLASS SEE REVERSE SIDE FOR'SPECIALh�4`P.P OV4L5'. O TRUCTION LENDER U AND BRANCHCL =. V) L_ T N0. OF NO. OF STORIES FAMILIES NEW !L USE OF ^' ADD STRUCTURE C — ALTER ❑ ��/q- a FN0AIrIQ � l?O-I )REPAIR ❑ 1••de,"r( £7Q- O- 7—,0.G O V4- AIA IJ�` •�' SIGNATURE OF MOL ❑ '� , APPLICANT �� 1:7A C'do �ya1) 1 r VALUATION $ ) APPROVALS DA E •INSPE R's s c ATURE P.C. PMT. FOUNDATION• LOCATION 9• /t- FEE $ FEE $ FORMS MATERIALS I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION FRAME: FIRE STOPS, , BRACING BOLTSAf AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY FURNACE: LOCATION, WITH ALL ORDINANCES AND LAWS REGULATING BUILDING CONSTRUC- GAS VENT DUCTS TION. I CERTIFY THAT IN DOING THE WORK AUTHORIZED HEREBY I WILL NOT EMPLOY ANY PERSON IN VIOLATION OF THE LABOR CODE LATH, INT. i OF THE STATE OF CALIFORNIA IN RELATING TO WORKMEN'S COM- - PENSATION INSURA�E. �' LATH, EXT. SIGNATURE OF �J//J, A HOUSE NUMBER CORRECT PERMITTEE 'f ^� ✓�' AND POSTED ADDRES`�-/ /- n7 1��" L FINAL JOHN F. LEWIS, PRINCIPAL ST URAL ENGINEER PLAN CHECK VALIDATION CK. M.O. CASH - PERMIT VALIDATION Ck• M.O. CASH [ APPLICATION FOR BUILDING PERMIT f1.1 V . .`1.•kCOUNTY OF LOS ANGELES, .: BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDI/G�ADDRESS,,/��(J� BUILDING ADDRESS Jt_�.G�.��I-if�C.l.2 I hereby affirm that I have a certificate of consent to self Insure, or a certificate of Workers' Compensation Insurance, or.a certified 9707 BIACKI-TIY copy thereof(Sec 3800, Lab.C) - CITY E. CITY 11 ZIP. 91780 LOCALITY Policy NO 1046140 Company STATE FUND SIZE OF LOT NO OF BLDGS NOW ON LOT ❑ Certified copy is hereb NEAREST CROSS . gl Certified copy is file with the CO my budding ins Ion TRACT BLOCK. LOT NO department. USE ZONE MAP NO - .1, -ASSESSOR MAP BOOK PAGE - PARCEL Date ApplicantSPECIAL CONDITIONS r, / CERTIFICATE-OF EXEMPTION FROM WORKERS' JOHN CORDES 2�$L O90- YES NO COMPENSATION INSURANCE WITHIN,1000 FT OF SCHOOLS (This section need not be completed If the permit Is for one hundred ADDRESS dollars ($100)or less) ' 9707 B1*CKLEY DISTRICT GROUP TYPE CONST FIRE ZONE PROCESSED BY CITY ZIP I certify that In the performance of the work for which this permit TEMPLE CITY 91780 Is Issued, I shall not employ any person In any manner so as to ARCHITECT OR ENG( EER TEL NO �' '-t"�° f Rs���✓ become Subject t0 the Workers;Compensation Laws. STATISTICAL,C IIFICATION APT CONDO Date Applicant ADDRESS CLASS I' Ste- DWELL UNIT NOTICE TO APPLICANT. If, after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST. Exemption, you should become subject t0 the Workers' CONTRACTOR TEL NO SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith RANDOL ROOFING 288-4040 FRONT comply with such provisions or this permit shall be deemed revoked ADDRESS - LIC NO P L 529 EAST VALLEY• BLVD -451937 SIDE LICENSED CONTRACTORS DECLARATION CITY LIC �fSS P L I hereby affirm that I am licensed underprovisions of,Chaptdr 9 SAN GABRIEL c- y SEWER MAP (commencing with Section 7000)of Division 3 of the Business and SQ FT SIZE NO OF STORIES NO OF FAMILIES Professions Code,and my license Is In full force and effect NEW ❑ BK PG a License Number 451437 Lic Class c-39 DESCRIPTION OF WORK ADD ❑ VALUATON O RANDOLROOFING 1-31-96 REROOF HOUSE A1TD GARAGE WITH $ 0 Contractor ate t ALTER ❑ ❑i am exempt under sec _— `-- -_- - -_-__ y 25- r CLASS A FIBERGLAS REPAIR ❑ Irs � O B&P C.forp eason = _ �� LIJ _ DEMOL_.❑___$ I �, < F-� 'SHIN . TEAROFF-EXISTING.-R00 V Date. USE OF EXISTING BLDG• URM ❑ Signa ure, _ APPLICANT(PRINT) TEL NO LDMA Perm# 1,. Z r ❑ I, as owner of the property, r �Vvees with wages as z ACCT e 8 their sole compensation, will do the work and the structure is ADDRESS not intended.or offered for sale (Section 7044, Business and FINAL DATE Q 335Q, 126.05 9 • Professions Code) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL — 1 ITEMS ❑ I, as Owner of the property, am exclusively COgtractln I�� OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE p p y, y g'w y - AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDEI FINAL BY ;j licensed contractors to construct the project Action* 7044' Business and Professions Code) YfS Cl` No❑ TOTAL 126� (31 WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING CHECK 126.05 OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH (J CONSTRUCTION LENDING AGENCY COAST GUIDuE AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR CHANE I hereby affirm that there Is a construction lending agency for YES❑ NO❑ n�� a the performance of the work for which this permit Is Issued(Sec � I HAVE READ THE HAZA�DOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING (�-Ullo�}n 1 ' 3097, CIV.C.) CHECKLIST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, � i +1, y,� N TITLE 2,CHAPTER 2'20 SECTIONS 2 20 100 THROUGH 2 20 140 CONCERNING HAZARDOUS - W U U ll h Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD ' o Lender's Address 4133 1 AM 11 e c 1 OWNER OR AGENT o I certify that I have read this application and state under penalty 0 of perjury that the above informa on Is co, t I agree to comply PC FEE PERMIT•FEE /f� ,(i $ II county ordinances tate aw�relating to budding O ' 'l • a constr tion, and hereby aut re ese atives of this County ISSUANCE FEE V m to enter pon the above- d pro rt or Inspection pur oses. INVESTIGATION FEE TOTAL FEE SC-1 01 IP11 1 a Ag- SEE REVERSE FOR`EXPLANATORY LANGUAGE tri WORKERS' COMPENSA71QN DECLARATION hereby affirm that I ,have a certificate of consent to Self APPLICATION FOR BUILDING P E RSA I T insure, or a certificate of Workers'Compenstion Insurance, or , a certified copy thereof (Sec 3800, Lab C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY . Policy No Company ❑ Certified copy .s hereby furnished FOR APPLICANT TO FILL IN BUILDINGADDRESS Certified copy is filed wifh the county building i'nspec- r BUILDING /1 / tion department 1 ADDRESS 7C �'I1-L. LOCALITY NEAREST `Date Applicant CITY 1,Q Q, L-� ZIP CROSS ST CERTIFICATE OF EXEMPTION FROM WORKERS' 11'' F O' OF BLDGS ASSESSOR ' COMPF EXEA TIbN FROM E - y. SIZE OF LOT 7� Xp/ �I !r -NOW ON LOT MAP BOOK PAGE PARCEL (This section need not be completed if the permit is for one - IUSEONE MAP hundred dollars ($100) TRACT BLOCK LOT NO O or less.) , TEL SPECIAL r I T s f I certify'thaf in,the performance of the work for which this OWNER .J C7 +" (?$' NO �"' CONDITIONS - �_ permit.is issued, I shall not employ any person,in any manner G '� GROUP TYPE FIRE E BY U so as to become subject to the Workers'Compensation Laws ADDRESS CZ c i©� Ji ,p CO ^, Li Q ��� `�1.7� LSC CITY ih �C ZIP � � !Q U 1_ Date ,d Applicants—erF �� STATISTICAL CLASSI ACATION APT ' CONDO (J Ce NOTICE TO APPL CANT If, after making this Certificate of ARCHITECT'OR TEL W Exemption, you should become subject to the Workers' t ENGINEER r NO 'CLASS NO�DWELL UNITS N Compensation provisions of the Labor Code, you must forth- ADDRESS SEWER MAP Z with comply with such, provisions or this permit shall be TEL ,� VALIDATION' deem ed'revoked. CONTRACTOR NO BK Z— PG• 7, ,LICENSED CONTRACTORS DECLARATION e LIC I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS; . NO VALUATION (commencing with Section 7000)of Division 3 of the Business and LIC Professions'Code, and my license is m'full force and effect CITY CLASS $ SQ FT .7,; NO OF NO OF CHECK License Number Lic Class SIZE /6 STORIES FAMILIES- NE y/ ae $ Contractor Date D S RIPTIOD4 OF WOR S�^�L�.? N •1,a,m exempt from the licensing,requirements as I am a It ty P11 :7 O ADD 'licnsed architect or a registered professional engineer ! �/ ALTER , ❑ FINAL .'acting in my professional capacity (Section 7051, .� p°i.GQ�L r , ❑ DATE f71 Business and Professions Code). REPAIR EXISTING BLDG g^.: By OL Lic.or Reg. No. Date APPLICANT, TEL EM - .�„ OWNER-BUILDER DECLARATION (PRINT) r NO.i-r� I hereby affirm thot,l am exempt from the Contractor's License Law for the following.reason (Section_7031.5, Business and ADDRESS 9707- ^ r1 Professions Code) PRESENT y /�� �`� a/'� .-93-82 0 r1 ' BUILDING 1, / 1, as owner of the property, or my employees with- -ADDRESS i wages as their sole compensation, will do the work and # o'0 0 0 0 1, the structure is not intended or offered for sale(Section LOCALITY 7044,•Business and Professions Code). MOVING TEL- 2 ? 2:7 1. 0 0 I•, as•owner of the property, am exclusively contracting CONTRACTOR NO 471Z'a119 ezC j with licensed contractors,to construct the project (Sec- ADDRESS (o - 2i7 1, C 0�I tion 7044;Business and Professions Code). REQUIRED TOTAL SETBACK FROM EXIST / O '1.2 1 —8 1 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 Q (Sec. 3097, Ctv C.). - SIDE Lender's Name P LtA ?� / �. P C Fee / "'� '`' Permit Fee _ Lender's Address I certify that I have read this application and state that the7 Issuance Fee aabove information is correct I agree'to comply with all County Investigation Fee 0 ordinances and State laws relating to,building construction, Total Fee and'hereby authorize representatives of this County to enter a up o above- enttoned property for inspection purposes. a r SEE REVERSE FOR EXPLANATORY LANGUAGE !' ignoture of Applicant or Agent Dat - OP s