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Home My Public Portal About9147 EMPEROR AVE_Building__ • -;t: r WORKER' COMPENSATION DECLARATION t t h/j I y r�J t `� //�/ ure fiFmto certif carte of Workers' ComI have'atpennsat on of coent Insuran elf APPLICATION FOR BUILDING PERMIT or a certified copy thereof (Sec. 3800, Lab. C. COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No._ Company ❑ Certified copy is hereby furnished-, x FOR APPLICANT TO FILL IN BUILDING PY P [AD ING ADDRESS J MPO 2 n rt M v L 444 Certified co s filed wit t e c nt byi ins ec- yttii/on deportment. -r- EESSS I /�'(/°D ' v FY J`1 P L £ G �'� Date ` +� !��8 Applicant �� / ry t. LE- CzT ZIP r LOCALITY L CERTIFICATE OF EXEMPTION FROM WORKERS' NO. OF BLDGS. NEAREST COMPENSATION INSURANCE' OF-CO7 JxNOW ON LOT ROSS ST.(This section need not be completed if the permit is for one T (/ BLOCK LOT NO. V ASSESSOR hundred dollars ($100)or less.) MAPBOOK PAGE PARCEL J . , U TEL6 USE Z NE MPER H NO.2 B I _ I certify that in the performance of the work for which this Z � NO. permit is issued, I shall not employ any person in any anner f�'l 4 SPECIAL ' so as to becomesubjectto the Workers'Eompensa on aws. ADDRESS CONDITIONS 0 Date • •�"' `�5 Applicant CITY ZIP NOTICE TO APPLICANT: If, after making tARCHITECT OR TEL. his Certificate of DISTRICT GROUP I TYPE FIRE 5:ESSED BY O Exemption, you should become subject to the Workers' ENGINEER NO. "�"` CONST. / ZOO U Compensation provisions of the Labor Code, you must forth- ADDRESS with comply with such provisions or this permit shall be aw TEL.57-)? STATISTICAL CLASSIFICATION APT. CONDO. to deemed revoked. CONTRACTOR eSt01 f 4� CG NS?. NO. 3'9��0 z LICENSED CONTRACTORS DECLARATIONIC. CLASS NO. DWELL. UNITS — I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS�BIb S-SA^'�oryrr+'�t�BCONO. 22)914 (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. CITY 54d <o.a.19r ie'L CLASS 9—/ 14 VALIDATION SQ. Fl;t. NO. OF / CHECK BK' P('' License Number T Lic.Class SIZE /. STORIES f FAMILIES ONE C� �Q VALUATION Contractor/2n 0 SEP41662 C*-4r Date I 8 �`� DESCRIPTION OF WORK NEW ❑ s / �j G ❑ I am exempt under Sec. �/j� n/� Al f•I-- ADD q ALTER B.&P.C. for this reason a/LC>TF3T' M. � D jST. REPAIR ❑ $ Date: USE OF EXISTING BLDG. 1b O�� N C'V. DEMOL ❑ Signature APPLICANT TEL. FINAL v OWNER-BUILDER DECLARATION PRINT) J�tmo gr�C�E2 NO. sZ3-f//0 DATE �Q U 9 4 9. 1 A I hereby affirm that I am exempt from the Contractor's License ADDRESS L8`6 S.S�►�a. £� G VC/_ S / # o 0.0 0 0 . Law for the following reason (Section 7031.5, Business and i•tic Q / FINAL Professions Code): 11 PRESENT BY a J 90.50 BU MING I, as owner of the property, or my employees with ADDRESS o o 90.5 0 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. OIL 2 9 8 8 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). REQUIRED TOTAL SETBACK F CONSTRUCTION LENDING AGENCY SET BACK YARD HWY 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 L LDMA Ref. # P.C. Fee$ Permit Fee (/ V Lender's Address i 1 certify that I have read this application and state that the h o Y PP Issuance Fee �V I LDMA P/C# above information is correct. I agree to comply with all County Investi .tion Fee 0 ordinances and State laws relating to building construction, g Total Fee r LDMA Perm.+# and hereby auth ere resentatives of this County to enter m n the above menti ed pr rty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Sign ture of Applicant or Agent Date } DEPARTMENT OF BUILDING AND SAFETY APPLICATION FOR PERMIT COUNTY OF LOS ANGELES B U I L 1 N G WM. J. FOX, CHIEF ENGINEER ®� FOR APPLICANT TO FILL IN FOR OFFICE USE ONLY DISTRJ16T NO. PLAN CK.NO. -PERMIT NO. BUILDING q /� ADDREBB A LOCALITY EI` Y DATE OF APPL�p`yf/j(/p�'�DATE ISSUED / NEAREST (/ ! CRDSS BT. D `® BUILDING OWNER � !,f� ADDREBB MAIL 1�J1 v v C LOCALITY_ +moi ! <I s ADDRESS J �y "'X47 - NEAREST j TEL. CROBB ST. CITY NO. FIRE NO.OF' TYPEGROUP_�-—' ARCHITECTOR TEL. ZONE — PLANS �- ENGINEER NO. BLDG. /�� RD.NO. ADDRESS SETBACK LINE I P. 7 APPROVED TEL. BY DATE CONTRACTOR NO. • USE / APPROVED ADDRESS ZONE BY DATE LEGAL CORRECTIONS DESCRIPTION c LL�OT NO. BLOCK 1 TRACT �� / NO.OF SLD09. SIZE OF LOT f/, (/ / NOW ON LOT USE OF NO.OF 0'7 EXISTING BLDG. FAM NO.I FAMILIES / I ROOMS DESCRIPTION OF WORK NEW ALTERATION ADDITION �n Yt_�I.r-� �(�Ut n,. .�, •��- 11�I / O REPAIR MOVING DEMOLISH •,Z--'��- �/ �� 54.FT. NO.OF _ . . ZD SIZE ROOMS STORIES WALL ROOF '" '"' r COVERING I COVERING USE OF-NEW BUILDING .mvJ i t I HEREBY ACKNOWLEDGE THAT•1 HAVE READ THIS APPROVALS APPLICATION AND STATE THAT THE ABOVE IS CORRECT FOUNDATION: LOCATION INSPECTOR DATE AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES FORMS,MATERIALS AND STATE LAWS REGULATING BUILDING CONSTRUCTION. FRAME: FIRE STOPS, SIGNATURE O BRACING,BOLTS PERMITTE�!.� /' ii/!/�fif/� I�_ LATH,INT.: AUTHORIZED AOT LATH,EXT.: oe9-3 SUM sera i-aB $ P.C.B PLASTER,INT. /1 FEE PLASTER,EXT. >8 VALUATION FEE FINAL ��"'`�' `� �JV APPLICATION FOR BUILDING PERMIT COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN Blt DDRESS r G� I hereby affirm that I have a certificate of consent to self insure, Buap ADgRE � (��C �"\ or a certificate of Workers'Compensation Insurance,or a certified ��77Cvv^ Xt copy thereof(Sec.3809,Lab.C.) Q C ^ ' ZI O LOCAL^ e , L r Com �n �-�E�IGP `- �''�1�lNkl` \��Y\ \ Policy P SIZE OF LOT BLDGS.NOW ON LOT ❑ Certified copy is hereby furnished. NEAREST CROSS ST. Certified Copy is filed with the county building inspection TRACT BLOCK LOT NO. deepjartmennt`._ A USE ZONE MAP NO. Date ` �` Al plicant 1�� ASSESSOR MAP BOOK PAGE PARCEL SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' WNE TEo - ` YES NO COMPENSATION INSURANCE _ WITHIN 1000 Fr.OF SCHOOL? (This section need not be completed if the permit is for One hundred r l �N� L DISTRICT GROUP TYPE CONST.' FIRE ZONE PROCESSED BY dollars($100)or less.) ZIP I certify that in the performance of the work for which this permit �i`.. R \ n 97:z) , b �' Y, ,3 is issued, I shall not employ any person in any manner so as to ARCHITECT OR ENGINEER TEL.NO. •J become Subject to the Workers'Compensation Laws. STATISTICAL CLASSIFICATION APT CONDO Date Applicant ADDR CLASS NO. DWELL UNITS NOTICE TO APPLICANT. If, after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST EL.N Exemption, you should become subject to the Workers' CONTRACTOR O. t SETBACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith •— s � FRONT comply with such provisions or this permit shall be deemed revoked. DR SS C NO. PL V F_Q Uv m LICENSED CONTRACTORS DECLARATION CIn SIDE P L a e, v I hereby affirm that I am licensed under provisions of Chapter 9 SEWER MAP (commencing with Section 7000)of Division 3 of the Business and SQ.FT.SIZE NO.OF STORES NO.OF FAMILIES C NEW ❑ BK PG Professions Code,and my IicQgse�s in full force ayr�ej�er� SCRIPTION OF WORK ADD ❑ AAALLLuuu License Numbe �� Lic.Class��,llj { r � �� y Contra r- iOtti1 `"F1a►� ALTER ❑ z ❑ I am exempt under Sec. N REPAI $ BARC.for this reason i DEMOL C3LDMAP/C# Date: OF EXIST^GBL URM. ❑ Signature L CANT(PRINT) zE�•I�q q LDMA Perm# S ❑ I, as owner of the property, or my employees with wages as �b O ?�-1-N`_� their sole compensation,will do the work and the structure is SS i1-j not intended or offered for sale (Section 7044, Business and FINAL DATE C .,r3=( _- =' - "�#! Professions Code. WI LL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL J j, OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN Q iiL:?•= ❑ I, as owner of the property, am exclusively contracting With THE AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL Y^�' 1�+ licensed contractors to construct the project.(Section 7044, ves❑ NO❑ u `" `2 ob Business and Professions Code.) WILL THE INTENDED USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING V OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH ) CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FOR GUIDELINES. I hereby affirm that there is a construction lending agency for YES ElNO 11the performance of the work for which this permit is issued(Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD 3097,CIV.C.). PERMITTING CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES ( i •— =i. aD. COUNTY CODE,TITLE2,CHAPTER 2.20SECTIONS 2.20.100THROUGH 2.20.140 CONCERNING i"1_[its--{ 1 (,L 't/.i."I'r 7 Lender's Name HAZARDOUS MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD. — Lender's Address OMER OR�GEW i =1 9,-47 o' I certify that I have read this application and state that the above P.C. EE PERMIT FEE information is correct. I agree to comply with all county . ordinances and State laws relating to building construction,and c� _ hereby authorize representatives of this County to enter upon ISSUANCE FEE / above-mentio rope ty for inspection purgose t3the INVESTIGATION FEE TOTAL FEE �•�, a a SEE REVERSE FOR EXPLANATORY LANGUAGE ' 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 1205240063 PHONE: (626) 285-0488 EXT: ILEGAL ID: NO. OF CONST BUILDING ADDRESS: ITR: 11990 LT: 10 SQ. FT STORIES TYPE 9147 EMPEROR AV I (STRUCTURE: V-B SGAB CA 917752018 ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET: 15382-012-031 THOMAS PAGE: 596 GRID: H1 LOCALITY: TEMPLE CITY, Cl TENANT: JEXIST BLDG USE: RESID USE ZONE: R-1 JISSUED ON: PROCESSED BY: 1EXIST OCC GRP: 105/24/12 SR I I 1 I I OWNER: TEL. NO: IBLDGS. NOW ON LOT: VALUATION: IFINAL DATE FINAL BY: CODE: ICHEN, STEVEN - 1 1,000 1 I 19147 EMPEROR AV I I ISGAB 917752018 1 FEES PAID IDESCRIPTION OF WORK I I IKITCHEN REMODEL I I FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: ( I (APPLICANT: TEL. NO: I I I IWU, JACK (626) 523-5819- IAA BLDG PERMIT ISSUANCE 27.80 1 1 1650 W. HUNTINGTON AV ;AB STATE GREEN BLDG FEE 1000.00 VAL 1.00 (SPECIAL CONDITIONS: I IARCADIA CA 91007 1AC STRONG MOTION RESID 1000.00 VAL 0.50 IB2 PERMIT W/ENERGY 1000.00 VAL 71.90 I I IFR INV WORK W/O PERMIT 342.20 DOL 342.20 ICONTRACTOR: TEL. NO: i TOTAL FEES 443.40 1APPROVALS DATE INSPECTOR SIGNATURE I IPACIFIC STONEGATE INC. (626) 523-5819- 1 1650 W. HUNTINGTON DRIVE #206 LIC. NO ILOCATION AND SETBACKS 1 IARCADIA, CA 91007 965340 B I I I I ISOILS ENGINEER APPROVAL I I I I I II I I 1ARCHITECT OR ENGINEER: TEL. NO: I IFOUNDATION/TRENCH FORMS I I 1 LIC. NO: J.�/ 1SLAB/UNDER FLOOR I I EO P �®`� V IRAISED FLOOR FRAMING I I I I I I IMAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP: 1 (UNDERFLOOR INSULATION I I I 1153H265 3 001 1 11 I I IFLOOR SHEATHING I I I INO. OF FAMILIES: DWELLING UNITS: APT/COND: STAT CLASS: I I I I I 0 NO 21 I IROOF SHEATHING I 1 1 I I I I I I SCHOOL WITHIN HAZARDOUS I ISHEAR PANELS I I I (AIR QUALITY: 1000 FEET MATERIALS I I I 1 NO NO NO 1 IFRAME INSPECTION I I I I 1 IFIRE SPRINKLER HANGERS 1 I ! I I I I I 12NSULATION/WEATHER STRIPI I I I I I I I I (INTERIOR LATH/DRYWALL j 1 I I 1EXTERIOR LATH I 1 I I I I I I IRATED FLOOR/CEIL ASSEM. I I I I I I I I I I IRATED WALL ASSEMBLIES 1 1 IRATED SHAFTS/OPENINGS I 1 I I I 1 I IT-BAR CEILINGS I 1 1 ILOT DRAINAGE 1 1 1 I IREPORT ID: DPR261 ROUTE TO: BS0508 I 1 1 I I I I I I I