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I6A639A CE*8098-64APPLICATION FOR BUILD.11<G PERMIT
COUNTY OF LOS ANGELES BUILDING
DEPARTMENT OF COUNTY ENGINEER ADDRESS
BUILDING AND SAFETY DIVISION LOCALITY
J
JOHN A. L . COUNTY ENGINEER NEAREST
COLEMAN W.. JENKIJENKINS¢uPT,oF BUILDING CROSS ST. -
-
DISTRICT
CONSTO./ GRD, . P OL§59Eb BYL
FOR APPLICANT TO FILL IN r 1 L Y1
BUILDING STATISTICAL L_ASSIFICATION SEW R MAP
ADDRESS S /Yjl CLASS NO. DWELL UNITS B PG
LOT NO. 29 BLOCK USE Z NE MAPNO
''-`,/r
TRACT A' �' (Z/ C S' (/r SPECIAL,
G NO. OF OLDOS. ? CONDITIONS ,
SIZE OF LOT��p �.� .T NOW ON LOT -
USE OF
C'I'T'N
0 BLDG, BLDG. SETBACK FROM
TEL S_ FRONT PROP. LINE OF (STREET)
OWNER L/,;o /J TYPE 01 ' E%19TING SE_TBAC%' HIGHWAY + YARD = TOTAL
A O DR ESS HIGHWAY ID 'I MCI. -
�+ + -
CITY BLDG. SETBACK FROM -
ARCHITECT R TEL. ISE PROP. LINE OF - (STREET)
ENGINEER (/ A ) NO. J-Pad/ TYPE OFE%ISTING SETBACK HIGHWAY + YARD = TOTAL
ADDRESS HIGHWAY WIDTH_ FROM C.L. O
TEL. + = V
CONTRACTOR
ADDRESS NO. CORNER CUTOFF YES NO O
CITY LI` 'SEE REVERSE SIDE FOR SPECIAL APPROVALS lull
DESCRIPTION OF WORK
r Crfi aG
Z. — ! o .� r z_
NEIV ADD ALTER REPAIR DEMOLISH
FT. NO. OP _ N0. OF _
S1ZE STORIES PA MI LIE
USE OF • '�• _A
STRUCTURE C' /4"0022'
a /�/� /h' /f.[Fd. ,/' .G�JC.✓� �/N�r
SIGNATURE 0 )
.APPLICANT F r
VALUA.TIO /'�Q A00
APPROVALS - DATE IN_eP EC TOR'8910 NATURE
P.C. �Q PMT. �[> FOUNDATION, LOCATION 1I I _.
PEE ^S J C} FEE r'J FORMS, MATERIALS IK
FRAME, FIRE STOPS, r
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION BRACING BOLT /\
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY FURNACE: LOCATION J
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING GAS VENT. DUCTS
9U ILOING CONSTRUCTION. I CERTIFY THAT. IN DOING THE WORK
AUTHORIZED HEREBY 1 WILL NOT EMPLOY ANY PERSON IN VIOLA- LATH. INT. `
TION OF THE LABOR COOL OF THE STATE OF CALIFORNIA RELAT. A
ING TO WORK MEN�i-C MPENBATION INB NCE. LATH. EXT. wAyV
SIGNATURE F ,HOUSE NUMBER COR-�
PERMITTEE
HOUSE
ANO PO STEO
ADDRES FINALDel Ir
JOHN F. LEWIS. PRINCIPAL STR URAL ENGINEER
PLAN CHECK VALIDATION cK. NO. DASH PERMIT VALIDATION cK. . M.D. CASH
r o ? os2023 0 .133D.50-
h
Lk14610 SAY 11 1 D 267.00-
APPLICATION F0 BUILDING PERMIT
FOR APPLICANT TO FILL IN (Pr10+ OI type pM,) {�
L1
BUIL
9557 Broadway BUILDING �- _
ADDRESS 7
CITY _ Templep Cit ZIP 91780 LocnuY !
NO.OF BLOCS.
SIZE OF LOT NOW ON LOT NEAREST
CROSS S� i[-
ASSESSOR
TRACT BLOCK LOT NO MAP BOOK PAGE PARCEL
TEL. DISTRICT GROUP TYPE FIRE SSED BY
OWNER T C Town OU NO. 26c�, CONST. ZONE/
ADDRESS 9551 Broadway
STATISTICAL CLASSIFICATION SEWER MAP
CITY Tem le Cit ZIP CLASS NO.��� .DWELL.UNITS ,DBK�,j
ARCHITECT OR - TEL. /y
ENGINEER NO. U ZONE NOP (.�
ADDRESS --� CON DII TIOAL NS
CONTRACTOR L t1e Roof in NOL 792 51
OAD OE PA RTMENT APPROVAL REQUIRED YES❑ NO ❑
LIC.
ADDRESS NO. BLDG.-SE T BACK FROM '
LIC. FRONT PROP.LI NE OF ISTREETI
CITY
Pasadena CLASS C-39
CONSTRUCTION LENDER HIGHWAY } YARD = TOTAL SETBACK FROM TYPE OF EXISTING
NAME AND BRANCH FRONT PROP. LINE HIGHWAY WIDTH
ADDRESS CITY }
r
SO. FT. NO. OF NO. OF CHECK SI DG.SET CK FROM d
SIZE STORIES FAMILIES - ONE .SIDE PROP. NEOF (STREET) U
U
ROM TYPE OF EXISTING K�
DESCRIPTION OF WORK
NEW ❑ HIGHWAY } YARD _
ADD ❑ SID OP. L NE IGH WAY WIDTH �.
'11
roof 2/15# f ALTER [I } a
Layer of Flexstone EPAIR:El CORNER CUTOFF YES ❑ NO ❑ Z
USE OF ❑
EXISTING BLDG. EMOL IN OPEN.SPACE AYES ❑ NO ❑
APPLICANT TEL IN COASTAL ZONE YES ❑ NO ❑
(PRINT) NO.
CATEGORICAL EXEMPTION YES[:] NO ❑
BY (SIGNATURE) ENVIRONMENTAL
Q / IMPACT E%EM PTION pEC LA Rq TION SI4NE0 - IOATEI
VALUATION Y A 6 G IMPACT REPORT PROCESSED (p ATE)
1 HEREBY,ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY -
WITH ALL ORDINANCES AND LAWS REGULATING BUILDING COx-
57RUCTIO N. I CERTIFY THAT IN DOING THE WORK AUTHORIZED
HEREBY 1 WILL NOT EMPLOY ANY PERSON IN VIOLATION OF THE
LABOR CODE OF THE STATE OF CALIFORNIA IP7 RELATING TO - -
WORKMEN'S COMPENSATION INSU NCE.
SIGNATURE OF .��
PERMITTEE P. DATE
O. Box 5327 .NAL �L �( ^ C
ADDRESS P.C. 2 PMT.P
Pasadena, CA TE 792 517 FEE Y ` FEE W 1. 75_
CITY NO.
PLAN CHECK VALIDATION C, M.D. CASH PERMIT VATION DH M.D. CASH
657rAhi 14 , 2 .1.75e
76A638B CEY803A 5/73 - -
APPLICATION FOR
BUILDING PERMIT
- 'FOR'APPLICANT TO FILL-IN - ADDRESS
BUILDING
ADDRESS - LOCALITY
NEAREST' /
CITY-'� ZIP. CROSSST
��jj l' /'ANO.OF$LDGS. - ASSESS
SIZEOF LOi V NOW ON LOT MAP BOOK V PAGE P C
qq 'DISTRICT T -GROUP. TYPE ``_ FIR E DBY
TRACT DG BLOCK LOT NO, X '�
TEL
OWNER R NO. _
STATISTICALCLASSFICATI N S ER MAP
ADDRESS - CLASSNO.' DWELL.UNITS BK
CITY ZIP ' UZ9NE MAP J}��
ARCHITECT OR
TEL (If_J NO ' e
ENGINEER NO. - - SPECIAL
CONDITIONS
ADDRESS - - ROAD DEPARTMENT APPROVAL REQUIRED VES ❑ NO'❑
CONTRALTO Zj
N [06,G BLDG.SETBACK FROM
CIC FRONT PROP.'LINEOF - (STREET)
ADDRESS NO ' TOTAL SETBACKFROM TYPE OF EXISTING
LIC. fj HIGHWAY +. (ARD = FRONT PROP.LINE HIGHWAY -WIDTH
CITY - ;CLASS C"3 /.
CONSTRUCTION LENDER - - - + a
NAME AND BRANCH _ BLDG.SETBACK FROM - uV
ADDRESS 'CITY. - SIDE PROP.LINE OF - `)STREET)- - Q
SD.FT. NO OF. NO
:OF -CHECK HIGHWAY + YARD TOTAL SETBACK FROM TYPE OF EXISTING U
SIZE STORIES FAMILIES ' ONE SIDE PROP.LINE HIGHWAY WIDTH -
o +. = Z
DESCRIPTION OF WORK NEW _
ADD ❑ CORNERCUTOFF ° YES •❑ NO ❑ '"
ALTER ❑ IN OPEN SPACE- YES ❑ NO ❑- _
REPAIR
USEOF INCOASTALPERMIi.ZONE. . . ..YES.'❑. NO; ❑ - .
,EXISTING BLDG. � DEMOL
APPLICANT - TEL .,/ 'I LAJ IPY -K 0,`L 6'9:r�
(PRINT) _ NO. 7
BY(SIGNATURE) 's S IV.
I HEREBY ACKNOWLEDGE THAT I HAVE BEAD THIS APPLICATION AND STATE
THAT THE ABOVE IS CORRKT AND AGREE TO COMPLY WITH ALL ORDINANCES - -
'AND LAWS REGULATING BUILDING'CONSTRUCTION,I CERTIFY THAT IN DOING THE
WORK AUTHORIZED HEREBY I WILL NOT EMPLOY-ANY PERSON IN VIOLATION OF,
'TH E LABOR CODE OF TH E STAT E OF CALI FORN I A IN RELAT I NG TO WORKMEN'S COM - - -
PENSATION INSURANCE. "" '
SIGNATURE OF
FINAL BY
..PERMITTEE _ '
DATE, _ -' _
. , . . .. ...
CITY '� '�'`"�' NL" �G P.C. Fee$ Permit Fee `
@ Issuance Fee
VALUATION y "1�'t�:^ - - '
Total Fee
-`PLAN CHECK VALIDATION CK. 'M.o! •-CASH' PERMIT VALIDATION C CK 'M.O. CASH
:D 3.1.00' At
®S 76A6389 CE b'803B 6/77 " '
WORKERS' COMPENSATION DECLARATION //�/pp��� �r�y�E���y y/ppE�`� �P � �FI�gIp�('q�, I��}�ry�r'f�/❑I1
. r I herQ4 affirm that I have a certificate of consent to self
insure, or acertificate of Workers' Compensation Insurance,
ar a ce/r�1if/i�6 c y�}l re'Sec 3800,, L�obb.`C,.)) � � �COUNIT.Y OFAIDS ANGELES .. ... BUILDING.AND.SAFETY.
Polic�M1fdy� Company, _. .
❑ Certified copy is hereby tnished. FOR APPLICANT TO FILL"IN ADDRESS S '
.� Certified copy,is,filed with the county bu nspec-. BUDDING
tion depa Intent. _ AD LIDINGS ,/// /� L/LVp ���•' -
-Date Applicant .. _- CITY / . .A/_�E :`riT zip - / I LOCALITY
_
NO. Ji- LUGS, NEAR
ERTI CATEOF EXEMPTION FROM'WORKER ' - SIZE OF LOT -" NOW ON LOT CROSS ST.
,.COMPENSATION--INSURANCE - _ ASSESSOR -
(This section need not be completed if the;.e it is,for one TRACT BLOCK LOT NO. - MAP BOOK - PAGE PARCEL
hundred dollars ($100) or less.)
%
OWNER.�' TEL. p USE ZONE MAP
AW d .. O. 7—Itl NO.
I:certify that-in the performance of the.work for which this /n/ `•7 SPECIAL _ >
permit is Issued;I shall not employ any,person In any manner ADDRESS. �.. xE� / CONDITIONS it
sons to become subject the Workers'Compensation Laws. - /r p �� - O.
.. CITY: T �.. �••/ , .. .ZIP_ 7/f 080 _ U
^ Date Applica nY• ARCHITECT OR TEL, Of
NOTICE TO APPLICANT: If, aftec,makin this Certificate.of ENGINEER - NO: - .DISTRICT GROUP TYPE - FIRE PROCESSED BY
g CONST. ZONE
Exemption; you .should become 'subject to .the; Workers' D'
Compensation provisions•of the Labor Code, you must forth, ADDRESS �Qa
with complywith such provisions or this permit shall be TEL. .I STATISTICAL CLASSIFICATION APT. CONDO..
Z '
deemed revoked. " - CONTRACTOR /�/ NO: .. ' -
LICENSED CONTRACTORS,DECLARATION, r 6690
6 IC-- - CLASS NO.�` �' DWELL UNITS_
I hereby affirm thafl am licensed under provisions of Chapter 9 ADDRESS 6'G3m/V `SNO. 7 67
_UC. SEWER MAP - -
(commencing with Section 7000)of Division 3.or file Business �,p '
and Professions Code,"dnd my Lcense is in full'forceand effect CITY G� GLASS `�'✓/ BK PG VALIDATION -
/J $O. F NO. OF NO OF /` CHECK
.License Number_�9D J, Lic if
SIZE �D .STORIES FAMILIES (O ONE -
/� C VALUATION 00
Contractor / /fir/r/ Date` DESCRIPTION OF WORK NEW ❑ADD $ 33S
/e + ❑
I❑I am exempt under Sec 00 ALTER ❑ D, .
B:BP.C. for this reason
r / USE OF / J / REPAIR
Date: -
EX ISTING$CDG.` "' DEMOL ❑ ,
Signaturer•. APPLICANT TEL DATE
"(PRINT) NO- __..-
O NER-BUILDI LARATION �7_
I hereby affirm thatl am exe t from the Contractor's License "10.wv �-*7__
Law for:the following re n (Section.7031 5,. Business and %+DDRESS v , FINAL
Professions Code), PRESENT. ey.
❑ 'I, as owner of the-property, or employees with- BUILDING
gDDRESS
wages as their solecompensmion,will do the work and -
the structure is not intended or offered for sole(Section LOCALITYD _ _ _
n.
7044, Business+and Professions Code.) - " MOVING TEL. =t -'-'-'
1, as owner of the property,am ekdusively contracting' CONTRACTOR NO.
i IrE l
with licensed controctorsda construct the projed•(Sec- - ADDRESS'
tion 7044, Business and Professions Code.),: - TOTAL 93 45-3REQUIRED TOTAL SETBACK FROM.t EXIST. _ _
CONSTRUCTION LENDING AGENCY'' 1 SET BACK YARD'. HWY PROP. LINE WIDTH - - 5.�, Y "-
+r - Thereby affirm LhaY-there isamnsirudion lending agency for`. ,�FRONT' - - -
a:NE' - _
he performance of the work for which this permit-isissued, 'P:I. - [:}{H}4E etfll. .
•(Sea. 3097, Civ, C). SIDE • -- -
.,
Pd - 1 .
,Lender's Nome. -
_ p CDMA Ref. H
P.C. Fee$ Per
. mit Fee " - .Q' 3
� - Lender's Address
,3.0`0CN , i , girls l
'l certify that have n=od this applicatian'and state that the -' Issuance Fee' "CDMA Pi ' - p .�
8 above information is correct.I agree to comply with all County Investigation Fee -
R ordinances and State laws relating to building.construction, - Total Fee •/ '�'�' 'LDMA'Perm. q -
a .and hereby authorize representatives ofthisCounty to enter i
m upon the above-mentioned property for inspection purposes.• - - - - - -
- SEE REVERSE FOR EXPLANATORY LANGUAGE '
Signature of Applicant or Agent - Date
WORKERS' COMPENSATION DECLARATION _
Iaffirm'
rWorkers'certificate e
insure, oracertifcate of Copensation Insurance, Q 'P P U C pT 50 H 'p� R',BU R D P R
67
or a certified copy thereof (Sec. 3800, Lab. C.) I '
COUNTY OF LOS ANGELES BUILDING AND SAFETY .
Policy No. Company BUILDING
Certified copy Is hereby furnished. .FOR APPLICANT TO FILL N (J„J '�. 3 ADDRESS S7
Certified.copy is filed with the county building inspec- BUILDING -�- ( • '
71
tion department. _ ADDRESS 5 LOCALITY . L. [ C�I
- c NEAREST --1 /J 11 `
Date - Applicant CITY G ZIP p '� CROSS ST. rq. 1,-e- / f>L
CERTIFICATE OF EXEMPTION FROM WORKERS' ` NO. OF BLDGS. ASSESSOR. - -
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL
(This section need not be completed if the permit is one USE ZO MAP
hundred dollars ($100)or less.) - TRACT BLOCK LOT NO. e_ NO.. .
/L TEL. _ SPECIAL y
OWNER /v -NO. 7• :� CONDITIONS - d
I certify that in the performance of the work for which this DISTRICT GROUP TYPE - 'FIRE PROCESSED BY O
permit is issued, I shall not employ any person in any manner ADDRESS S S 3 /LV'0.0 Q ONST. - ZONE - V
so as to become subject to the Workers'Compensation Laws. ad
�;O(/ Q - O
o I LL• 0
Date Applicant CITY ZIP STATISTICAL CLASSI KATION APT. CONDO. _ V
NOTICE TO APPLICANT: If, after making this Certificate of ARCH ECTO TEL. - �'7 /
.Exemption, you should' become subject to the Workers'' ENGINEER NO. CLASS NO.�_DWELL. UNITS= a
Compensation provisions of the Labor Code, you must forth- ADDRESS f - SEWER MAP
with comply with such provisions or this permit shall be _ Z
deemed revoked. TEL' •BK. 'PG. VALIDATION
CONTRACTOR NO.
LICENSED CONTRACTORS DECLARATION -- UC. -
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 " -
Professions Code, and myLIC
.license is in full force and effect. CITY CLASS E
SQ. FF. - NO.OFNO. OF CHECK
License Number Lic:Class SIZE STORIES '� FAMILIES ONE f
,
NEW ❑ E -
Contractor Date DESCRIPTION OF WORK -. -
ADD .
I am exempt under 5ec IF ALTER ❑ FINAL
BAP.C. for this reason - - REPAIR •� DATE
Date: USEDEMOL ❑ ., B NAL J I/' x'9`3 9,5•A
EXISTING BLDG. - - T -�¢,.`v
APPLICANT TEL.
Signature OWNER-BUILDER DECLARATION PRINT NO. - "�{' a.°r°:° ✓� -
hereby affirm that I am exempt from the Contractor's License -
law for the following reason (Section 7031.5, Business and ADDRESS D''• - - -
�Profe�ssions Code): - PRESENT
- -
as owner of the property, or my employees with ADDRESS - ,ING 2,7° O 4.9`8.8
wages as their sale compensation,will do the work and
the structure is not intended or offered for sale(Section LOCALITY ° ° 0,4 9 8 air
7044, Business and Professions Code). - . . MOVING TEL
4 1, as owner of the property, am exclusively contracting CONTRACTOR NO. 0 1.2,7,.'—8.3
Y' with licensed contractors to construct the.project (Sec- ADDRESS
"
'lion 7044, Business and Professions Code). - _ .. ...
REQUIRED TOTAL SETBACK FROM EXIST. `
CONSTRUCTION LENDING AGENCY _ - SETBACK' YARD HWY -PROP. LINE WIDTH. D ' -
Ihereby affirm that there isaconstruction lending agency foY.,, FRONT.. .
the performance of the work for which this permit is issued P.L:
(Sec. 3097, Civ. C.). SIDE
'P.L. -
Lender's.Name
$ Lender's Address P.C. Fee'$ Permit Fee
F
I certify that I have read this application and state that the Issuance fee `��•
. above information is correct. I agree to comply with all County Investigotion Fee -
g ordinances and State laws relating to building construction, Total Fee
and hereby authorize representatives of this County to enter
upon a above
.-mJention�propertyfor inspection purposes.ps.Y s SEE REVERSE'FOR EXPLANATORY LANGUAGESignature of Applica - Date r��C "' / � � ,• ®s
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 0912230003 _
PHONE: (626) 285-0488 EXT:
LEGAL ID: I NO. OF CONST BUILDING ADDRESS:
ICE: 30243 ON: 24 1 SQ, FT STORIES TYPE 9557
- I - STRUCTURE: V-B TEMP CA0917803159
(ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET: TEMPLE CITY BLVD.
18588-005-058 THOMAS PAGE: 596 GRID: S4 LOCALITY: TEMPLE CITY, Cl
(TENANT: IEXIST BLDG USE: RESID USE ZONE: R-1 IISSUED ON: PROCESSED BY:
1EXIST OCC GRP: 112/23/09 " SR 1
OWNER: TEL. NO: IBLDGS. NOW ON LOT: VALUATION: (FINAL DATE FINAL AY: CODE: , 1
IOLSZEWSKI MARIE (626) 309-2850 1 7,500
19557 BROADWAY
ITEMP 917803159 FEES PAID IDES PON OF WORK
I IKITCHEN AND BATHROOM REMODEL CABINETS & COUNTERTOPS
I IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT: I
(APPLICANT: TEL. NO:
IMATHSON (323) 806-2840-' 1AA BLDG PERMIT ISSUANCE - 27"75
900 PALMA DR. JAB STATE GREEN BLDG FEE 7500.00 VAL 1.00 ISPECIAL CONDITIONS:
IARCADIA, CA 91006 IAC STRONG MOTION REBID 7500.00 VAL 0.75
1 IB2 PERMIT W/ENERGY 7500.00 VAL 201.30
FR INV WORK W/0 PERMIT 257.00 DOL 257.00
CONTRACTOR: TEL. NO: TOTAL FEES 487.80 (APPROVALS DATE INSPECTOR SIGNATURE
MATHSON, STEVE (3231 806-2840- I
1900 DA OLIC. NO _ LOCATION AND SETBACKS
AACADIA,IA, CA 91 91006 NONE
ISOILS ENGINEER APPROVAL _.
ARCHITECT OR ENGINEER: TEL. NO: (FOUNDATION/TRENCH FORMS
LIC. NO: (SLAB/UNDER FLOOR
1 - RA'--SED FLOOR FRAMING -
IMAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP: ( (UNDERFLOOR INSULATION
1147H269 3 - 001
CUti"'\qv 1kto �. IFLOOR SHEATHING - -
NO. OF FAMILIES: DWELLING UNITS: APT/COND: STAT GLAS$; V"l'\\\F 11
NO 21 IROOE SHEATHING
SCHOOL WITHIN HAZARDOUS ISHEAR PANELS
AIR ANALITY: 1000 FEET MATERIALS
NO NO NO 1 1FRAME INSPECTION
(REQUIRED TOTAL SETBACK FROM EXIST IFIRE SPRINKLER HANGERS
ISET BACK YARD: HWY: PROP LINE: WIDTH:
FRONT PL- INSULATION/WEATHER STRIPI
SIDE PL- -
_ 1 (INTERIOR LATH/DRYWALL
EXTERIOR LATH
1 - (RATED FLOOR/CEIL ASSEM.
RATED WALL ASSEMBLIES
" I RATED SHAFTS/OPENINGS
T-BAR CEILINGS
I
(LOT DRAINAGE I I
I 1
- IREPORT ID: DPR261 _ ROUTE TO: BS0508 1