HomeMy Public PortalAbout9575 BROADWAY_Building__ APPLICATION FOR,BUIL''DING PERMIT
FOR APPLICANT TO FILL IN (PRTI O, rYDB PMY) {.
BUILDING
ADDRESS 957.5 %Broadwa� BUILDING
A'DORESS G
(/7/Y
CITY Temple City ZIP .91780
LOCALITY
NO.OF SLOGS. NEAREST -
SIZE OF LOT NOW ON LOT CROSS ST.� -
ASSESSOR
TRACT BLOCK LOT NO, MAP BOOK PAGE RCEL
TEL DISTRICT GROUP TYPE FIRE PROC SSED BY
OWNER Temple .Cit T H� No. 285' 972 CONST _ ZONE
'67 .14 � .
-ADDRESS 9551 Broadwa '
STATISTICAL CLASSIFICATION WER.MAP
CITY Temple Cit :.P 91.780-, - .L
ARCHITECT OR TEL. �-, „CLASS NO. _.DWELL.UNITS
ENGINEER _ _ ✓' NO. ' IkU ZONE NOP C - (..jo >0
ADDRESS - ' SPECIAL ,J y� / 31
,i. -
TEL. - CON OI TIONS (, (JJ J
CONTRACTOFL tl NO - -
NO ROAD DEPARTMENT APPROVAL REQUIRED YES❑ NO.❑
ADDRESS
ETP 6K FROM
FRONT '
LIC: FRONT PROP.LINE OF ISTREETi
CITY
Pasadena CLASSC-89
CONSTRUCTION LENDER HIGHWAY YARD c TOTAL SETBACK FROM TYPE OF IEXISTING
NAME AND BRANCH Unknown FRONT PROP. LINE HIGHWAY WIDTH
ADDRESS - CITY + - d
50. FL NO. OF NO. OF CHECK BLOG.SETBACK FROM - - �
SIZE - •- STORIES .2 FA MILIE ONE SIDE PROP, LINEOF 1ST TI
C
NEW El HIGHWAY . + YARD - TOTAL SETBACK,FROM TYPE OF EX TING C)
DESCRIPTION OF WORK - SIDE PROP. LINE HIGHWAY WI IT U
DD -1W
ALTER ❑ Z
fleXStone LL�II CORNER CUTOFF YES ClNO_❑
USE OF
REPAIREJ
EXISTING BLDG. Residence • DEMOL ❑ IN OPEN SPACE I YES ❑„ NO ED -
APPLICANT, TEL IN COASTAL ZONE YES ❑, NO ❑
BY (SIGNATURE) 7 CATEGORICAL EXEMPTION YES❑ NO ❑
'ENVIRONMENTAL
Q IMPACT EXEMPTION DECLARATION SIGNED (DATE). -
VALUATION Y F V VDIMPACT REPORT PROCESSED-(DATE)
I HEREBY ACKNOWLEDGE THAT I HAVE REAO THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WIT HALL ORDINANCES AND LAWS REGULATING BUILDING CON
-
iTRUCTION, I CERTIFY THAT IN DOING THE WORK AUTHORIZED
HEREBY I WILL NOT EMPLOY ANY PERSON IN VIOLATION OF THE
LABOR CODE OF .THE STATE OF CALIFOA NI IN RELATING TO
WONKMEN'5 COMP ATION INSURANCE,
SIGNATURE OF FINAL �j _B.Yy^/ P -
PERMITTEE DATE G / , / /, -
ADDRESS P.O. Box ' 5.327 PMT.P.C. a Y
FEE FEE
TELy 7
CITY_ Pasadena NO. / � 7-S� '
PLAN'CHECR VALIDATION CK M0 CASH PERMIT VALIDATION
6 5 4�U'AFR 14 1 U ? G 1.7 `J n>s.
-
]6g63RB CE#603q 6/73
76A6386 C9R8038L 64 APPLICATIO - FOR BUILD*
UI DING PERMIT_ '
COUNTY OF LOS ANGELES BUILDING
DEPARTMENT OF COUNTY ENGINEER ADDRESS' J
;.
,rsr. BUILDING AND SAFETY DIVISION LoCALITv -
JOHN A. LAMSIE. COUNTY ENGINEER NEAREST
COLEMAN W. JENKINSSUP•T.OF BUILDING CROSS ST
DISTRICT NO/' GR U. TYPE- OC SED BY
FOR APPLICANT TO FILL IN J' )-_� Co NST
BUILDING �y - STATISTICAL C ASSIFICATION SEVER MAP �7//
/ I iJ .
ADDRESS C7"� CLASS NO. DW EIL UNITS B PG G
LOT NO..- Z'l BLOCK- USE ZONE MAP of �
TRACT 4 C �' ++-r--�— SPECIAL J
o
NO. OF BLOG9. CONDITIONS
SI Z OF LOT t,?�.(� r 'J •S NOW ON LOT.
USE OF -- -
EXISTING BLDG. SETBACK FROM
T�E Iy/�y� FRONT PROP. LINE OF (STREET)
OWNER/ 'fir / d TYPE OF EXISTING SETBACKHIGHWAY } YARD - TO TAIL.
ADDRESS I� HIGHWAY WI TH I! OM C.L.
CITY /
IM
ARCHITECT PRSLOG. SETBACK-FROM
ENGINEER, �/J NO. r O / 910E PROP. LINE OF (STREET)
.} TYPE OF EXI9TIN0 SETBACK HIGHWAY" } YARD = TOTAL
ADDRESS � -- /
)♦ W / HIGHWAY WIDTH FROM C.L. -
JJ TEL. } _ O
CON TRA CTO ;;d/ O - U
'ADDRESS
LICCORNER CUTOFF YES
NO. , NO � O
CITY . GASS SEE REVERSE SIDE FOR SPECIAL APPROVALS V
W
DESCRIPTION OF WORK ,� G l Z
NEWS ADD T ALTER .REPAIR DEMOLISH ` i //O�
5 FT. J NO OF NO_ OF /v' - ,V�`/�Sr'�
SIZE / O STORIES'- FAMILIES/ �
USE OF
STRUCTURE 4
SIGNATURE OF
APPLICANT'
VALUATION g O CYV ,. -
A'PPROVALS DATE INSPECTOR'S SIGNATURE
C. �. D PMT, o2� FOUNDATION, LOCATION �/ - -
FEE$ h FEE$ J �J '— FORMS,.MATERIALS - �:) -LQ�
`FRAME, FIRE STOPS, I'
I HEREBY ACKNOWLEOCE'THAT I HAVE READ THIS APPLICATION BRACING BOLT
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY FURNACE:.LOCATION
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING GAS VENT. DUCTS
9U ILO INC CONSTRUCTION. I CERTIFY THAT IN OOINF THE WORK qy
AUTHORIZED HEREBY I WILL NOT EMPLOY ANY PERSON IN VIOLA' LATH. INT. V/a„G1M I
TION OF THE LABOR{ODE OF THE STATE OF CALIFORNIA REZAT-
ING TO WORKMEN'S NSATION,INSURAN
LATH. EXT.
SIGNATURE OF HOUSE NUMBEROCOR-�
PERMITTEE RES ANO POSTED6`7 1 ) ,/./
Y'" 1
ADDRESS _ FINAL. I/7/
JOHN F. LEWIS. PRINCIPAL ST URAL ENGINEER
PLAN CHECK VALIDATION M OM.O. CASH PERMIT VALIDATION CK: M.o. CASH
tni c o / 1 nIPK 20 2 3. D 7. 5 1 .5 0 n..
L' 1464 `r9P,Y11 1 D 303.0/90~ 4 "/
APPLICATION FOR NTYOFL JGEI,B'UILDING PERMIT BUILDNGAOFSAFEONR
FOR APPLICANT TO FILL IN
BUILDING
-
ADDRESS i �Y LOCAUT •
NEARES
CITY is /Y- ZIP CROSS ST.
/7NO.OF BLDGS. ASSESSOR, ,
SIZEOELLOOT�3 (/NOW ON LOT ` MAPBOOK r' PAGE-A AR
TRACT..�JG BLOCK LOT NO. N ISTRIQ�ij -GROUP; CONST,S 1 TYPEF E P ESS BV ,,
TEL
Ff .
OWNER NO. ,
STATISTICAL CLASSIFICATI N - SE MAP
ADDRESS - CLASS NO.�DWELL UNITS
CITY ZIP' - USNp MAP �{
ARCHITECT OR TEL.
.ENGINEER NO., r3 SPECIA
J CONDITIONS
ADDRESS ROAD DEPARTMENT APPROVAL REQUIRED - VES ❑ NO ❑
TEL.
CONTRACT N O6(�i BLDG,SETBACK FROM
Nr
/ FRONT PROP.LINE OF (STREET)
ADDRESS NQS 6 TOTAL SETBACK FROM TYPE OF EXISTING
LIC - HIGHWAY' + YARD = FRONT PROP.LINE HIGHWAY WIDTH.
CITY CLASS L' 'S?
CONSTRUCTION.LENDER + _ }
NAME AND BRANCH BLDG SETBACK FROM d
ADDRESS CITY
SIDE PROP.LINE OF (STREETI O
- rJ
SO..FT. NO OF NO.OF CHECK HIGHWAY + YARD TOTAL SETBACK FROM i.VPE OF EXISTING
SIZE STORIES FAMILIES ONE SIDE PROP.LINE HIGH WAV WIDTH O
❑ + - ~
DESCRIPTIO F WORK NEW (�
ADD, ❑ CORNER CUTOFF YES ❑ NO ❑ W
_ a
ALTER ❑
IN OPEN SPACE VES ❑ NO ❑ Z
REPAIR
USE OF ❑ IN COASTAL PERMIT ZONE YES ❑ NO ❑
EXISTING BLDG. DEMOL
APPLICANT TELId C�Lp Le7*O
(PRINT) TEL Vl/ �+Z R/r.I
BY SIGNATURE(
HEREBY ACKNOWLEDGE THAT I HAVE READ-THIS APPLICATION AND STATE / ✓" f Tv � � �h //(/�
THAI THE ABOVE 15 CORRECT AND AGREE TO COMPLY WITH ALL ORDINANCESAND LAWS REGULAING
HE
WORK UTHORIZD? BUILDING
HEREBYILL NOT THAT
ANY PERSONINT IN DOING T
VIOLATION OF
THE LABOR CODE OF THE 57ATE Of CALIFORNIA IN RELArING TO WORKMEN'S COM,
PENSATION INSURANCE.'
SIGNATURE OF FINAL TBYPERMITTEE DATE
ADDRESS
CITY��-i++�� TELP.C. Fee$ Permlt Fee
Issuance Fee
VALUATION $ �gCrL) Total Fee
PLAN CHECK VALIDATION CK. M.O. CASH _ PERMIT VALIDATION -cK. _.O. CASH
_a g.2 o�neR 14 .;i o_. 3 1.00 ®sb
76A636A CE NBO3A 6/76
. 7GA630A CE#8035-61APPLICATION FOR BUILDING PERMIT u
COUNTY OF 'LOS'ANGELE$ BUILDING
DEPARTMENT:OF COUNTY ENGINEER ADDRESS
BUILDING AND SAFETY DWISION LOCALITY
JOHN A. LAMBIE, COUNTY ENGINEER NEAREST - II
WILLIAM A. JEN BEN, SUPT OF BUILDING CROSS ST, L R i+
FOR APPLICANT TO FILL IN SiTs7s °Isrglcr NO.' OR P/ TYPE SEED BY
CONST. ,(
JBUILDING STATISTICALCLASS (CATION ISEERMAP .
ADDRESS K 'PG
CLASS.NO DWELL.UNITSFF�����
LOT NO. , BLOCK WATER NOT REQUIRED I ][,_'RECEIVED
"� /J CERTIFICATE: _ �-aF��
TRACT1f ���,c�•� LlfiA{L� MAP HIGHWgv STATE
MAJOR ON L'
NO, OF SLDGS. NO. mlacLEl
SIZE OF LOT NOW ON LOT USE ZONE - SPECIAL
USEOF � CONDITIONS E S 57
EXIBTING////B��L11DG. F. + /F� 3
OWNER/1f4lY NEO/ -B�/D SUILI EXIST.
SETBACK , YARD HWY STREET NAME WIDTH
ADDRES'�^�L,/��,L/ N_ �g [C.�.,�__ ,FRONT /
ARCHITECT OFY" .. TEL. P. L. - 1(�� j �.'
ENGINEER NO. ,S LE ti t O
ADDRess
s'�TE INSPECTIO RECO
' CONTRACTOR o,vy
n
ADDREB 4"Y;L? - V
DESCRIPTION OF.WORKci
d
Z,
E ADD ALTER - REPAIR ' DEMOLISH
Q.FT. �.--�` NO.OF NO.OF
$IZE STORIES FAMILIES -
USE OF
STRUCTURE
Z _ 5/10�'W45 f/�
SIGNATURE
j f
VALUATION'$✓
APPROVALS DATE, INSPECTOR'S SIGNATOR
" FOUNDATION: LOCATION /:2 I
• 'FEE $ �' FEE $ FORMS,MATERIALS «C
FRAME: FIRE STOPS. .F
I HEREBY ACKNOWLEDGE THATI HAVE READ THIS APPLICATION BRACING, BOLTS
AND STATE THAT THE ABOVE'IS CORRECT AND AGREE TO COMPLY FURNACE: LOCATION, / / �• ",
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING GAS VENT DUCTS
BUILDING CONSTRUCTION. I CERTIFY THAT IN DOING THE WORK
AUTHORIZE. HEREBY I WILL NOT EMPLOY ANY PERSON IN VIOLA- 'LATH, INT.
TION'OF THE LABayG, pE DF.TME STATE OF CALIFORNIA REIgT"
ING TO WORKM ✓�C IPENSATION INSURANCE. LATH, EXT.
SIGNATUR OF ' HOUSE NUMBER COR. V
PERMITTEE W, RECT AND POSTED ,
ADDRESS FINAL e�• �
CLYDE N. DIRLAM, PRINCIPAL.STRUCTURAL ENGINEER
PLAN CHECK VALIDATION CK. N.D. u H BERMIT VALIDATION cn: m.o.' .c N
L`i�D4 0 2 4.y• JLtL27 1 D 8.00-
76A838A CEd 803 R.a3 APPLICATION FOR BUILDING PERMIT �� �/�
COUNTY OF LOS ANGELES ADDRESS
ISS 1 3(24 /ADwl i
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION LOCALITY
JOHN A. LAMBIE. COUNTY ENGINEER NEAREST
WILLIAM A. JENSEN, SUPT OF BUILDING CROSS ST.
oJ3[t I CT ROUP TYPE
FOR APPLICANT TO FILL IN -- 1 CONST.
BUILDING/1��1� ^ J STATISTICAL CLA IFICACT•ION SEWER MAP
ADDRESS L l ��/v �.LL��G �J K
/� CLASS. NO.ir J_DW ELL. UNITS
LOT NO. o BLOCK WATER NOT REQUIRED RECEIVED
CERTIFICATE:
TRACT {-l(-SS(O V MAPDO (
NO.OF BLOTSNO. c RCLE) STATE MAJOR SECOND. LOCAL
.
SIZE OF LOT NOW ON LOT USE ZONE SPECIAL
USE OF CONDITIONS
EXISTING BLDG. J QQ y�
OWNER /-0 I 'J70.• �` 5 BUILDING EXIST.
[�
/ SETBACK YARD HWY STREET NAME WIDTH
ADDRESS I QLQ LIJ GL LL_ FRONT
ARCHITECT OR f�e� (p� TE
ENGINEER (/LJ��J(L.. LX _ NO �J��OQ• SIDE
ADDRESS -('�y"dc> l— PnL ����//
- NO. 7 � .�f 1?FL /!- -� 00
CONTRACTOR - "
U
ADDRESS . } / A c. ` ^ ` O
.�,
DESCRIPTION OF WOK
NEW ADD ALTER REPAIR DEMOLISH
-�) NO. OF NO. OF
SIZE { �� STORTM -FAMILIES
USE OF
STRUCTU I
,SIGN URE OF _ `�_� -G
APPLICANT
VALUATION $ OO '
APPROVALS jDATE. INSPECT R'S SICNAT R
cY) FOUNDATION.. LOCATION
FEE $ FEE $ J FORMS, MATERI ALS
FRAME: FIRE STOPS,
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION BRACING. BOLTS
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY FURNACE: LOCATION.
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING GAS VENT. DUCTS
BUILDING CONSTRUCTION. I CERTIFY THAT IN DOING THE WORK
AUTHORIZED HEREBY I WILL NOT EMPLOY ANY PERSON IN11011LATH. INT,
TION OF THE LABOR CODC- OF THE STATE OF CALIFORNIA RELAT-
ING TO WORKMEN' COMPE 10 cuRANCE. LATH. EXT.
S IGNATU RE OF HOUSE NUMBER COR.' / ^
PERM ITT RECT AND POSTED
ADDRESS O/- FINAL
JOHN F. LEWIS. PRINCIPALS T � U RAL ENGINEER
PLAN CHECK VALIDATION cK. M.D. ,DASH. PERMIT'VALIDATION DK. M.D. CASH
CAU-0.-5 6 0 4G' SEP 15 2 3 D C%. 5,., `•; _
hLC 5 �6/ 0 5:� SEP 15 1 D 1 ^.5 U
�'iv c'�iCih%C/
76A63BA CEa003.5-65 APPLICATION FOR BUILDI G PERMIT
COUNTY OF LOS ANGELES BUILDIN �—
DEPARTMENT OF COUNTY ENGINEER ADDRESS
BUILDING AND SAFETY DIVISION LOCA LI TI - �
JOHN A. LAMBIE. COUNTY ENGINEER NEARES /
COLEMAN W. JENKINS.BUP'T OF BUILDING CROSS TLo
DIST ICT NO TYPE SPR QC E55 IH
FOR APPLICANT TO FILL IN CONST.
STA ISTICASSI FICA TION SEW ER�Aj9P/
ADDRESS ODR E55 N4 ""••�G"- / CLAS S NO. DWELL UNIT$ L+'�G
LOT NO. / � '� ZC/ BLOCK USE ZONE MAP
'77 D O
TRACT Q ,? } ]� SPECIAL
N0. OF SLOGS. CON DI TIO Cl
SIZE OF LOT NOW ON LOT
USE OF a
EXISTING B G. Ife S C -2.S BLDG. SETBACK FROM
OWNER / �/ ' G��i�<xot ZJ77O FRONT PROP. LINE OF _ EET)
TYPE OF EXISTING SETBACK HIGHWAY } YARD - T TAL
ADDRESS W�I1 HIGHWAY WIDTH FROM C.L.
CITY -
BLDG. SCTBACK FROM
ARCHIT CT OR TEL. SIDE PROP. LINE OF (STREET)
ENGINEER NO.'
TYPE OF EXISTING SETBACK HIGHWAY } YARD - TOTAL
ADDRESS HIGHWAY WIDTH FROM C.L.
TEL. } = Yd
CON TRA CTO NO O
LIC CORNER CUTOFF YE NO U
ADDRESS NO
CITY CL` S SEE REVERSE SIDE FOR SPECIAL APPROVALS G
DESCRIPTION OF WORK
NEW / YA/41G- hall -4mle
qDD ALTER REPAIR DEMOLISH
T.�O STOROF IES ES / FAMILIES
- ri13 �' I�+tI&Y ✓lR/lft.1�'V�:./':cZ�L'J.! ����U-Cf,AM�Z
SIZE
USE OF ��)) QQ ./VO(.L �A�IE.(T.f�✓
STRUCTURE L C>GIJ C Y/( G$��OegJ ,C'
SIGNATURE O
APPLICANT iRd
VALUATION .�Eb
APPROVALS DATE INSP ECTOR'B SIGNATURE
PMTUNDA
F E FEES L� FO FORMSI MATERIALSON
FRAME, FIRE STOPS, lFiL/� `Q��r /'•LN A '
LHEREBY 4CKNOW LEDGE TNAT�I HAVE READ THIS APPLICATION BRACING BOLTS /
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY FURNACE: LOCATION F �L
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING GAS VENT. DUCTS
9UILDING CONSTRUCTION. I CERTIFY THAT. IN DOING THE WORK n -
AUTHORIZED HEREBY I WILL NOT EMPLOY ANY PERSON IN VI !-A- LATH. INT.
TION OF THE LA80R CODE OF THE STATE OF CA FORNIA RELAT.
ING TO WORKMEN'S C ENSATION IN SU
LATH. EXT. a. 117/Z
SIGNATURE OF l��r HOUSE NUMBER COR- C F
ECT AND POSTED
PERMITTEE l�� R
ADOREss FI NAL
JOHN F. LEWIS, PRINCIPAL 5-<U-CRTAL ENGINEER
PLAN CHECK VALIDATION DK. M,o. CASH _ PERMIT VALIDATIO K. M.0 CASH
;6;6:2.8 OCT 2'0 23 D 7-,50- a
.7y,:i, 6 29- DCT 2 0 .1 D 1. 5-00' ev
WORKERS' COMPENSATION DECLARATION
Li FrerZ)Py'affirm that I have a certificate of consent to self /�(]L` t���r D �pp�11 (/��a �Ip�'��I@gIppI�� FOR �rrr�� �FI�p,�p�,/l��s �rr�y��p}�rRy�g/���
insure, ar a certificate of Workers' Compensation Insurance,' WII �LS�V- ����OV;'-u '�uV ����D�.�,�/ 11 "IS IlU11VO�� - "•
or/a�c(��(t III copLyy thereof (Sec 3800, Lob. C.) .'COUNTY OF LOS ANGELES. - BUILDING AND SAFETY r
.. Pory'fJ�if'L Company, /:VWA ' ' . . 1 11
❑ Ceriiffed'copy is'hereby furnished. . FOR APPLICANT TO FILL IN ADDRESS S "
:.❑ Certified copy is filed with the county b Ing inspec - BUILDING ESS
4s�.S - n^ wo
tion department..
ADDR !J /w
t o' _A114 A/' clTv �E/fJ [E'CT' zIP / 7' O ocAutr
Dote' 1�CfATEf/Applicant NO. OF BLDGS. NEAREST
-L' - RTIF ATE OF EXEMPTION FROM WOR S' SIZE OF LOT •� NOW ON LOT CROSS ST. '
COMPENSATION INSURANCE _ _ ASSESSOR
(This section need not be completed if th ermit is for one " TRACT "' BLOCK LOT NO. MAP BOOK PAGE PARCEL
h Yndred dollars ($100) or less.) TEL
OWNER' f' O. 7. USE ZONE MAP
. I certify that in.the performancetof the work for which this qq NO.
O /[ _ _ - y� -�j SPECIAL
Fermi t is iecom .I shall not temploy anyhe.Woker person many manner ADDRESS- r O il. ✓ CONDITIONS a
so as tobecome subject to theWorkers'Compensation Laws, ,l - - O
. CITY' �� C.c 'GIT ".ZIP 9/7-9:,3-- U
Date Applicant' r ARCHITECT OR _ TEL -
NOTICE TO APPLICANT: If; after..makingthis,Certificate of ENGINEER.. - NO. - "- DISTRICT' GROUP TYPE FIRE PROCESSED BY_ CONST. ZONE
Exemption, .you should become subject to. the Workers'- " _�, /,
Compensation provisions of the.Labor Code,.you must.forth . ... ADDRESS _ V
STATISTICAL CLASSIFICATION APT. CONDO: N
with comply with wch_provisions or this ,permit%shall be - C1 tEL Z
deemed revoked. - CONTRACTOR V11-C NO. _
LICENSED CONTRACTORS DECLARATION - /' ! OQ Z C. • �p6 CLASS NO.�DWELL UNITS
I hereby affirm that I am licensed under provisions of Chapter 9. ADDRESS fQ b J �(/ /
LIC. i SEWER MAP
(comm Tessio,with Section y Iicenf is in fuII of the Business L dS 2�/_�Te - C__99
'-
and.ProfessionsCode,and'myl¢ense is in fullforce and effect. ' CITY /Y yes CLASSBK. PG: L: -VALIDATION
! SQ. F NO. OF NO. OF CHECK License Number - ,�Q 'CD `Lic. Class C �.q SIZE. STORIES FAMILIES ONE
• ,fes /. El VALUATION
Contractor / l �L'.1 !' Date" 0� DESCRIPTION OF WORK NEW rjnp
'ADD ❑ $-S/ /O D r
1:11 am exempt under Sec. �E 00
- .. .ALTER"_❑
B.BP.C. forthis reason REPAIR S
Date:
USE OF
8 ✓/ L.¢ 'DEMOL ❑
EXISTING BLDG. QW h- OND S
Signature' APPLICANT TEL. _ FINAL -
(PRINT) •55'EA NO. /8
OWN R-BUILDER LARATION ,. per/ A.,O d . _ DATE
I hereby affirm that I am exE from the Contractor's License gDDRESS /J 7 OKL/T �/ / r "
Law for the fallowing re n (Section 7031.5, Business and /r a FINAL
Professions Code): - PRESENT - - FINAL
'
BUILDING•
❑ I, as owner of the property, or my employees with
wages as their solecompensation,will do the work and ADDRESSthe structure is not intended or offered for sale(Section LOCALITY
El 1,
Business and Professions Code.) MOVING. TEL. -
C C
I, as owner of the property, am exclusively contracting CONTRACTOR NO.
• with licensed contractors to construct the project'(Sec- ADDRESS '41'l�,y'i { 'f- SC "
tion 7044, Business and Professions Code.) =
:REQUIRED` TOTAL SETBACK+ROM' EXISTa- - -'
CONSTRUCTION LENDINGAGENCY SET BACK YARD HWY pROP. LINE WIDTH 1 _
-"-1 hereby affirm that there is a construction lending agency for - FRONT -- - - _ ,-•A '
the performance of the work for which this permit is issued " P.L I -!RNVE UU'
(Sec. 3097, Civ. C.). SIDE-.
Lender's Name C (." �i luf'T
LDMA Ref. N .. I('1 IL)-i It I`1_.,k L s -i
P C Fee$ Perm iP Fee
l:ID
Lender's Address e_;�
a.' �� . :Iv
.1 certify that I have.read this application and state that the Issuance Fee _DMA N -
` above information is correct.I agree tocomply with all County Investigation Fee, .. /� ".,
orclmcmces•and.State'laws relating to building construction,
Total Fee JO- LDMA Perm. If
a and hereby authorize representatives of this County to enter
m upon the above-mentioned property for inspection,purposes. -
a
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or'Agent Date
COUNTY OF LOS ANG.Q-i S, �,. BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN - BUILDN DD -
" BUILDING AD RE
hereby affirm that 1 have a certificate of consent to self insure, J L� J ,
or a certificate of ,3800,5 Compensation Insurance, or certified r - n _
copy)thereof(Sea,380Q,..Lab.C.)� CITY zip/ _ a.¢ ,
LOCALITY
Policy No. Company SIZE OF LOT - "NO,OF BLDGS.NOW ON LOT
❑ Certified copy is hereby,furnished.
'❑ Certified copy is filed with the county building inspection TRACT - BLOCK - - LOT NO. -
Up ROment. - - - - _ USE ZONE MAP NO.
Date Applicant ASSESSOR MAP BOOK G PAGE . PARCEL
D SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' NE - L
COMPENSATION INSURANCE u�+c--[ cL- GI/ WITHIN 1000 FT.of SCHOOL' YEs No
This section need not 6e completed'if the eimit is for one hundred ADDR S
( P DISTRICT GROUP TYPE CONST FIRE ZONE ROCESSEDBV
dollars ($100)or less.) -
CITY ZIP
I certify that in the performance'of the work for which this permit �O y. �=p
is issued, I shall not employ any person in af]Y manne D-as t0 ARCHITECT OR ENGINEER- - - - TEL NO. -
becomeW;ctPoLt,,he WOrkers'90 lorf Laws. STATISTICAL CLASSIFICATION qPT CONDO
CA% .- _ - -. CLASS NO s�L/ DWELL UNITSADDRESSCE NT ter 'making this Certificate of UIRED 'TOTAL SETBACK FROM EXIST
Exemption; you ShOUI become sublect t0 the Workers' O L NK �i-� SET BACK YARD HW V PROP LINE WIDTH
Compensation provisions of the Labor.Code, you must forthwith, 7(r/ FRONT
- comply with such provisions or this permit shall be deemed revoked. gODRE nlt2LIC. �� / PL -
LICENSED CONTRACTORS DECLARATION SIDE
CITE 7 LIC.CLASS P L
Choppy affirm that I am licensed underprovisions of Chapter 9 SEWER MAP
(Commencing with Section 7000)of Division 3 o the Business and SO.FT.SIZE NO.OF STORIES N0:OF FAMILIES '
Professions Code,a y�l�ljc in full force and a `/ NEW ❑ ,BK 'PG D - }
License Num G�/ Lia Class - D RK 'ADD- ❑ VALUATION a
Contra '�� a r ALTER $ Z0 O
I e.eempt under Sec. REPAIR ❑ $ Q
BAP.C.for this reason DEMOL .❑ LMMA P/C.a LUU
Date: USE OF EXISTING BLDG. URM .❑
d
Signature5 - 1 -
A PLI 9,NT1 I J T N A Perm 4 _ Z.
1, as owner of the property, or my.employees with wages as U fes- / - ""Z ACCT:
their.sole compensahon;,will do the work and.the structure is AD 3303 '.242,Ej
not intended or offeredfor sale (Section 7044, Business and lAJ FINAL DATE //q� �_ 1' ITEMS- . -1
PIOf25510D5 COd2) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL
OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE J
❑ 1, as owner Of the property, am exclusively Contracting with AMOUNTS SPECIFIED HAZARDOUS MATERIALS INFORMATION GUIDES FINAL BY f j TOTAL - 242- 35
licensed contractors to Construct the project (Section 7044, ,/pyLiME
Business and Professions Code.) YES❑ NOp - /4.1[•tI/`, '` '}47 V�
WILL THE INTENDED USE MI THE BUICLINGCONSTRUCTION
BY THE APPLICANT ON RUTH.
T BUILDING WIC .00 ,
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION Ofl MODIFICATION G CHECKLIST
SOUTH f•L NCE'
- CONSTRUCTION LENDING AGENCY 'GUIDE AIR ouauTv 111��ygg11MPP/���cEMErvT olsrRlcro lscaornm SEE PERMrrnrvacHECKusT FOR - - - - 4n111'IVL. -
LINES
I hereby affirm that there is a construction lendini for YES[1 ry - (�� (]
the 7, Ci C.) Of the WOfk for WtllCh this permit is Issued(SCC. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING 0000-0001 -8,11/-/C
m 3g97, fiIV.Ci.) CHECKLIST. UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, _ �/
TITLE 2,CHAPTER 220 SECTIONS 220.100 THROUGH 2.20.Me CONCERNING HAZARDOUS 1p 1J 1 AM10 N 00
Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD. 8 A "1
F- Lender's Address
o _ avlueri oR nxFL
o I Certify that have read this application and state.under penalty _
O Of perjury that the above information is correct. agree f0 Comply RC.FEE - PERMIT FEE
IN -with 'all cou ty Fudinances State laws relating to building V
m cons ucho , and hereby a h rize representatives of thi County ISSUANCE FEE
w ent the abrNe- d property for insp(erypon urpos
�J INVESTIGATION FEE TOTAL FEE - -
SEE REVERSE FOR EXPLANATORY LANGUAGE -