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HomeMy Public PortalAbout9987 BOGUE ST_Building__ •APPLICATION. F R BUILDING PERMIT BUILDING FOR APPLICANT TO-FILL IN ADDRESS BUVLDING �` n ADDRESS / � ,J V LOCALITY ry -7 p NEAREST CITY �L/� C% ZIP I /p O CROSS ST f7 NO OF.'BLDGS ASSESSOR SIZE OF LOT �(/� / NOW ON LOT'. -MAP BOOK PAGE PARCEL Lf DISTRICT GROUP TYPE, FIRE RO SED BY TRACT T: BLOCK LOT NO Og CONST ZE .TEL OWNER ISiC l L Ih NO (�74 ' STATISTICAL CLASSIFICATION SEWER MAP ADDRESS "F �_. �,�.f' b. .�: ' lT L� CLASS NO �—DWELL UNITS BK PG CITY - fLi� �C < ,ZIP {•/ L 5 �+` USE ONE MAP ARCHITECTOR TEL'- ' NO , Q ENGINEER NO SPECIAL R�� NDITIONS m ADDRESS j f.; ROAD DEPARTMENT APPROVAL REQUIRED YES ❑ NO❑ TEL CONTRACTOR,0 ��L�!LNO BLDG-SETBACK FROM LIC FRONT-PROP LINEOF (STREET) 'ADDRESS NO HIGHWAY + YARD = TOTAL SETBACK FROM TYPE OF EXISTING LIG FRONT PROP LINE iHIGHWAY WIDTH CITY CLASS- _ CONSTRUCTION LENDER + CL } NAME AND",BRANCH BLDG SETBACK FROM' ADDRESSCITY SIDE'PROP LINE OF STREET( Q SQ FT NO OF NO OF- CHECK HIGHWAY + YARD = TA TBACK FROM TYPEOF EXISTING - SIZE D O STORIES . FAMILIES ONE DE PROP LINE HIGHWAY WIDTH. N Z DESCRIPTION OF WORKNLf} L 1'�t NEW ❑ +' %V. ADD ® CORNER CUTOFF YES ❑ NO ❑ ; ALTER ❑ IN OPEN SPACE YES ❑ NO ❑' REPAIR ❑ USE OF ❑ INCOASTAL-PERMIT ZONE, YES NO Q EXISTING BLDG DEMOL,' APPLICANT _ TEL, ' 4 (PRINT) NO BY(SIGNATURE) (`HEREBYACKNOWLEDGE'THAT I HAVE READ THIS-APPLICATION-AND STATE THAT THE ABOVE IS CORRECT.AND"AGREE TO COMPLY WITH ALL ORDINANCES - AND LAWS REGULATING BUILDINGCONSTRUCTION CERTIFY THAT IN DOING THE WORK'AUTHORIZED HEREBY WILL NOT-EMPLOY-ANY PERSON'IN VIOLATION OF THE LABOR CODE OF,THE STATE OF CALIFORNIA IN,RELATING TO WORKMEN'S COM-, PENSATION INSURANCE' - .. _ � 4 SIGNATURE OF Z`( FINAL (/�' BY PERMITTEE- DATE i ADDRESS Permit Fee rr��c4� P.C. Fee$' CITY�• �•` NO - Issuance Fee VALUATION ) 1 of Fee PLAN CHECK-VALIDATION- C'K. M..0. CASH' PERMIT VALI TcK M.O. CASH ©S '76A6388'CE X80313 6/76 - ' 76A638A CE #803 1/71 4 k ' APF?LICATION FOR BUILDING PERMI • r COUNTY OE/L'I tS ANGELES' ASSESSOR DEPARTMENT OF 0 UNTY ENGINEER MAP BOOK PAGE PARCEL BUILDING AND SAFETY DIVISION BUILDING ADDRESS COLEMAN W. JENKI'NS, SUPT OF BUILDING LOCALITY FOR APPLICANT TO.FILL IN NEAREST Print ort a only) CROSS ST. DISTRICT NO GROU TYPE R S D B ADD EBUILDISSNG r J2 .7,_ D CONST, STATISTICAL LASSIFIOATION SEWER MAP. LOT NO. �, BLOCK . CLASS NO.al_DWELL,UNITS B TRACT USE ZONE MAP i1 i NO.OF BLDGS. NO. C) SIZE OF LOT NOW ON LOT SPECIAL USE OF. , CONDITIONS EXISTING BLDG. TEL. OWNE NO BLDG.SETBACK FROM ADDRESS 2E&G G/ FRONT PROP.LI NE OF (STREET) •� TYPE OF EXISTING SETBACK HIGHWAY } YARD = TOTAL CITY - HIGHWAY WIDTH FROM C.L.to L ARCHITECT R TEL, r } _ ENGINEER NO. BLDG.SETBFROM ADDRESS SIDE PROP. LI (STREET) TEL TYPE OF EXISTING SETS HIGHWAY } YARD = TOTAL CL. HIGHWAY WIDTH FROM C.L. CD NO, C7 LIC. ADDRESS NO. LIC. U CITY CLASS CORNER CUTOFF YES E] O ❑ Iy CONSTRUCTION LENDERn- NAME AND BRANCH SEE REVERSE SIDE FOR SPECIAL APPROVALS ADDRESS SQ,. FT. NO. OF NO. OF NEW SIZE STORITES FAMILIES USE OF ADD ❑ STRUCTURE •��/�, BrL �'' (� �� ALTER ❑ . REPAIR❑ SIGNATURE O APPLICANT OEMOL ❑ VALUATION $ APPROVALS DATE INSPECTOR'S SIGNATURE P,C. PMT. FOUNDATION: LOCATION �j Q�� FEE S FEE $ FORMS, MATERIALS J-s3d yy V), 0 2' ,14 FRAME: FIRE STOPS, ` 1-'HERESY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION BRACING, BOLTS AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY FURNACE: LOCATION, WITH ALL •ORDINANCES, AND LAWS REGULATING BUILDING CON- STRUCTION ON- GAS VENT, DUCTS STRUCTION.I CERTIFY THAT IN DOING THE WORK AUTHORIZED HEREBY I WILL NOT EMPLOY ANY PERSON IN VIOLATION OF THE LATH, INT. LABOR CODE OF THE STATE OF •CALIFORNIA�INREL ING O WORKMEN'S C MPE ATION INSURANCE. L. LATH, EXT. SIGNATURE OF / HOUSE NUMBER COR- RECT AND POSTED ADDRESS ` FINAL ' PLAN CHECK VALIDATION CK M 0 CASH JOHN F. LEWIS PRI CIPAL ST R RAL ENGINEER PERMIT VALIDATION CK MO CASH 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 1209100046 PHONE: (626) 285-0488 EXT: ILEGAL ID I NO. OF CONST I BUILDING ADDRESS: ITR: 14984 LT- 2 1 SQ. FT STORIES TYPE I 9987 BOGUE ST 1 I (STRUCTURE: 4 V-B I TEMP CA 917802606 1' (ASSESSOR INFORMATION NUMBER: I NEAREST CROSS STREET: BALDWIN 18588-014-024 I THOMAS PAGE. 597 GRID: A3 LOCALITY: TEMPLE CITY, Cl I I I I (TENANT: IEXIST BLDG USE: DETAC USE ZONE: R-1 (ISSUED ON: PROCESSED BY: IEXIST OCC GRP: 109/10/12 SR I I I I (OWNER: TEL.- NO: IBLDGS. NOW ON LOT: VALUATION: IF AL DATE FIN L BY: CODE: ICHANG, JEFFREY (626) 285-5275- 1 1,000 1 19987 BOGUE ST - j 1 0- _ ITEMP 917802606 I FEES PAID JDASCRIPTION OF WORK • I IREMOVE OLD CAL SHAKE ROOF INSTALL 7/16 OSB BOARD 1 LAYER 30 I _IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT: ILB FELT INSTALL 30 YR COMPOSITION SHINGLES DETACHED GARAGE 1 (APPLICANT: TEL. NO: I I IAJ HARDING CONSTRUCTION (909) 949-2292- 1AA BLDG PERMIT ISSUANCE 27.80 I 11179 E 9TH ST IAB STATE GREEN BLDG FEE 1000.00 VAL 1.00 ISPECIAL CONDITIONS: (UPLAND, CA 91786 1AC STRONG MOTION RESID_ 1000.00 VAL 0.50 ID2 PERMIT W/O EN-HC'" 1000.00 VAL 65.40 _I TOTAL FEES 94.70 ICONTRACTOR: - TEL NO: 1 IAPPROVALS DATE INSPECTOR SIGNATURE 1 IAJ HARDING CONSTRUCTION, INC. (909) 949-2292- 1 _ 11179 EAST 9TH STREET LIC. NO (LOCATION AND SETBACKS 1 (UPLAND CA 91786 913191C-39 I I (SOILS ENGINEER APPROVAL (ARCHITECT OR ENGINEER: TEL. NO: IFOUNDATION/TRENCH FORMS I I I LIC. NO: I (SLAB/UNDER FLOOR I I (RAISED FLOOR FRAMING IMAP NO- SEWER MAP BOOK: PAGE: FIRE ZONE: CMP. J (UNDERFLOOR INSULATION I I 1147H269 3 001 " I I I _ IFLOOR SHEATHING INO. OF FAMILIES: DWELLING UNITS: APT/COND: STAT CLASS: I I I /� 0 NO 21 (ROOF SHEATHING SCHOOL WITHIN HAZARDOUS ISHEAR PANELS I IAIR QUALITY: 1000 FEET MATERIALS I NO NO NO - _ IFRATlE INSPECTION . IFIRE SPRINKLER HANGERS I I I I I I INSULATION/WEATHER STRIPI I I I I I I (INTERIOR LATH/DRYWALL I I I I I I I I IEXTERIOR LATH I I I I I I I I I (RATED FLOOR/CEIL ASSEM. I IRATED WALL ASSEMBLIES I IRATED SHAFTS/OPENINGS I I I I I I IT-BAR CEILINGS I ILOT DRAINAGE I I I I I I I REPORT ID: DPR261 ROUTE TO: BS0508 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 1209100044 PHONE: (626) 285-0488 EXT: ILEGAL ID: NO. OF CONST BUILDING ADDRESS: ITR: 14984 LT: 2 SQ. FT STORIES TYPE 9987 BOGUE ST ' STRUCTURE. 20 V-B TEMP CA 917802606 ASSESSOR INFORMATION NUMBER: - NEAREST CROSS STREET: BALDWIN 18588-014-024 i i THOMAS PAGE: 597 GRID: A3 LOCALITY• TEMPLE CITY, Cl TENANT: IEXIST BLDG USE. RESID USE ZONE. R-1 (ISSUED ON: PROCESSED BY: I IEXIST OCC GRP: 109/10/12 - SR (OWNER: TEL. NO: IBLDGS. NOW ON LOT. VALUATION: JFINALDATE FIN BY: CODE: 1CHANG, JEFFREY (626) 285-5275- 4,300 19987 BOGUE ST II TEMP 917802606 FEES PAID JD2SCRfIPTION OF WORK (REMOVE OLD CAL SHAKE ROOF INSTALL 7/16 OSB BOARD 1 LAYER 30 I 1 IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT: ILB FELT INSTALL 30 YR COMPOSITION SHINGLES HOUSE I 1APPLICANT: TEL. NO: I I - - IAJ HARDING CONSTRUCTION (909) 949-2292- IAA BLDG PERMIT ISSUANCE 27.80 1. 1 11179 E 9TH ST. IAB STATE GREEN BLDG FEE 4300.00 VAL ' 1.00 �ISPECIAL CONDITIONS. 1 1UPLAND, CA 91786 IAC STRONG MOTION RESID 4300.00 VAL 0.50 I I ID2 PERMIT W/O EN-HC - 4300.00 VAL 132.60 I I 1 TOTAL FEES 161.90 1 1 (CONTRACTOR: TEL. NO: 1 (APPROVALS DATE INSPECTOR SIGNATURE IAJ HARDING CONSTRUCTION, INC. (909) 949-2292- 1 1 I 11179 EAST 9TH: STREET LIC. NO 1 (LOCATION AND SETBACKS I (UPLAND CA 91786 913191C-39 1 I I I (SOILS ENGINEER APPROVAL I 1 ARCHITECT OR ENGINEER: TEL. NO: IFOUNDATION/TRENCH FORMS I I I LIC. NO: 1 1SLAB/UNDER FLOOR I I I I I I (RAISED FLOOR FRAMING I I I I I IMAP NO: SEWER MAP BOOK- PAGE: FIRE ZONE: CMP: ( (UNDERFLOOR INSULATION I I I I147H269 3 OOI I I I I I I (FLOOR SHEATHING I I I INO. OF FAMILIES: DWELLING UNITS: APT/COND: STAT CLASS: - I I •.-h 0 NO 21 i iROOF SHEATHING I SCHOOL WITHIN HAZARDOUS I ISHEAR PANELS I I (AIR QUALITY: 1000 FEET MATERIALS I I I 1 NO NO NO I IFRAME INSPECTION I I I IFIRE SPRINKLER HANGERS I 1 I I I I I (INSULATION/WEATHER STRIPI I I I I (INTERIOR LATH/DRYWALL I I I I I I I 1EXTERIOR LATH I I 1 I I I I I (RATED FLOOR/CEIL ASSEM. I I I I I (RATED WALL ASSEMBLIES I I I I I (RATED SHAFTS/OPENINGS I I I I I I IT-BAR CEILINGS I I 1 I I I I I ILOT DRAINAGE I- I I I I (REPORT ID: DPR261 ROUTE TO: BS0508 I I 1 I I I I I WORKERS'COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self insure, or a certificate of Workers' Compensation Insurance, A P P L I CATION •FOR, BV I•L D I N G PERMIT ' . or a certified copy thereof (Sec 3800, Lab. C ) ' ' ' COUNTY OF LOS ANGELES BUILDING AND SAFETY r Policy Nolo T i i-0I Company_4. „tom ❑ Certified copy is hereby furnished. FOR.APPLICANT TO*FILL IN BUILDING c3 ADDRESS • / r Certified copy'is filed with the county building inspec- BUILDING 19Q, - tion department. ADDRESS r r Dat Applicant CITY " ZIP LOCALITY CERTIFICATE OF EXEMPT FRWORKERS' NO OF 9LDGS NEAREST COMPENSATIO INSURANCESIZE OF LOT NOW ON LOT CROSS ST (This section need not be completed if the permit is for oneLqa ASSESSOR hundred dollars ($100)of less.) TRACT BLOCK LOT NO MAP BOOK PAGE, PARCEL y TEL USE ZONE MAP I certify that in,the performance of,the work for which this OWNER //� NO. NO. permit is'issued, I shall not employ any person in any manner SPECIAL ,• so,as to become subject to the Workers'Compensation Laws. ADDRESS CONDITIONS - U • ., t "CITY ZIP � Date Applicant ARCHITECT,OR TEL. NOTICE TO APPLICANT: If, ,after making this Certificate of ENGINEER NO DISTRICT GROUP TYPE, FIRE PROCESSED BY O Exemption, you should become subject:to the Workers' /'v/ {n CONST../` ZONE V Compensation provisions of the Labor Code, you must forth- ADDRESS 5 V - LU i with comply with such provisions or this permit shall- be -• • L. STATISTICAL CLASSIFICA ION APT V7DO. N deemed revoked. CONTRACTOR NO. c Z LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. ,�. DWELL. UNITS - 4 hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS' NO. 7 SEWER MAP (commencing with Section 7000)of Division 3 of the Business and J101 LIC. Professions Code, and my license is in full force and effect. CITY CLASS BK PG VALIDATION SQ. FT. NO.OF NO. OF CHECK License Number:1 2!,J r 52 Lic.Class (Z ni 2 SIZE STORIES FAMILIES ONE T VALUATION Contracto ate /z e- DESCRIPTION OF WORK ' NEW ❑ q/J ❑ / ADD ❑ $ I am exempt under Sec. ED LTER B.&P.C. for this reason REPAIR ❑ $ Date- 914 USE OF DEMO" ❑ ;29725A EXISTING BLDG. APPLICANT TEL. Si nature FINAL g WNER- ILDER DECLARATION (PRINT) NO _ DAT '� # o e o • o-1 I hereby affi that I m exempt from the Contractor's License I 'o.] •1 5 5 O Law for the following reason (Section 7031.5, Business and ADDRESS F L' Professions Code)- -PRESENTs ❑ BUILDING o- 1 •1 5'5 0 5 I, as owner of the property, or my employees with ADDRESS wages as their sole compensation;will do the work and the structure is not intended or-offered for sale(Section LOCALITY 7044, Business and Professions Code) MOVING TEL. ❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO. with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY SETQBACKD YARD HWY TOTAPROPpLINE WIDTFROM H 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. (Sec. 3097, Civ. C.). SIDE P.L. Lender's Name LDMA Ref # ' m P.0 Fee S' Permit Fee Lender's Address - /� •• I certify that I have read this application and state that the' . Issuance Fee G, LDMA P/C# o above information is correct. I agree to comply with all County Investigotion Fee _ >a ,`t '• 0 ordinances and State laws relating to building construction, Total Fee LDMA Perm.'#, 'R' and hereby author' a presentatives of this County to enter m upo he above- entio ed property for inspection purposes. a, SEE REVERSE FOR EXPLANATORY LANGUAGE Sign ure of.Applicant or Agent Date WORKERS'-COMPENSATION DECLARATION r hereby affirm that I have r certificate of consent to Self APPLICATION - F,OR.. B U I L D I N G PERMIT,-., R insure, or a certificate of Workers' Com�:���sation Insurance, • or a certrfi co y thereof (Sec. 3800�Lab.`C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY. Policy No. Company vv rr ' BUILDING` 9 CIS �+ r ❑ Jeertified copy is hereby furnisher(, F FOR APPLICANT TO FILL IN ADDRESS L. Certified copy is filed with t e countY" �1111ing inspec- BUILDING Tion department. >� ADDRESS. 9-�i� " +y ci.Y. 155ri L iT! ZIP Dare Applicant f;1^�' NO OF BLDGS. LOCALITY NEAREST CERTIFICATE OF EXEMPTION'FROM WORKERS' SIZE OF LOT NOW-ON LOT ' CROSS ST COMPENSATION INSURANCE " ASSESSOR _ (This section need-not be completed if,the•permit is for one TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL "hundred dollars'($100)or less.).-- DTEL. (,y-�,Y. OWNER 0(Z-)F OHC&O.Zb /�C:��O. USE ZONE MAP NO. certify that m the performs P e�f the work for which this �.� V!_ SPECIAL permit is issued; I shall not em to an erson in an manner ADDRESS- CONDITIONS so as to become subject to the.Workers' Compensation Laws. O CITY ����L� C�;r� ZIP Date Applicant ARCHITECT OR' ' '� v / TEL. NOTICE TO•�APPLICANT:� If,- after making,,this Certificate of- ENGINEER C�T �iyU NO. Y DISTRICT G OUP TYPE' FIRE OCESS _� CONST ZONE• U Exempption, yoP should become .subject t the Workers' ma�yy;; -•� a Compensation rovisions of the Labor Code,-you must.forth- ADDRESS Slur© /`L 6 9-APW ''' with comply.with such provisions.or.this permit shall be G TEL. (� STATISTICAL CLASSIFICATION - APT CONDO. N deemed revoked.. CONTRACTOR Ii*--F`C' NO.S�S'2 WSJ - Z_ LICENSED CONTRACTORS DECLARATIO NLIC CLASS NO DWELL UNITS I hereby affirm that I am licensed under provisions of-Chapter 9 ADDRESS �« �, C1ZL�f�•1� NO�7 1/1 _ SEWER P (commencing with Sect ian,7000)of Division 3,of the Business. LIC G f 1 /4��G/U lJ , and Professions CITY CLASS Code,and my license is in,full force and effect. BK PG VALIDATION 1 lZ SQ .FT NO OF NO. OF CHECK' ' License,NumberZ�Z111 Aic, Class SIZE Z7Cv` STORIES FAMILIESONE �" VALUATION Contractor D Date DESCRIPTION OF WORK /4LL7� /}Tw "NEW, ❑ 64 ADD � C��(f ► ❑I am exempt under Sec. F- .• ALTER ❑ B.&P.C. for this reason REPAIR ❑ s Date: USE OF EXISTING BLDG DEMOL ❑ Signature APPLICANT �q/, (PRINT) Gam' Oe�U E�L NO_ (= 8.�` DATE �V ` 'OWNER-BUILDER DECLARATION D hereby affirm that I am exempt from the Contractor's License Law for the following reason'(Section 7031.5, Business and. ADDRESS j/7� Y -G/�1-�G �, FINAL Q Professions Code): PRESENT- By G UILDING ❑ I, as owner of the property; or my'employees with ADDRESS ACCT.AT wages as their sole compensation,will do the work and = -• the structure is not intended or offered for sale(Section LOCALITY ' B07 49,E 7044, Business and Professions Code.) MOVING TEL' T ❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO. 1.ITEM"S -with licensed contractors to construct the project (Sec- ADDRESS TOTAL-- 41110.'10`8' 8 tion 7044, Business and Professions Code.) GO REQUIRED TOTAL SETBACK FROM - EXIST. „. CHECK .49 88 CONSTRUCTION LENDING AGENCY ' SET BACK- . YARD HWY PROP. LINE WIDTH I hereby affirm that there is a construction-lending agency for FRONT CHANGE aC� the performance of the work'for which this peifmit is-issued P.L. - ' (Sec. 3097, Civ..C.). SIDE_ P.L _ Lender's Name ( � - ��1 • 9/26/89 P C Fee$ Permit Fee o LDMA Ref q e Lender's Address = 5$91 '1'.' .AI'f 8:50 , 0 1 certify that I have read this'application'and state that the Issua'n'ce Fee' '�! LDMA P/C# 8 above information is correct.-I agree to comply with all County Investigation Fee N ordinances an Stat flaw I ing to building construction, Total Fee LDMA Perm tY < and her au on r tatives of this County to enter I upon the abo me ti openly for inspection'purposes. a — ��(�(T SEE REVERSE FOR EXPLANATORY LANGUAGE _ Signature of Applicant or Agent Date ' WORKERS' COMPENSATION DECLARATION • I' hereby affirm that l havecertificate of consent to self APPLICATION 'FOR,"BUILDING PERMIT, insure, or a certificate of Workers' Compensation Insurance,- ' - � ' or a certifiqd copy�th�ejreof (Sec 3800, COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. �•/-� ompdny BUILDING El 'Certified'copy..s hereby furnished. • - • FOR APPLICANT TO FILL IN ADDRESS _ 4ed' copy:is filed witFi thecounty buildiri spec- BUILDINGa ment. -� ADDRESS Date ` ApplicantCITY ZIP LOCALITYNO OF BLDGS. NEAREST CATE•OF EXEMPTION•FROM WORKERt'. ,, SIZE OF LOT ; NOW ON LOTCROSS ST. COMPENSATION INSURANCE / /J�� ASSESSOR , (This section need not'be completed if the'perm'it is 'for one TRACT '7 BLOCK LOT NO. MAP BOOK , GE � , PAGE PARCEL hundred dollars ($100)or less.'). : TEL.OWNER USE ZONE MAP NO" •-.I'certify that in the performance of the work for which this NO. permit is issued-1 shall not employ any1persbn in'any,manner ADDRESS �_ / SPECIAL CONDITIONS CONDITIONS -so as To become subject to the Workers' Compensation Laws. „-� _ � CITY ZIP Date Applicant ARCHITECT OR TEL DISTRICT GROUP TYPE FIRE PROCESSED BY O NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER- NO.: CONST ZONE U Exemption, you',should become-.subject -to• the--Workers' Compensation provisions of the Labor Code,-.you must forth- ADDRESS N with comply with such,rpro4isions,or this permit ,shall be TEL STATISTICAL.CLAS IFICATION -`APT CONDO. Z .deemed revoked. CONTRACTOR NO. UO' _ _ LICENSED CONTRACTORS-DECLARATION LIC.6��31-7 CLASS NO �� DWELL UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRE NO SEWER MAP - (commencing with Section•7000)of Division 3-of the Business t LIC -= , and Professions Cod ,and my license,is in full force and.effect.. CI LASS BK PG VALIDATION SQ. T i�� NO. OF NO F' CHECK 'License Number 'Lic. Class SIZE ` STORIES FAMILIES ONE ti VALUATION Contractor D DESCRIPTION OF WORK NEW ❑ Qom- - nA ADD ►' ❑I am exempt under Sec: _ j.-_ (I ALTER BAP.C. for this reason' _ REPAIR ❑ s f't€' USE OF'. t� r Date:. EXISTINGBLD DEMOL El i APPLICANT T i_:+' Signature (PRINT) N FINAL _ _ S'iT T== OWNER-BUILDER DECLARATION DATE �/ I hereby affirm that I am exempt from the ContractoY's License - Law'for the following reason (Section 7031.5, Business and ADDRESS FINAL Professions Code): PRESENT By `_)' '4 Sr•' ❑ - I,-as owner of theproperty, or m em to ees with BUILDING ° _ 7 f+fy�i1�i Y P Y ADDRESS :J'-'` n L wages as their sole compensation,will do the work and LOCAu7Y , �(�(•,��Q the structure is not intended or offered for sale(Section d 7044, Business and Professions Coe:)- - MOVING ❑ 1, as owner of the property, am exclusively contracting CONTRALTO with licensed contractors to construct the project-(Sec- ADDRESS tion 7044, Business and Professions Code.)' REQUIREDTOTAL SETBACK FROM- EXIST W -CONSTRUCTION LENDING-AGENCY, SET BACK YARD, HY 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. (Sec. -3097, Civ. C.) - SIDE P L. _ Lender's Name LDMA Ref # P C Fee$ V Permit Fee O Lender's AddressPoo. ; 0 1 certify that I have read this applicafion"and state that the . Issuance Fee' / LDMA P/C# 8 above information is correct. I agree to comply with all County Investigation Fee / - ordinances and State laws`relating'to building construction, Total Fee (O LDMA Perm # a and he;4y authorize representatives of this Cou ty to enter upon t above-me ti�edpra�perty inspSEE REVERSE FOR EXPLANATORY LANGUAGE. Signature of Applicant ok Ag t