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Home My Public Portal About5004 DOREEN AVE_Building__ TRA6]9i EEA8030-.� APPLICATION: FOR-BUILDING PERMIT . COUNTY OF LOS ANGELES BUILDING DEPARTMENT OF COUNTY ENGINEER ADDRESS BUILDING AND SAFETY DIVISION LOCALITY C JOHN A. LAMBIE. COUNTY ENGINEER'. `NEAREST WILLIAM+A. JENS EN. SUPT OF BuILOING CROSS ST. - DISTRICT NO. GROUP. T E R CESSED'BY - FOR APPLICANT TO FILL IN. O CONST. t BUILDINGI STATISTICAL CLASSIFICATION I tEWER MAP - ADDRESS /) - ' �/ CLASS. NO. DW ELL.UNITS BK G LOT BLOCK WATER -" CERTIFICATE: NOT REQUIRED ❑ RECEIVED.❑ TRACT. .!" - -MAP "—H ICHwgv- STATE MAJOR SECOND. L CAL NO.OFBLDGS. NO. p/ IRC LEI ` SIZE OF LOT NOW,ON LOT USE ZONE -SPECIALUSE OF ♦ CONDITIONS EXISTING BLDG.. / / - TEL. OWN NO. BUILDING ,YARDHWY STREET NAME EXIST: SETBACK. WIDTH .ADDRESS -FRONT I / ARCHITECT OR Qa. - STEL. P. L: ENGINEER s NO. SIDE ADDRESS y CONTRAC 5,-TEL: Q ADDRESSTOR NO:• ,y ^� r, 0/� O D SCRIPTION OF WORK. NEW .ADD ALTERREPAIR ' DEMOLISH -, — i• Z SO. FT. NO. OF NO. OF I SIZE STORIES FAMILIES USE OF /-(,or STRUCTUR L�(�(/ LGLI�I/LL - ( y I SIGNAT RE OF L ' APPLICANT - VALUATION $ -�-� - APPR-OVA LS' I �7 //)DATE�J INSP �ECT OR'$�SIGNATURE - F E $ �� FEE $. FOUNDATFORMS• MATERIALS 91,;LOCATION HEREBY HAT THE ABOVE THAT HAVE READ GREE TO CO TIONWITH BRACING, BOLTS 2% /� K� AND STATE .THAT THE ABOVE IE CORRECT AND AGREE REGULATING COMPLY . O FURNACE: LOCATION. - - BUIL ALL COUNTY TIO, I CE5 ANO STTTE LAWS THEWRK GAS VENT. DUCTS A BUILDING CONSTRUCTION. CERTIFY THAT IN DOING THE WORK' - TFONOF THE HEREBY I WILL NOT EMPLOY ANY PERSON IN REDLY- LATH. INT. - TIG OF THE LABOR CODE' SA THE STATE OF CALIFORNIA RELAT. INGTO WORKMEN'S COMPENSYT ON INSUR E. LATH. EXT. - SIGNATURE OF L� �' �]_/ HOUSE NUMBER COR- - PERMITTEE 7f�"" RECT AND'POSTED O ADDR ESS - J FINAL" '• -JOHN F. LEWIS. PRINCIPAL STRUCTURAL ENG. PLAN CHECK VALIDATION CK. M.o. ;CYSH PERMIT VALIDATION DK. MD. EASH ;: ; . u ico 7 5 .3.2 ^ JUL 16 1 D 6.0 0- s . ¢ � APPU AMOK FOR BULDING PERT �'•+.+^A'� COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS hereby affirm that BUILDING have a certificate of consent to self insure. or a certificate of WorkersCompensation Insurance,Or a Certified �1 copy thereof (Sec.3800,Lab.C.) CITY ` - _ '\ L. ZIP Policy No.e)4t 4-,, -,I if- Company '�� I r \ t -Qui G�� LOCALITY SIZE OF LOT NO OF BLDGS.NOW ON LOT ++%✓/ ��- / // + `❑`'Certified copy is hereby furnished. NEAREST CROSS ST / ,J- ❑ Certified copy is filed with the county building inspection TRACT BLOCK LOT NO. 1 1 �'L de ASSESSOR USE ZONE , MAP NO. Date -;I Z♦"I-I C. Applicant I I I�� .5. ASSESSOR MqP BOOK PAGE ' PARCEL SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER TEL NO. COMPENSATION INSURANCE WITHIN 1000 FT OF SCHOOL? YES NO I (This section need not be completed if the permit is for one hundred ADDRESS dollars 1$100)or less.) S J�"1 ��-N?�,l}1 /\4� DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY CITY ZIP certify that in the performance of the work for which this permit - ) "t t 1\�\ 1=_ Cr\\� j is issued, shall not employ any person at any manner so a5 to T I'A /,OUR I.fa- become subject to the Workers'Compensation Laws. ARCHITECT OR ENGINEER TEL NO. 1 .Q C.r-,.L 71 STATISTICAL CLASSIFICATION APT CONDO Date Applicant ADDRESS GLASS NO DWELL UNITS NOTICE TO APPLICANT. If, atter making this Certificate Of C-\QLIL A REQUIREDLYARD TOTAL SETBACK FROM EXIST Exemption, you Should become Subject to the Workers' CONTRACTOR ' TEL NO. SET BACKMWV PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith �l fy 1151h1\'l c\9N `S CFi- i fl:.'i \.) FRONT 0- comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC.NO, P L O n LICENSED CONTRACTORS DECLARATION 1)'Al\\�� `>f L —IC C I ZT"7 b BIDE Ed CITY T LIC CLASS P L W I hereby affirm that I am licensed underprovisions of Chapter 9 SEWER MAP J (commencing With Section 7000)of Division 3 of the Business and SO.FT SIZE NO.OF STORIES NO F FAMILIES lL Professions Code,and my license is in full force and effect. I , I NEW ❑ BK PG D Ol License Number �LD 51�' Lia Class -I DESCRIPTION OF WORK ADD ❑ VALUATION Q Contractor i-Iln h'1"•tN It Date '\.{7 L.{•in K=�J CP•v.IC_CJ C_1{�k.w\ti�� ALTER '❑ $ 0- J.\�L' C.. \_: C. . REPAIR ❑ El am exempt under Sec. $ B.SPC. for this reason1+� .-I\ �\;�TFi DEMOL ❑ Edd LDMA P/C x Date: usE OF EXISTING BLDG. URM ❑ 1 Signature APPLICANT(PRINT) TEL NO. LOMA Perm A w ,a tt-s:�ti Z ACCT., ❑ I, as owner of the property, or my employees with wages as f1IA I`IA lh.i\� �\. �+� nL"•I'i io their sole compensation, will do the work and the structure is ADDRESS., n _ O 3303 326.815 not intended Or offered for Sale (Section 7044, Business and �•U \>�?- 'x`{15 {�Vi tYl�Iv\\T �y;?A) ( � Pln� FINAL DATE Q Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A NAZAROpUS MATERIAL 1 ITEMS OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE J (� LL ❑ I, en owner Of the property, am exclusively contracting 44, AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE4 FINAL BY 1 TOTAL 326 Business contractors to construct the protect !Section 7044, YES❑ No ti rvn�Ml aC Business and Professions Code.) (�,fIE`.r\ S26+.05- WILL THE INTENDED USE OF THE BUIDUNGCONSTRUCTION BY THE APPLICANT OR FUTURE BUILDING OCCUPANT REQUIRE q PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH pl I/,tlrE�IJr� CONSTRUCTION LENDING AGENCY COAST AIR OUAUTY MANAGEMENT DISTRICT ISCAGMD)SEE PERMITTING CHECKLIST FOR NO CE I hereby affirm that there is a construction lending agency for YES NOS /Y�[ J the 7,performance Of the WOfk for WtllCfl this permit IS 155UCd(Sec. IHAVE READ THE HAZARDOUS MATERIALSINFORMATION GUIDE AND'HE SCAOMDPERMITTING 0000-00-01 3/,(,Q/51E 3097,t)IV.D.) CHECKTIT LE 2LIST.I UNDERSTAND MY RCHAPTER 2 20 SECIONEQUIREME2 20 100NTS UNDER THE LOS ANGELES COUNTY CODE, ir Lender's Name I Q` �• I A C'\1` MATERIALS RIIPORTING ANDTFORSOBTAIN NGTA PERMIT FROM HEOSCAOMO 14 0 G HAZARDOUS 5519 L CU12 A Y4 Lender's Address ZNPOICA. VAIL 3 I certify that I have read this application and state under penalty 0- of perjury that the above information is correct. agree to Comply ur with all county ordinances and State laws relating to building W construction, and hereby authorize representatives of this County ISSUANCE FEE .� to enter upon thye ab we-mentioned property for inspection purposes. w I ` ,\N, + o ` �.'7I,1A INVESTIGATION FEE TOTAL FEE SEE REVERSE FOR EXPLANATORY LANGUAGE 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 0711090013 PHONE: (626) 285-0488 EXT: LEGAL ID: NO. OF CONST BUILDING ADDRESS: ITR: 11290 LT: 80 BL: .001 SQ. FT STORIES TYPE 5004 DOREEN AV ISTRUCTURE: 13 VN TEMP CA 91]80343] (ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET: 1 18585-022-041 THOMAS PAGE: 597 GRID: C4 LOCALITY: TEMPLE CITY, Cl ITENANT: (EXIST BLDG USE: REBID USE ZONE: R-1 (ISSUED ON: PROCESSED BY: EXPIRES ON: IEXIST OCC GRP: 111/09/07 SR 05/07/08 TOWNER: TEL. N0: IBLDGS. NOW ON LOT: VALUATION: IFINALT FIMMNAL BY: CODE: TERRAZONE, DONNA - 5,360 /�/ 6 15004 DOREEN AV ` ITEMP 91]80343] FEES PAID (DESCRIPTION OF WORK IREROOF HOUSE ONLY TO REMOVE (E) ROOFING TO THE SHEAT W/OSB 1 IFEE DESCRIPTION: QUANTITY: DOM: AMOUNT: IPLYWOOD d THEN INSTALL 30 YR FIBER GLASS THREE DIMENSOAL CLA (APPLICANT: TEL. N0: ITOMAS L. (626) 285-9011- IAA BLDG PERMIT ISSUANCE 27.75 1585 N. HILL AVE UNIT IAC STRONG MOTION REBID 5380.00 VAL 0.54 ISPECIAL CONDITIONS: 1 PASADENA, CA 91006 ID2 PERMIT W/O EN-HC 5380.00 VAL 149.40 1 TOTAL FEES 177.69 (CONTRACTOR: TEL. NO: (APPROVALS DATE INSPECTOR SIGNATURE IHAUKOM ROOFING INC. (626) 233-0771- 1585 N. HILL AVENUE UNIT 1 LIC. NO (LOCATION AND SETBACKS (PASADENA, CA 91106 438338 C39 TSOILS ENGINEER APPROVAL ARCHITECT OR ENGINEER: TEL. NO: FOUNDATION/TRENCH FORMS I LIC. NO: (SLAB/UNDER FLOOR RAISED FLUOR FRAMING MAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP: I (UNDERFLOOR INSULATION 14]H2]3 3 Oil I_ 11 I IFLOOR SHEATHING NO. OF FAMILIES: DWELLING UNITS: APT/COND: STAT CLASS: NO 21 iA00F SHEATHING I,. b 11 SCHOOL WITHIN HAZARDOUS (SHEAR PANELS VI (AIR QUALITY: 1000 FEET MATERIALS I -NO NO NO JFRAME INSPECTION I I 11 (REQUIRED TOTAL SETBACK FROM EXIST IFIRE SPRINKLER HANGERS ISET BACK YARD: HWY: PROP LINE: WIDTH: I IFRONT PL- INSULATION/WEATHER STRIP I SIDE PL- I - TINTERIOR LATH/DRYWALL (EXTERIOR LATH I IRATED FLOOR/CEIL ASSEM. I RATED WALL ASSEMBLIES (RATED SHAFTS/OPENINGS IT-BAR CEILINGS ADDITIONAL DATA ON FILE I (LOT DRAINAGE REPORT ID: OPR261 ROUTE TO: BS0508 I I I I I I COUNTY OF LOS ANGELES TEMPLE CITY # 0508 j BUILDING PERMIT DEPARTMENT OF PUBLIC WORKS 9071 LAS TUNAS ALTERATION/REPAIR BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA _ BL 0508 9608280029 PHONE: (818) 285-0488 .EXT: EGA ID: NO. OF CONST BUILDING ADDRESS: TR: 11290 LT: 80 BL: .001 SO. FT STORIES TYPE 5004 DOREEN AV STRUCTURE: 0 V TEMP CA 917803437 ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET: LOWER AZUSA RD. 8585-022-041 THOMAS PAGE: 597 GRID: C4 LOCALITY: TEMPLE CITY TENANT: EXIST BLDG USE: RESID ISSUED ON: PROCESSED BY: EXPIRES ON: EXIST OCC GRP: 08/28/96 TC 08/28/97 OWNER: TEL. NO: BLDGS. NOW ON LOT: VALUATION: FINAL DATE FINAL BY: CODE: TERRAZONE, DONNA (818) 575-0652- 1 2,000 5004 DOREEN AV TEMP 917803437 FEES PATO DESCR�IPTIOF OF WORK ALTERATION TO MASTER BATH NO NEW SQ. FOOTAGE APPLICANT: L. NO- FEE DESCRIPTION: QUANTITY: UON: AMOUNT: DIAMOND CONSTRUCTION (909) 396-8363- AA BLDG PERMIT ISSUANCE 27.75 AC STRONG MOTION RESID p— 2000.00 VAL 0.50 SPECIAL CONDITIONS: D2 PERMIT W/O EN.-MC 1 P-- 2000.00 VAL 82.20 ' 9.. TOTAL FEES 110.45 V' to CONTRACTOR: TEL. NO:. ®J _ APPROVALS DATE INSPECTOR SIGNATURE DIAMOND CONSTRUCTION (909) 396-8363- (�,q P. 0. BOX 5811 LIC. NO ®Psa LOCATION AND SETBACKS DIAMOND BAR, CA 91765 7024768 � SOILS ENGINEER APPROVAL ARCHITECT OR ENGINEER: TEL. NO: F�f10N TR CH OR 5 LIC. NO: SLAB/UNDER FLOOR ,p�p RT FLOOR FANG MAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: LMP: PU B U C W®�KS UNDERFLOOR INSULATION 147H273 3 01 N0. OF FAMILIES' DWELLING TS: /CO STAT CLASS: O 0 •'' } r^ FLOOR SHEATHING- NO HEA HI GNO 21 O O ROOF CHEATHING SCHOOL WITHIN HAZARDOUS Y� D O`v SHEAR PANELS AIR QUALITY: 1000 FEET MATERIALS NO NO NO O _\�` FRAME INSPECTION REQUIRED TOTAL SETBACK FROM EXIST _ .^+ `el ,��111 FI E P RI KLER HANGERS SET BACK YARD: HWY: PROP LINE: WIDTH: E?�i �('M(p FRONT PL- g `` INSULATION/WEATHER STRIP SIDE PL- ce INTERIOR LATH DRYWALL EXTERIOR LATH 1 RATED FLOOR/CEIL ASSEM. RATED WALL ASSEMBLIES RFTWEDSHA TS/OPEN NGS T-BAR CEILINGS OT DRAINAGE REPORT ID: DPR261 ROUTE TO: 5S0508 D63-3 SSM SETS 6-4L Jif EIF DEPAli1'MENT 40F BUILDING AND SAFETY APPLICATION RhIIT COUNTY OF LOS ANGELES g V l I, P I N G WM. J. FOX. CHIEF ENGINEER FOR APPLICANT TO FILL IN FOR OFFICE USE ONLY DISTRICT NO. PLAN CK. NO. PERMIT NO. BUILDING i ADDRESS 17 LOCALITY ��/ T / RECEIVED BY DATE OF APPL. DATE ISBII[D / NEAREST CROSS BT. , O BUILDING / OWNER [ [J/f/hrC�d1 ! ; ADDRESS MAIL ♦ f LOCALITY ADDRESS - ADD /) / "8"1 7 5 1- N� NEAREST ✓ /l� L`��,Q TELyo --sc I CR055 BT. NO .E. (1RiFIRE I NO.of I TYPE -i I GROUP ARCHITECT C ' .�� TEL. ZONE PLANS ENGINEER NO. BLDG. �j ORD. No. SETBACK LIN[ ADDRESS APPROVED TCL. BY DATE CONTRACTOR NO. USE APPROVED ZONE BY DATE ADDRESS -/ LEDAL /Y I BLDCK CORRECTIONS D E9CRIPTION 'LJOT ND. TRACT / V r a NO. OF SLOGS. SIZE.or LOT/OO ) I NOW ON LOT USE EX Of LD No. or 3.. ♦ I f!I FAMILIES / I RD Mo C DESCRIPTION OF WORK NEW ALTERATION ADDITION O A REPAIR OVIN DEMOLISH BO• FT. 00 .or / SIZE !ROOMS STORIES WALL ROOF COVERING I IC13VERINO USE OF NEW U BUILD D to � Rv el APPROVALS I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS INSPECTOR DATE APPLICATION AND STATE THAT THE ABOVE 19 CORRECT FOUNDATION: LOCATION. - AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES FORMS, MATERIALS AND STATE LAWS REGULATING BUILDING/CONSTRUCTION. FRAME: FIRE STOPS. BRACING. BOLTS •^✓YNL✓ SIGNATURE OF - OWNER ' /- '__ _- - _ LATH. INTA AUTHORIZE AOT � ..LATH. IXT.I P. D. PLASTER. INT. FEE `�`(� PLASTER. EXT. VALUATION ✓�"� C� FE[ (] ✓ FINAL 1 APPLICATION FO.1 .DING PERMIT COUNTY OF LOS ANGELES" . " '' BUILDING AND SAFETY DING ADDRESS FOR APPLICANT TO FILL IN _ WORKER'S COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self insure, BUILDING or a certificate of Workers' Compensation Insurance,or a certified O� �Q��GN I• copy thereof (Sec.3800,Lab.C.) CITY R ZIP C� kt`L--�i1�46 cl � L,�i G\ +� LOCALITY Policy NO. Company �• :� 512E OF LOT NO.OF BLDGS.NOW ON LOT i3Certifie l copy is hereby furnished. NEAREST CROSS ST. ❑ Certified copy is filed with the ou ty binding inspection TRACT BLOCK LOT NO f'sL JSIE* \ departman (( USE ZONE MAP NO. 73 Date 9D Applicant ASSESSOR MAP BOOR PAGE PARCEL j� ' -- �+1' .� / SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS; OWNER TEL NQ. 1. L COMPENSATION INSURANCE h.\ r IE- JS"(3(0SZ WM-IN 1000 FT.OF SCHOOL( YESSCONM (This section need not be completed if the permit is for one hundred ADDRESS Q'� ,� DISTRICT GROUP TYPE CONST. FIRE ZONE BY dollars ($400)Or less.) CITY ZIP I certify that in the performance of the work for which this permit � G`*�-1 r is issued, 1 shall not employ any person in any manner so as tO become subject t0 the Workers'Com enation Laws. ARCHITECT OR ENGMEER TEL NO D C G ^t\ — STATISTICAL CLASSIFICATION a- oDate Applicant ADDRESS CLASSNO. �L DWELL UNITS NOTICE TO APPLIGINT.' If, after making this Certificate Of e.� C\LUA..k� Ohl { REQUIRED TOTAL SETBAExemption, you should become subject tG the Workers' CONTRACTOR TEL NO. SET BACK YARD HWY PROP LI Compensation provision of the Labor Code, you must forthwith 1 ti.l. C alcf,- '0 36> FROM comply with such provisions or this permit shall be deemed revoked. A KESS�` LIC,NO P L } r�lWk 1 -7Q'2-L[-7k- SIDE O' LICENSED CONTRACTORS DECLARATIONOU GIT LIG CLASS P L I hereby affirm that I am_licensed underprovisions of Chapter 9 ` 'T�lu� 6( �-4' �� L f� SEWER MAP (commencing with Section 7000)Of Division 3 of the Business and - SO.FT.SIZE NO.OF STORIES NO. F FAMILIES C NEW [1 eK �- PG J F- Professions Cotle,and my license is in full farce and effect. _ F-. License Number ��Z�17 b C_lo DESCRIPTION OF WORK _ ADD ❑ VALUATION L`i,, Lic. Class Contractor Date �I2FI56 GCO I ALTER ❑ $ �S CL Z CQzT, W't\ 1e'- ❑ I aexempt Un Cs'J1y Sec. REPAIR ❑ $ Z m B.BP.C.for this reason _ \p\ DEMOL ❑ LDMA P/C Af Date: USE OF EXISTING BLDG. URM ❑ i Signature APPLICANT(PILN7) TEL N0. LDMA Perm r ACCT.AT AT 1 A�N� CO�S� 1 - 96-9363 z ' 1, as owner of the property, Or the employees with wages as ;2. nr their sole compensation, will do the work and the structure is ADDRC, ,5103 J .ti•''"= net intended Or offered for Bale (Section 7044, Business and '\rO ` 1� ��°LTIOM\ 9t7bS FINAL DATE Q 1 IT-II Professions Code. (� I WILL THE APWCANT OR FUTURE BUILDING OCCUPANT HANDLE A XAZARDWG MATERIAL C ❑ as owner Of the property, am exclusively contracting with OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EOUAL TO OR GREATER THAN THE Q ;I J} _ 8 p p y y g AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY ' TOTAL ,�.a-'- licensed contractors to construct the project (Section 7044, + " - Business and Professions Code.) TEs❑ No •�, �„ CHECK 3_¢:,"t: WILL THE INTENDED USE OF THE BU10.1NG BY THE APPLICANT OR FUTURE BNLOING OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH Ir i HANGE •I-'� CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT ISCAOMDI SEE PERMITTING CHECKLIST FOR GUIDELINES I hereby affirm that there is a construction lending agency for YES NO ' the performance of the work for which this permit is issued Sec. !T_ (1; ;�r'i ,„' h 3097,CIV.t) ( IHAVEREADTfGIANIU. RS MATE INFORMATION GUIDE AND THE SOAOMDPERMITTING •V ODO'.j 0J•31 CHECKL18T.1 Y REWIREMENTS UNDERTHE LOS ANGELES COUNTV CWE,e TILE Y,CHA0B TIONS 220.100 THROUGH 2.20.1<D CONCERNING HAZARDOUSCC�.'ILender's Name � cT-A--c-A GS C_ nn MATERIALS RG FO 0 AWING A PERMIT FROM THE SCAOMD. �1-1='+� Lender's Address 2 .-QP, e_.0.[,\.:d MONY. TraGa n o�meP oK e.r 1 certify that I have read this application and state under penalty R- P.O.FEE PERMIT FEE p of perjury that the above information i0 carred. agree t0 comply ell�5;�- with all county ordinances and State laws relating to building NI constructs n, and he by authorize representatives of this County ISSUANCE FEE l0 enter a Cn t abC1� erentioned property for inspection purpD e0. D dI INVESTIGATION FEE TOTAL FEE ' j �. mw SEE REVERSE FOR EXPLANATORY LANGUAGE ate, APPU,CAMO l FO .M0NIG f�[�f�NT . �•'• ��,,.. 'j COUNTY OF LOS ANGELES - BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN . ..vV G ADDRESS T�p�� ' BUILDING RESS - w�A7 I hereby affirm that I have a certificate of consent to self insure, or a certificate of Workers' Compensation Insurance,`or a certified copy thereof (Sec.3800.Lab.C.) CITY /i �" ZIP ` (�Z14A-h686 eC i1 L•Li G\ 1 LOCALITY P��OIi��Gy N0. Company SIZE OF LCT NO OF BLDGS.NOW ON LOT IS-Certified Copy IS hereby furnished. NEAREST CROSS ST. ❑ Certified copy'a filed with the o ty bu ding inspection TRACT BLOCK LOT NO. AL 1 1 Caper Men (( USE ZONE MAP NO/�� ,h,a 73 Date q0 Applicant ASSESSOR MAP BOOK PAGE PARCEL /, R- SPECIAL CONDITIONS CERTIFICATE OF EXE ION FROM WORKERS' OWNER TEL NO. COMPENSATION INSURANCE 5r1 t&- 75-06SZ WITHIN I000 FT OF scnoo�� ves No (This section need not be completed if the permit is for one hundred ADDRESS - tlollars (5100)or less.) DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY , CITY - 'ZIP I certify that in the performance of the work for which this permit D� is issued, I shall not employ any person in.any manner so as to �LC =/r become subject to the Workers'Compensation Laws. ARCHITECT OR ENGINEER TEL NO, L-A1 P C G ^iL _ 0- STATISTICAL CLASSIFICATION , APT CONDO Date Applicant • ADDRESS p CLASS NO. �S1_ DWELL UNITS NOTICE TO APPLICANT: If- after making this Certificate of e. Ck�L-� O l� REOUIRED TOTAL SETBACK FROM EXIST _ Exemption, you should become Subject to the Workers' CONTRACTOR TEL NO. SET BACK YARD HWV PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith �-OC-Qt-4'�T FRONT comply with such provisions or this permit shall be deemed revoked. AV LIC.NO P L } t�fWk ` -702-�.7� SIDE d LICENSED CONTRACTORS DECLARATION aT 2^^ LIC CLASS PL - I hereby affirm that I am licensed underprovisions of Chapter 9 ��VI Ot`1Y� 1�^�[ �' �•� I SEWER MAP ' (commencing with Section 7000)of Division 3 of the Business and SO.FT SIZE , NO.OF STORIES NO.QFF ILES NEW ❑ BK PG y Professions Code,arid.my license is in full force and effect. l License Number HOZ 3 0 21 b Lic.Class G-lo DESCRIPTION OF WORK ADD ❑ VALUATON D - W GCO 1��TLJ ALTER ❑ �S Contractor�-�fC�ate -�12(,�5'6 $ _ z ❑ 1 am exempt un Sec. REPAIR ❑ $ Z BAP.C.for this reason �� SfpY DEMOL ❑ LOW P/C r Date: USE OF EXISTING BLDG. URM ❑ { Signature APPLICANT'(PRI2 TEL NO. LDMA Perm r 1 A hA�t�A CONS\ f - 96-8363 Z ACCT.T ❑ I,their owner of the property, or my employees with wages as ? VC their sole compensation, will dothe work and the SIrUCWre is ADDR S _ 0 3.�0.�i - J�6• not intended or offered for sale (Section 7044, Business and Wo `fz) SRIF p91W FINAL DATE a0 1 ITEMS P(OfC5510n5 Code.) WILL THE APPLICANT OR.FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL I� 1 _ ❑ I, as owner of the property, am exclusive) contracting Wlm OR A MI%TURE CONTANING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE v Q TOTAL m ��' y g AMOUNTS SPE01 EO ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY � licensed contractors to construct the project !Section 7044, - . ,� I� " e Business and Professions Code.) YES C1 NO CHEC:Kt -32 6..O WILL THE INTENDED USE OF THE SUIDLINo BY THE APPLICANT OR FUTURE BUILDING OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH CHANGE -.00 CONSTRUCTION LENDING AGENCY COAST AIR OUAUTY MANAGEMENT DISTRICT ISCAOMI SEE PERMITTING CHECKLIST.FOR I GUIDELINES , I hereby affirm that there is a construction lending agency.for YES N0 the performance Of the work for which this permit is issued(Sec. S 0(�Q(�_QQ11 3/26/96 (HAVE READTPD�ERATA.iU.Y`A.T6'CUIREMENTS PW $ RIALS INFORMATION GUIDE AND THE BCAOMO PERMITTING � , ' 3097, CIV.C.) CHECKLIST,I UNDER THE LOS ANGELES COUNTY CODE. F4dLN E 2 CHA0 S TIONS 220100 THROUGH 2.20.140 CONCERNWG HAZARDOUS I/ CC37 1 PM 12 44 Lender's NameC�') G"�L MATERIALS RG FO O INING A PERMIT FROM THE$CADMO ='� Lender's Address 2 K-006 0"Q-C.L-� Re.DA e I certify that I have read this application and state under penalty a of perjury that the above information is correct. agree PC.FEE PERMIT FEE p /J �C m with all county ordinances and State laws relating too Comply building O� J m construct . a d he by authorize representatives of this County ISSUANCE FEE- , to enter BIT tf abc a-mentioned property for inspection purPo;sis. Q —�2t,lm INVESTIGATION FEE TOTAL FEE a SEE REVERSE FOR EXPLANATORY LANGUAGE