HomeMy Public PortalAbout9969 BROADWAY_Building__ • APPLICATION FOR ,
OF LOS ANGELES
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN'. BUILD G
BUIL INt,A�ESS r ! L
I hereby affirm that I have a certificate of consent to self insure, C -
or a certificate of Workers'Compensation Insurance, or a certified
copy thereof
(Sec.3�8T00 Lab.C.) CITY_ �r zip;
Policy No. / ?7I L�� Company � LV`.� L III 76W LOCALITY
SIZE OF LOTNO.OF BLDGS.NOW ON LOT
C1 Certified copy is hereby furnished. "7Q � NEAREST CROSS ST.
Certified copy is filed with the county building inspection TRACT BLOCK LOT N0,
d ertm nt I , USE ZONE MAP NO.
Dat o-r � Applicant ��0__L_L ASSESSOR MAP BOOK PAGE PARCEL
!F e 671 C� CC/ SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' OWNEIj TEL NO.
COMPENSATION INSURANCE WITHIN 1000 FT.OF SCHOOLS YES No
(This section need not be completed if the permit is for one hundred ADDRE
dollars(S 100)Or less.) - � L' DISTRICT GROUP TYPE CONST FIRE ZONE PROCESSED BY
I certify that in the performance of the work for which this permit MY �'� ZIP �'
is issued, I shall not employ any person in any manner s0 as to ARCHITECT OR ENGINEER TEL LA0. J
become subject to the Workers'Compensation Laws. STATISTICAL CLASSIFICATION APT CONDO
Date Applicant ADDRESS CLASS NO. ? DWELL UNITS
NOTICE TO APPLICANT: It, after making this Certificate of REQUIRED' TOTAL SETBACK FROM EXIST
Exemption, you should become Subject t0 the Workers' CONTRACTOR TEL NO, 6--1
..• SET BACK YARD HWV PROP LINE WIDTH
Compensation provisions of the Labor Code, you must forthwith Com.'wt FRONT
comply with such provisions or this permit shall be deemed revoked. AD RESS LIC.NO, P L
LICENSED CONTRACTORS DECLARATION a .3` z SIDE
CR,'/ _ �/ LIC. ASS. P L
1 hereby affirm that I am licensed underprovisions of Chapter 9 � / _
(commencing with Section 7000)Of Division 3 of the Business and SO.FT. NO.OF GTO IES NO.OF FAMILIES SEWER MAP
Lt .T
Professions rode,and my license.is in full force and eft t. NEW ❑ BK PG o
DESGHIPT NOF WORK VALUATI N
License Number � Lia Class �-_ AJC ADD � -- o
Contractor L ' 2� Date �-��' �G� 2 ! TT-
ALTER i-l'i_
1 ❑ w
31 L3 14 'TOT'iL 60-4- o 90a
❑ 1 am exempt under Sec. REPAIR ❑ $ Q p a0, p•d _ .Z
J i+r : :
88P.C.for this reason DEMOL ❑ CDMA PIG z _•{'�CnfNt OLI4.`'LI—
Date: USE OF(fEXISTING BLDG. x URM ❑ � +L:-MANGE ,UIJ
Signature qp 4 06(PRINT) L.l TEL NO. CDMA Perm+t , f�:-i.i
❑ I,as owner of the property, or my employees with wages as P - Z r`,T- -1
Ofi,}:_fev_I {,II Iv,l
their sole compensation, will do the work and the structure is ADDRE^�5 ,�1, §ti3n�J!-`r
rat intended or offered for sale (Section 7044, Business and �' / �rW ( . I .1 - f17 RNAL Da� Q ,3-,c
Professions Code.) WILL THE APPLIG4NT OR FUTURE&11LDING OCCUPANT HANDLE A IUZAABUA MFTER
J
❑ I, as owner Of the property, am exclusively Contracting with AMOUNTS SPECIFIED ON THE HAZARDS MATERIALS INFORMATION GLADE? FINAL BY 7 A Ij A �•T
OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE
W
licensed contractors to construct the project (Section 7044, �-
Business and Professions Code.) YES❑ NO❑ J ' ��.". , ;�.._'7
WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING HENCE,'
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH Lt l
CONSTRUCTION LENDING AGENCY COAST AIR OUAUTY MANAGEMENT DISTRICT ISCAOMDI SEE PERMIT➢NG CHECKUST FOR
GUIDEUNES _THAL 359 - S9
1 hereby affirm that there is a construction lending agency for YES❑ NO❑
the performance of the work for which this permit is issued(Sec. �[;�.'� -ne.;_;c
p, IHAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCACMD PERMITTING
3097,CIV.C.) CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, ii r
\ TITLE 2,CHAPTER 2.20 SECTIONS 220 100 THROUGH 2,20 140 CONCERNING HAZARDOUS L.Tlyl'gl]E R I�I�
Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD.
o Lender's Address
p W NVI OR AGENT
o I certify that I have read this application and state under penalty
4 of perjury that the above information is correct.I agree to comply P.C.FEE C PERMIT FEE
N with all county ordinances and State laws relating to building T� �i�si t1
m Construction, and hereby authorize representatives of this County iT `y,.� ITSSUANCE FEE �O
m an,M ^ o the ab ve- entioned property for inspec on purposes.
INVESTIGATION FEE TOTAL FEE
m l
Mponr ar I
SEE REVERSE FOR EXPLANATORY LANGUAGE
APPLICATION FOR BUILDING PERMIT
FOR APPLICANT TO FILL IN (Prior or type only)
BUILDING COUNTY OF LOS ANGELES
ADDRESS C - DEPARTMENT OF COUNTY ENGINEER
CITY \
QkW ZIP C(\)KO BUILDING AND SAFETY DIVISION .
1. j NO.OF BLDGS. BUILDING
SIZE OF LOT NOW ON LOT 1 ADDRESS
TRACT BLOCK I LOT NO. LOCALITY
^�
TEL NEAREST
OWNER t 1 \ C NO. ' CROSS ST.
ASSESSOR
ADDRESS 1 MAP BOOK PAGE PARCEL
DISTRICT GROUP TYPE FIRE CESkS� BY
CITY ZIP U ��`d np CONST F.
ARCHITECT OR /� c TEL.
ENGINEER 0u-, NO' r)1yI1
�' STATISTICAL CLASSIFICATION
SEWER MAP
ADDRESS r: - L. CLASS NO.�__DWELL.UNITS C. BK //PG
TEL.
CONTRACTOR • NO US ZONE NOP LJ V
LIG ,/ SPECIAL
ADDRESS NO. I CONDITIONS
CITY . LIC.
(`AI CLASS ROAD DEPARTMENT APPROVAL REQUIRED YES NO
CONSTRUCTION LENDU ,,.
NAME AND BRANCH R 1 O I2) BLDGSETBACK FROM
O1�0 gyp. �� �� FRON PROP.LINE OF (STREET)
ADDRESS \ CITY R TOTAL SETBACK FROM TYPE OF EXISTING
HIGHW V } YARD
SQ. F _ NO. OF NO. OF CHECK FRONT PROP. LINE HIGHWAY WIDTH
SIZE STORIES ' FAMILIES I 'ONE
DES'C RI PT OF WORK QOE EW ❑ } O
BLDG.SETBACK U
L)UV ^ ADD S I DE PROP.LINE OF fSTREETI O
< ALTER ❑ HIGHWAY } YARD = TOTAL SETBACK FROM TV EXISTING U
REPAIR❑ SIDE PROP. LINE HIGNWA IDTH d
USE OF + = H
EXISTING BLDG. DEMOL ❑ I Z
APPLI CANL TEL CORNER CUTOFF YES C1 No 1:1(PRINT)
_C) 7Z LRWatwk
BY (SIGNATURE) IN OPEN SPACE YES ❑ NO ❑
- aa Cp IN COASTAL PERMIT ZONE YES [I NO ❑
VALUATIONS gQO V
I HEREBY ACXVOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY )
WITHALL ORDINANCES AND LAWS REGULATING BUILDING CO.- � 11U� f�df:�l3'-✓
STR UC TION, I CERTIFY THAT IN DOING THE WORK AUT NOR)ZEp
HEREBY I WILL NOT EMPLOY ANY PERSON IN VIOLATION OF THE
LABOR CODE OF THE STATE OF 'CALIFORNIA IN RELATING TO
WORKMEN'S CO MpE NSATION INSURANCE.
SIGNATURE O
PERMITTEE
ADDRESS t•�t T i°s
TEL.}yy` FINAL / _z1_7 L BY
CITY NO. Cl, ! DATE /! __71
/6 2
J1:1 KE L"HECI:S PAIAULE TO: PEE' PEE
:$
HARVEY T. BRAN DT, COUNTY ENGINEER
K. M.o. CASH / PERMIT VALIDATION' u
crc. N.o. sH
PLAN CHECK VALIDATION J
9 S U,FEB G6 i 6 2.2 S e c
1GA630A CII #BG3 5/74
7GA638A CE08D3 B-63 APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES ADDD" n &
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION LOCALITY
JOHN A. LAMBIE, COUNTY ENGINEER NEAREST —1
WILLIAM A. JENSEN, SUPT OF BUILDING CROSS ST. a-/
DISTRICT NO. I GROUP TYPE kCESSED BY
FOR APPLICANT TO FILL IN `s T CONST.
BUILDING �`` C+r STATISTICAL CLASSIFICATION SEWER MAP
ADDRESSIF
, �y BK PG
CLASS. NO DWELL. UNITS sC
LOT NO. / BLOCK WATER
CERTIFICATENOT REQUIRED RECEIVED
TRACT IF ❑
_ :
aS MAPHIGHWAr
SIZE OF LOT IG®l1- /��i NOW ON LOT0OFBLDGS . L
NO. 2Q �� IEIRCLEI STATECOAJSECON OCAL
USE ZONE SPECIAL
USE OF CONDITIONS
EXISTING BLDG. _ /
TEL.
OWNER ^/n�NO '}3 BUILDING EXIST.
,O /+ _ SETBACK YARD HWY STREET NAME WIDTH
ADDRESS -/ G, ,W7 71 FRONT
ARCHITECT OR 1 EL. P. L. ZL% rGQC �(1
ENGINEER NO. SIDE. /[1
ADDRESS Or.
TEL. Q
CONTRACTOR a �;/ NO. - V
ADDRESS III:
0
DESCRIPTION OF WORK
W
6
NEW ADD ALTERDEMOLISH N
SO. FT. NOEPAIR. NO. OF Z
SIZE STORIES FAMILIES
USE OF LZ
STRUCTURE >- �
In
SIGNATURE O
APPLICANT
VALUATION $ j3e
APPROVALS DATE INSPECTOR'S SIGNATURE
P.C. FIAT. FOUNDATION: LOCATION
FEE 5 FEE S �� FORMS. MATERIALS
FRAME: FIRE STOPS,
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION "ACING. BOLTS
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY FURNACE'. LOCATION.
WITH ALL COUNTY OROMANCES AND STATE LAWS REGULATING GAS VENT, DUCTS
BUILDING CONSTRUCTION. I CERTIFY THAT IN DOING THE WORK
AUTHORIZED HEREBY I WILL NOT EMPLOY ANY PER �V IN VIOLA- LATH. INT.
TION OF THE LABO - OF THE STATE O ALI WNIA RELAT-
ING TO WORKM'c NSgTION INSURANCE.
.� LATH. EXT.
SIGNATURE HOUSE NUMBER COR-
PERMITTEERECT AND POSTED
f i /
ADDRESS FINAL I2-IS-6 ¢-
JOHN F. LEWIS. PRINCIPAL ST URAL ENGINEER
PLAN CHECK VALIDATIONcK. M.D. GASH PERMIT VALIDATIO GK. M.O. CASH
LrICO 6 7 66DEC 1 4 1 D 11 ,50-
v
APPLICATION FOR BUILDING PERMIT E0
FOR APPLICANT TO FILL IN (Pt pt p. type only)
[ADDRESS
UILDING `l .�� �� COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
ITY' -Mp Q ZIP (A7NO,
7 BUILDING AND SAF DIVISION
NO.OF BLDGSBUILDING
IZE OF fL�OT/� F NOW ON LOT ADDRESS
RACT I J V BLOCK LOTnni� LOCALITY
BAREST
OWNER
R NOL y$ ��1 CROSS ST. ;
ASSESSOR
ADDRESS MAP BOOK PAGE PARCEL
DISTRICTGROUP TYPE FIRE SSED BY
CITY�� C ZIP 0 CONST ZONE O
ARCHITECT OR TEL. �.0 �- w�C-Z
ENGINEER W NO. III qlAr)I STATISTICAL CLASSIFICATION
NO-VI SE WE'R/ AP
4
ADDRESS q� �, V CLASS . _DWELL.UNITS Z Bry PG
CONTRACTOR N0. fRO
NE MAP
LIG. NO'
ADDRESS _ NO. SPECIAL
LIC. CONDITIONS
CITY CLASSCONSTRUCTION LENDS EPARTMENT APPROVAL REQUIRED YES NONAME AND BRANCH ': s%l-r SETBACK FROM PROP.LINE OF (STREET)
ADDRESSa�� V CITYCOY } YARD - TOTgL SETBq CK FROM TYPE OF EXISTING V
SQ. FT ^^� ,�,, NO. OF NO. OF CHECK - HIGHWAY WIDTH DEC
SIZE ��e-K/ STORIES FAMILIES ONE FRONT PROP. LINE CD
DESCRIPTION OF WORK qpp N D�L�`! NEW ❑k.H
}
ELI
ETBACK FROM y
� p 011 pQ 5` ,Y ADD BOP.LINE OF (STREET) Z
ALTER ❑ } YA RO - TOTAL SETBACK FROMTYPE OF EXISTING
REPAIR❑ SIDE PROP. LINE HIGHWAY WIOTR
USE OF +EXISTING BLDG. DEMOL ❑
APPLICANT TEL CORNER CUTOFF YES ❑ NO
(PRINT) ND.BY (SIGNATURE) N SPACE YES NO
Q5TAL ZONE YES NO
VALUATION Y CA. EGORICAL EXEMPTION YESC] NO
HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION ENVIRONMENTAL
ARE
STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY IMPACT EY PTIO ECLARATION SIGNED (DATE)
WITHALL ORDINANCES AND LAWS REGULATING BUILDING CDN-
ST RUC TION. I CERTIFY THAT IN DOING THE WORK AUTHORIZED M C RPP RT PROCESSED (GATE)
HEREBY I WILL NOT EMPLOY ANY PERSON IN VIOLATION OF THE
LABOR CODE OF THE STATE OF CALIFOR A IN RELATING TO /
WORKMEN'S COMPENSATION INSURA HCE. �J
I Y
SIGNATURE OF /
PERMITTEEr.
ADDRESS C N
TEL.
FINAL .�/ BY
CITY NO. 7 DATE Y
)LIKE CHLC -KS YABLL' 10; FEE $ FEE
HARVEY T. BRANDT, COUNTY ENGINEER L^
PLAN CHECK VALIDATION N. Mo. CASH — JPERMIT VALIDATION cK. M.D. LASH
o61�Ul iU2 'S 45.4 ' Ayd
76g633A CEU803 12/72 /'.I
APPLICATION FOFnjB..LJILDING PERMIT
FOR APPLICANT TO FILL 1 Io, D�o tvoe oHw
BUILDING Q �. A COUNTY OF LOS ANGELES
ADDRESS DEPARTMENT OF COUNTY ENGINEER
CITY / - C��.z1P q�2r'q)?,,
BUILDING AND SA DIVISION
NO.OF BLDGSBUILDING G y�
SIZE OF LOT
r/'\ NOW ON LOTADDRESS
TRACT�.S dvS BLOCK LOTLOCALITY
,/ TEARESTOWNER /`[ NOSS ST.
pp ASSESSOR
ADDRESS / ( '�(� (T MAP BOOK PAGE RCEL
CITV�� / 1 ZIP /�J U DISTRICT GROUP TYPE FIRE RO ESSEO BY
���� ONS T. ZONE \
ARCHITECT OR TEL.
ENGINEER S' - �^ NO.
STATISTICAL CLASSIFICATION EWER MAP
ADDRESS S/v M rz CLASS NODWELL.UNITS BK// PG
CONTRACTOR /SMC.+ NOL o2U USE ZONEMAP
LIC. NO. U
ADDRESS S M!Z NO. SPEC AL
CITY CC LIC. CONDITIONS
M I✓ CLASS ROAD DEPARTMENT APPROVAL REQUIRED YES❑ NO❑
CONSTRUCTION LENDER
NAME AND BRANCH No" rL BLOG.SETBACK FROM
FRONT OP.LINE OF GNEY (STREET)
ADDRESS CITY HIGHWAY + YARD TOTAL SETBACK TYPE OF EXISTING
SQ. FT. ST I NO. OF CHECK FRONT PROP. LINE HIGHWAY WIDTH
512E STORIES FAMILIES ONE
(� d
DESCRIPTION OF WORK AAP. 43, OF NEW B D
�^ . / ADD ❑ BLDG.SETEtA OM C.1
yb IT.IL SIDE PROP.LINED (STREET) ¢
�F �_ �I 1 // i
ALTER ❑ HIGHWAY + YARD = TOTAL SETBACK FROM TYPE OP EXISTING V
`y G REPAIR❑ �/1 S10E PROP. LINE HIGHWAY WIOTHH �y
EXISUSE OTING BLDG, EMOL ❑ + /✓ 1/00 Z_
APPLI CANTLEQma, Co�1 R OL ,1� CORNER CUTOFF YES ❑ NO ❑
PRINT) q
BY ISIGNATUR IN OPEN SPACE YES ❑ NO ❑
VALUATION$ q0 / o
IN COASTAL PERMIT ZONE YES ❑ NO ❑
�0 q /J ,1
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION / �2 V OG II I r4 \
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY �q
WITH ALL ORDINANCES AND LAWS REGULATING BUILDING CON- rN T // O� .I L.
ST RUC TI ON. CERTIFY THAT IN DOING THE WORK AUTHORIZED
HEREBY I WILL NOT EMPLOY ANY PERSON IN VIOLATION OF THE
LABOR CODE OF THE STATE OF 'CALIFORNIA IN RELATING TO
WORKMEN'S COMPENSATION INSURANCE.
SIGNATURE OF
PERMITTEE 1.. G�
ADDRESS Y� 3/w
1 L�J TE Lz5" 9y7111 FINAL DATE BY
CITY 11:1"1P1_�z C1Tl NO. � 7- 7� / / , ✓//,�,Jy�
.IIA KE CHECKS PA7"ABLE 7O: P.C. $ PMT.,Q
FEE' FEE Y
HARVEY T. BRANDT, COUNTY ENGINEER
PLAN'CHECK VALIDATION CH. M.o. CASH P MIT VALIDATION cH, o. DASH
0 8 rrwc 1 0 1 5.0 0 `0
]BA630A CER005 5/74
APPLICATION FOR BUILDING PERMIT
FOR APPLICANT TO FILL IN (Prlm or Ivoe oHIv)
B LDING COUNTY OF LOS ANGELES
ADDRESS DEPARTMENT OF COUNTY ENGINEER
CITY ZIP V BUILDING AND SAFETY DIVISION
0.OF BLDGS. BUILDING ^
SIZE OF LOT OW ON LOT ADDRESS / ' J
TRACT BLOCK LOT NO. LOCALITY
TEL. NEAREST
OWNER CROSS ST. I
ASSESSOR
ADDRESS MAP BOOK PAGE PARCEL
DISTRICT IGROUPITYPE 41RE
Y
CIT 1 ZIP �✓ yo� CONS�j.
ARCHITECT Cr— -hQlTEL ENGINEER O. STATISTICAL CLASSIFICATION ADORES , VflCLASS NO.3 DWELLUNITS
CONTRACT USE ZONE[MAP rJ/1OQ
LK. '/T NO.
ADDRESS O. -� CON
ONS
CITY LIC C Cl S
A56 ROAD DEPARTMENT APPROVAL REQUIRED YES NOE]
CONSTRUCTION LENDER
NAME AND BRANCH SLOG.SETBACK FROM
FRONT PROP.LI NE OF (STREET)
ADDRESS CITY
HIGHWAY } YARD TOTAL SETBACK FROM TYPE OF EXISTING
SQ. FT // NO. OF NO. OF CHECK FRONT PROP. LI I< HIGHWAY WIDTH
SIZE ,; 3p STORIES FAMILIES 'ONE
} - 1
D CRIPTION OF WORK NEW J
ADD 10 BLDG.SETBFROM
AZAA SIDE PROP.LIN LINE OF _(STREET) LC
ALTER ❑ = T T LSE BACK FROM TYPE OF EXISTING 4~.l
,I H ❑ HIGHWAY } YARD EPAIRIDE ROP. LINE HIGHWAY WIDTH Ly
1
USE OF } = n
EXISTING BLDG. DEMOL ❑ Z
APPLICANT TEL-)C) a CORNER C TOFF YES ❑ NO
(PRINT) NO. o
IN OPEN SPACE YES 0 NO ❑
BY (SIGNATUR�)
IN COASTAL PE MIT ZONE YES ❑ NO
VALUATIONS
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION _
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL ORDINANCES AND LAWS REGULATING BUILDING CON-
STRUCTION. I CERTIFY THAT IN DOING THE WORK AUTHORIZED
HEREBY I WILL NOT EMPLOY ANY PERSON IN VIOLATION Of THE
LABOR CODE OF ST TE OF 'CALIFOR IA IN RELATING TO
WORKMEN'S COMP S TI N INSURANCE.
SIGNATURE OF A
PERMIT
7
ADDRESS
FINAL BY
'Y TEL. o DATE
CITY NO.�
P.C. Q PMT.,$
dIA FF CHECKS P.11'rIBLE TOr FEE2 FEE D
HARVEY T. BRAN DT, COUNTY ENGINEER /
K
PLAN'CHECK VALIDATION cK. M.D. CASH _ PERMIT VALIDATION CH. o. CASH
044PnnT 823 D 21.15
76A638A CE%903 5/74
APPLICATION FOR BUILDING PERMIT
FCA'�.A'PPLICANT TO FILL IN (PHat Or tvPB GRIY)
BUILDING ' £ o aGn DEPARTTMECOUNNT OF COUNTYY OF LOS GELES
ENGINEER
ADDRESS
CITv ( _ CA — ZIP BUILDING AND SAFETY DIVISION
O.OF BLOGS. BUILDING
SIZE OFi LOT (l ��I Z� NOW ON LOT ADDRESS
TRACT BLOCK I LOT NO. I LOCALITY NEAREST
OWNER l_e'0 t�% CO P—e NOLZ 946/ CROSS ST. `�.�1T-tJ��icN'•s-+�,
/� _ ASSESSOR
ADDRESS - �O/-N MAP BOOK PAGE PARCEL
/` LDISTRII/CC,,T 'GROUP TYPE FIRE`( PRO ESS/ED BY
CITY J"l. I -�M . ZIP �� ) 0cP .6.f�i i` CONST. ZONE
\ - Y-r��
ARCHITECT O _ M TEL nt
ENGINEER -1 1I ie'S NO. w
STATISTICAL
CC��__ / SEWER AP
ADDRESS%OIO SO. R�(��-rSa� CLASS NO. - � / OWELL,UNITS F BK// PG
CONTRACTOR 1 NEOL33�0�8 USE ZONE MAP "3,^
/� LIC. NO,
C/
ADORES A'z.V NO. ��I SPECIAL
LIC. CONDITIONS
CITY N CLASS �-J ROAD DEPARTMENT APPROVAL REQUIRED YES❑ NO C]CONSTRUCTION LENDER
NAME AND BRANCH BLDG.SETBACK FROM
FRONT PROP.LI NE OF (STREET)
ADDRESS CITY
SO. F . NO. OF NO. OF CHECK HIGHWAY } YARD = TOTAL SETBACK FROM HIGHWAY EW pTIHG
.FRONT PROP. LINE
SIZE STORIES FAMILIES ONE
} = d
DESCRIPTION OF WORK NEW O
U
ADD BLOG.SEBACK FROM
SIDE PRO INE OF (STREET) O
ALTER ❑ HIGHWAY } YA _ TOTAL SETBACK FROM TYPE OF EXISTING U
711
REPAIR❑ OP. LINE HIGHWAY WIDTH Ww
USE OF + = n
EXISTING BLDG. DEMOL ❑ z
APPLICANT TEL CORNER CUTOFF YES El NO
(POINT) I N0.
BY (SIGNATURE)TUREI y / IN OPEN SPACE YES [:1 NO ❑
t_- IN COASTAL PERMIT ZONE YES ❑ NO ❑
VALUATIONi — I TQQ
1 MEREBT ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION ON
ANO STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL ORDINANCES AND LAWS REGULATING BUILDING CON- //7'7 NQr/6� Z l(3�yF PGgj�'Y
STRUC TI ON. 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 'CA FORHIA IN RELATING TO 4-17776-,0V �0 Vlff'�
WORKMEN'5 COMPEN TION INSURANCE.
SIGNATURE OF
PERMITT
ADDRESS
FINAL ' /
TEL. DATE
CITY �� NO.
MAKE CHECKS PA)ABLE TO: P.C. $ PMT. -
HARVEY T. BRANDT, COUNTY ENGINEER FEE' FE
PLANCHECK VALIDATION 0.-- M.0. CASH PERMIT VALIDATION cK M.o. CASH
69941SEp 1721 070O�SF 17 . 1 0 35.25Ab
1 0.5 8 Apt - -
76A638A CE#803 5/74
WORKERS' COMPENSATION DECLARATION
hereby affirm fI have certificate of consent to self APPLICATION FOR BUILDING PERMIT C,lul�
insure, or o certificate of Workers' Compensation Insurance,
oro certifiedied I (Sec. 3800 . C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No Company
Certified copy is hereby furnished. BUILDING
❑ FOR APPLICANT TO FILL IN ADDRESS
❑ Certified copy is filed with he county 'ng inspec- BUILDING / ri
tion deportment. - ADDRESS f'J G.
Dale / Applica CITY ZIP LOCALITY .
CER IFICATE OF EXEMP FRO WORKERS' SIZE OF LOT OX I ZL NO. OF BLDGS. NEAREST
COMPENSATI INSU NCE m6 NOW ON LOT CROSS ST. Or
(This section need not be c pleted if the permit is for one �.30 OS ASSESSOR
TRACT BLOC - .
hundred dollars ($100)or less.) LOT NO. MAP BOOK PAGE PARCEL
r" TEL USE ZONE MAP
OWNER /
permit
that in the performance of the work for which this NO. NO.
permit is issued, I shall not employ any rson in any manner / //�� SPECIAL
so as to become subject to the Wor r C mpensation ws. ADDRESS l/� CONDITIONS O
Date ! App licanT AIRCHITECT OR ZIP TEL.
NOTICE 7 APPLICANT: If, of making-this Certificate of DISTRICT GROUP TYPE FIRE OCESSED BY O
Exemption, ENGINEER NO.
p you should be< a sub'ect to the Workers' /y} CONST. ZONE U
Compensation provisions of the Labor Code, you must forth- ADDRESS p Ld
with comply with such provisions or this permit shall be
deemed revoked. EL. STATISTICAL CLASSIFICATION APT.
CONTRACTOR NO GYa'G Z
LICENSED CONTRACTORS DECLARATION LIC CLASS NO. DWELL. UNITS_
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS ,6 NO. .2,
(commencing with Section 7000)of Division 3 of the Business and LIC SEWER MAP
Professions Code, and my license is in full force and effect. CIT CLASS 3/p BK PGVALIDATION
SO. FT. NO, OF NO.OF CHECK
License Number—' / Lic.Class SIZE STORIES FAMILIES ONE
VALUATION
ADD
Contract g DESCR TION OF WORK NEW ❑ 9
ate ,jJ ❑ Fo ,
❑ I am exempt under Sec. _ {�� ALTER ❑
B.BP.C. for this reason /F REPAIR ❑ $
Date: USE OF
EXISTING BLDG. DEMOL ❑
Signapithot
APPLICANT TEL. FINAL 2
WNER-BV LD DECLARATION PRINT NO. DATE
1 hereby a I a exempt from the Contractor's LicenseLaw for towing reason (Section 7031.5, Business and ADDRESS FIN
Professions Code): R N
❑ BUILDING
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). CC B QQ A
CONSTRUCTION LENDING AGENCY RE BACK YARD HWY TOTAL PROP,ACK FROM
LINE WIDTH T A^ V
I hereby affirm that there is a construction lending agency for FRONT
the performance of the work for which this permit is issued P.I. �70�
(Sec. 3097, Civ. C.). SIDE
P.L.
Lender's Name
33./3 LDMn Ret. x / t1/3, 63
m Lender's Address P.C. Fee E Permir Fae �_
I certify that I have read this application and state that the Issuance Fee ld LDMA P/C N C�"I
above information is correct. I agree to comply with all County Investigation Fee x / '.�� Y_ g�
ordinances and State laws relating to building construction, Total Fee f�J yLDMA perm. N
and Wreby out representatives of this County to enter
$ upo he abov -men 'oned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Sign re of Applicant or Agent pate
WORKERS' COMPENSATION DECLARATION
hereby affirm that I have certificate of consent to self APPLICATION FOR BUILDING PERMIT
insure, or a certificate of Workers;Compensation Insurance,
or a certified copy thereof (Sec. 3800, Lob, C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS BUILDING ' E
0.
❑ Certified copy is filed with the county building inspec- BUILDING
tion department. ADDRESS - Y W4
Date Applicant CITU ZIP � 7�d LOCALITY 2.w (� -+
NO. OF BLDGS. NEAREST 1T T� aa �
CERTIFICATE OF EXEMPTION FROM WORKERS' SITE OF LOT NOW ON LOT CROSS ST, 1J Yo 4lJ.Lx.9G- d-- J JLUI V,
COMPENSATION INSURANCE ASSESSORTg p r /��
(This section need not be completed if the permit is for one TRACT BLOCK LOT NO. MAP BOOK 13 o G PAGE 0IJ PARCEL 4W
hundred dollars ($100) or less.) l 1 I. USE ZONE MAP
OWNER V C_ew' L�C01O tL-ZJQ- -�s _ / NO.
I certify that in the performance of the work for which this SPECIAL d
permit is issued, I shall not employ any person in any manner ADDRESS 'T`O WG- CONDITIONS O
so as to become subject to the Workers' Compensation Laws. b 0
CI YZIP
Date OR Applicant ARCHITECT TEL. a'
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO DISTRICT GROUP TYPE FIRE PROCESSED BY O
CONST. NE H-
Exemption, you should become subject to the Workers- - ! (/ `/ 0-
Compensation provisions of the Labor Code, you must forth- ADDRESS � �J QO �',3 V 0-
with
with comply with such provisions or this permit shall be TEL STATISTCA CIA$SIFiCAitO APT. CONDO. Z
deemed revoked. CONTRACTOR t(ZO NO.
LICENSED CONTRACTORS DECLARATION LIC CLAS O. D ELL. U ITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO.
(commencing with Section 7000)of Division 3 of the Business
I.C. SEWER MAP
and Professions Code,and my license is in full farce and effect. CITY CLASS BK PG VALIDATION
50. FT. NO, OF NO. OF CHECK
License Number Lic. Class SIZE STORIES FAMILIES ONE
VALUATION
Contractor Date DESCRIPTION OF WORK h 'E-h tC, NEW ❑ $ poo
ADD pool
Elexempt under Sec. +t G 4s+s
ALTER ❑
B.BP.C. for this reason REPAIR ❑ $
Of
Dater EXISTIING BLDG. Ss �e (+G r.w
2' t1�lMe_ DEMOL ❑
APPLICANT FINAL
Signature TEL
OWNER-BUILDER DECLARATION (PRINT) NO. DATE �D
I hereby affirm that I am exempt from the Contractor's License -
Law'for the following reason (Section 7031.5, Business and ADDRESS FINAL i
.Professions Code): PRESENT By
IF�]Ij BUILDINGI_i_�
y
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 'r J..J
7044, Bus(ness and Professions Code.) MOVING TEL.
�y
I, as owner of the property, am exclusively contracting CONTRACTOR NO.
ADDRESS /// Q�e- � €T^I ~�
with licensed contractors to construct the project (Sec- ,y ,f t_ ,
tion 7044, Business and Professions Code.) _ sr „� - _
REQUIRED TOTAL SETBACK FROM EXIST. i
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH
s -
hereby affirm that there is a construction lending agency for FRONT •' I e,li l
the performance of the work for which this permit is issued P.L.
t hANG
(Sec. 3097, Civ. C.). - SIDE -
Pt.
Lender's Name.
Q LDMA Ref. # _
P,C. Fee$ Permit Fee 01 "177
3
Lender's Address , l
I certify that I have read this application and state that the Issuance Fee 17S LDMA P/C g
8 above information is correct. I agree to comply with all County Invesngalion Fee /
ordinances and State laws relating to building construction, Total Fee LDMA Perm. q
a and hereby authorize representatives of this County to enter
m u n e above-mentioned pro rty for ipspection purposes.
a /l
J/—ZS-1 I SEE REVERSE FOR EXPLANATORY LANGUAGE _
Signature of Applicant or Agenl Date
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 0007180009
PHONE: (626) 285-0488 EXT:
LEGAL ID: NO. OF CONST BUILDING ADDRESS:
TR: 13805 LT: 1 SQ. FT STORIES TYPE 9969 BROADWAY
STRUCTURE: 0 VN TEMP CA 917802635
ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET: BALDWIN
8588-015-001 THOMAS PAGE: 597 GRID: A3 LOCALITY: TEMPLE CITY
TENANT: EXIST BLDG USE: REBID USE ZONE: R-1 ISSUED ON: PROCESSED BY: EXPIRES ON:
EXIST OCC GRP: 07/18/00 UT 01/15/01
OWNER:- TEL. N0: BLOBS. NOW ON LOT: VALUATION: FINAL DATE FIN L BY: CODE:
MAICHROWICZ VINCENT H;DEBORAH L - 1 20,000
9969 BROADWAY i-10-c>(
TEMP 917802635 FEES PAID DESCRIPTION OF WORK
KITCHEN REMODEL IN EXISTING SQ. FT.
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT:
APPLICANT: TEL. N0:
TOM O'LEARY CONS. - AA BLDG PERMIT ISSUANCE 27.75
5823 AGNES AC STRONG MOTION RESID 20000.00 VAL 2.00 SPECIAL CONDITIONS:
TEMPLE CITY, CA D2 PERMIT W/O EN-HC!77--`20000.00 VAL 384.60
STOT`AL-FEES 414.35
TOM
CONTOA'LEARY CONSTRUCTION (818)CTOR: TEL. N 287-0927- ,/ �Q5 �n✓AL APPROVALS DATE INSPECTOR SIGNATURE
5823 AGNES AVENUE LIC. NO s LOCATION AND SETBACKS
TEMPLE CITY, CA 91780 489354 B-1
SOILS ENGINEER APPROVAL
ARCHITECT OR ENGINEER: TEL. N0: /p/ � -�-�� � \\ FOUNDATION/TRENCH FORM
LIC. NO:4/ SLAB/UNDER FLOOR
RAISED FLOOR FRAMING
MAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP.: i UNDERFLOOR INSULATION
147H269 3 �
FLOOR SHEATHING
NO. OF FAMILIES: DWELLING UNITS: APT/GOND: STAT CLASS:--—-- -- - - -- - ,
NO 21 - V / I' ROOF SHEATHING
O �
SCHOOL WITHIN HAZARDOUSL'
AIR QUALITY: 1000 FEET MATERIALS 5Ti � T'• SHEAR PANELS
NO NO NOj FRAME INSPECTION
o '._ �s
REQUIRED TOTAL SETBACK FROM EXIST '-� FIRE SPRINKLER HANGERS
SET BACK YARD: HWY: PROP LINE: WIDTH: Vb/' _ �p<
FRONT PL- 7C Servc_e'%ha�� INSULATION/WEATHER STRIP
SIDE PL- -_
L,INTERIOR LATH/DRYWA4l G
EXTERIOR LATHtV
we
RATED FLOOR/CEIL ASS M.
RATED WALL ASSEMBLIES
RATED SHAFTS/OPENINGS
T-BAR CEILINGS
LOT DRAINAGE
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 0511280072
PHONE: (626) 285-0488 EXT:
LEGAL ID: NO. OF CONST BUILDING ADDRESS: )
TR: 13005 LT: 1 SQ. FT STORIES TYPE 9969 BROADWAY /
STRUCTURE: 400 VN TEMP CA 919802635
ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET: BALDWIN
8559-015-001 TPGYA9 Parc: 591 GRID: 112 LOCALITY: TEMPLE CTTY, C
-,... .. . -.•.. 'C:fE: CS SLED ON: .:i3I6EE 0:.:
EXIST OCC GRP: 11/28/05 SK 11/23/06
OWNER: TEL. NO: BLDGS. NOW ON LOT: VALUATION: FINAL DATE FINAL BY: CODE:
MAICHROWICZ VINCENT H;DEBORAH L - 1,700 .Y--
9969 BROADWAY 1-2
TEMP 917802635 FEES PAID DESCRIPTION OF WORK
(REPAIR) REMOVE ROOFING FROM 2 SIDES OF ROOF REINSTALL SAME
FEE DESCRIPTION: QUANTITY: DOM: AMOUNT: PROTEX SHARES
APPLICANT: TEL. NO:
TEMPLE CITY ROOFING, CO. - AA BLDG PERMIT ISSUANCE 27.75
1216 BEGNONIA COURT AC STRONG MOTION REBID 1700.00 VAL 0.50 SPECIAL CONDITIONS:
UPLAND, CA 91784 D2 PERMIT W/O EN-HC 1700.00 VAL 82.20
FR INV WORK W/O PERMIT 257.00 DOL 257.00
TOTAL FEES 367.45
CONTRACTOR: TEL, NO: APPROVALS DATE INSPECTOR SIGNATURE
TEMPLE CITY ROOFING CO. (909) 608-0622-
1216 BEGONIA COURT LIC. NO LOCATION AND SETBACKS
UPLAND, CA 91784 HIC
SOILS ENGINEER APPROVAL
ARCHITECT OR ENGINEER: TEL. NO: FOUNDATION/TRENCH FORMS
LIC. NO: SLAB/UNDER FLOOR
RAISED FLOOR FRAMING
MAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP: UNDERFLOOR INSULATION
147H269 3 01
FLOOR SHEATHING
NO. OF FAMILIES: DWELLING UNITS: APT/CONDI STAT CLASS:
NO 21 ROOF SHEATHING
SCHOOL WITHIN HAZARDOUS j SHEAR PANELS
AIR QUALITY: 1000 FEET MATERIALS
NO NO NO FRAME INSPECTION
REQUIRED TOTAL SETBACK FROM EXIST FIRE SPRINKLER HANGERS
SET BACK YARD: HWY: PROP LINE: WIDTH:
FRONT PL- INSULATION/WEATHER STRIP
SIDE PL- INTERIOR LATH/DRYWALL
jEXTERIOR LATH
RATED FLOOR/CEIL ASSEM.
RATED WALL ASSEMBLIES
RATED SHAFTS/OPENINGS
T-BAR CEILINGS
ADDITIONAL DATA ON FILE
LOT DRAINAGE
REPORT ID: DPR261 ROUTE TO: BS0508
COUNTY OF LOS ANGELES TEMPLE CITY k 0508 BUILDING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ALTERATION/REPAIR
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 BL 0508 1208200007
PHONE: (626) 285-0486 EXT:
ILEGAL ID: I NO. OF CONST I BUILDING ADDRESS:
ITR: 13805 IT 1 SQ. FT STORIES TYPE 9969 BROADWAY
I (STRUCTURE: 2900 V-B TEMP CA 917802635
(ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET: BALDWIN
18588-015-001 THOMAS PAGE: 597 GRID: A3 LOCALITY: TEMPLE CITY, Cl
1TENANT: II EXIST BLDG USE: RESID USE ZONE: R-1 (ISSUED ON: PROCESSED BY: I
EXIST OCC GRP: 108/2J/12 SR
(OWNER: TEL. NO: IBLDGS. NOW ON LOT: VALUATION: IF TrIT FI L Y: CODE:
MAICHR0WICZ VINCENT H;DEBORAH L - 10,500 i
19969 BROADWAY I r
ITEMP 917802635 FEES PAID DESCRIP ION OF WORK
IREMOVE CALSHAKE ROOF INSTALL 1/2 OSE PLYWOOD ON SOME SECTION(
(FEE DESCRIPTION: QUANTITY: DOM: AMOUNT: IS AND INSTALL LIFE TIME COMP CLASS "A" FIRE RATED SHINGLED I
APPLICANT: TEL. NO: I (AND RIDGE CAP
KEEFERS, BRIAN (909) 608-0622- IAA BLDG PERMIT ISSUANCE 27.80 1 1
1216 BEGONIA COURT IAB STATE GREEN BLDG FEE 10500.00 VAL 1.00 SPECIAL CONDITIONS: I
UPLAND CA 91784 IAC STRONG MOTION RESID 10500.00 VAL 1.10 1 1
D2 PERMIT W/O FN-HC 10500.00 VAL 233.40
TOTAL FEES 263.30
((CONTRACTOR: TEL. NO: I APPROVALS DATE INSPECTOR SIGNATURE I
IKEEFER'S ROOFING (909) 608-0622- 1 1
11216 BEGONIA COURT LIC. NO I
1 LOCATION AND SETBACKS
UPLAND CA 91784 760903 C39
SOILS ENGINEER APPROVAL
I
(ARCHITECT OR ENGINEER: TEL NO I IFOUNDATION/TRENCH FORMS I
ISLAB/UNDER FLOOR
I LIC. NO:
I ARISED FLOOR FRAMING
MAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP: 1 (UNDERFLOOR INSULATION I
1147H269 3 coI 1 11
I I IFLOOR SHEATHING I
INO. OF FAMILIES: DWELLING UNITS: APT/COND: STAT CLASS: I I
I 0 NO 21 (ROOF SHEATHING 1
I SCHOOL WITHIN HAZARDOUS SHEAR PANELS 1/
1AIR QUALITY: 1000 FEET MATERIALS I
I NO NO NO 1 (FRAME INSPECTION
I I IFIRE SPRINKLER HANGERS
(INSULATION/WEATHER STRIPI
IINTERIOR LATH/DRYWALL
IEXTERIOR LATH
RATED FLOOR/CEIL ASSEM.
I 1 (RATED WALL ASSEM1IDLIES I I I
(RATED SHAFTS/OPENINGS
T-BAR CEILINGS
I I I
1LOT DRAINAGE I I I
I REPORT ID: DPR261 ROUTE TO: BS0508
1