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APPLICATION FOR BUILDING PERMIT
COUNTY-OF LOS ANGELES BUILDING AND SAFETY
WOHKER'S COMPENSATION DECLARATION FOR APPLICANT TO Ful IN
ve
I hereby affirm &of I haa certf Icate of consent to sett blears, BL;'DM
or a certificate of Mck:ors' Compermation IrrmrraFND%or a certified
copy thereof(Sec.3800,Lab.C.) CTTY �. MP
Poky No_ Comerry Sof OI= Na OF BLDGS.NOW ON LOT
❑ Certriled 000y le hereby furnished. 0 NEAREST CRDSS SF.
❑ CArttfle l coot'fa flied wttb fire c,=ty W.ink hNxKtbn TRACT LOT NO.
L1S£ZONE �=P,4aDatet ASSE38ORµAP BOOK( -PAGE PARCEL, SPECAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' 5S z 3 YES NO
COMPENSATION INSURANCE wmtN Toao FT.OF SCHOOL?
(Th}b secfial need not be cornpieted If the permft!e for one hundred DIST1 CT GROUP FRE ZONE PROCESSED BY
dollers ($100)(5r leas)
I certify that In the per'for wfm of tie work for which tib perrNt , r�, �.
Is beued, I shall not employ any person In any maturer so as to
become wbject to the wbr-ker&'Comparleatlon Law8_ QCT OR ENGNEER TEL Na
8191BTK'1L CLA83FIG41QN APT CONDO
Date AWPllcantADDRESS CLAS$Na—� L7VIE7J_UNITS
NOTPCE TO -AffVC 4.NT If, after making thla Cartffloafe of FEWIRED TOp,L SETBACK FROM EXIST
Exemption, you ehouid become •suil3}eot to the workers' CONTRACTOR TEL Na SET BACK Vim Hyiy 'PROP LANE yypTH
Compensation provisions of the Labor Code, you must torftwft FRCW
comfy v4tb.such provisions or dib pwTnft ehall be deemed reroked. ADDRESS LJC,40. P L
LICENSED CONTRACTORS DECLARATION P L
, CSTY Lla CLASS P L
I hereby affirm that I em Ilcermed inderpro l lorm of Chapter 8 SEWER P.4 P
(Commend With Seddon 7000)of Dlvblon 3 of the Business arld n . Na OF SToRE8 NO.OF FAAi1ES
NEW BK Pa ,
Pro(easLorts and my licerrae Is In foil force and effect
s Q
License Number Llo.ClaesADD 11 V�uaroN V
Contactor r Date r - ALTER 0
rr
Q,I am exempt urdaf Seo. REPAIR ❑
BAP.C.for this reason DEMOL ❑ LDMA P/C+ 77LLLL��II
Date: USE OF EXISTING BLDO_. URM ❑
1
APPLIGMT(PFNVT) TEL Na. LDMA Prm t
es o4vner d the property, or rry errrplOyeea .Ith wages ea Z' ACCT.T -
their acie compensation, wm do tide work and the str-Lrctlrre is ADDRESS -- y
net Intended or offered for &ale (Sectlon 7044, Buales
ne 'and MAL DATE � ,7 33 105.tea]
Profesalara coda.) waL THE APN_r_&.R oR FUTURE BUR-DW 0="KT HA a A wz400ua MKERnL -/2 �r��-rum
❑ I, as owner at the property, am exchrekvefy oontr'acting with OR A MUTIFE OWM00e A FiAZ�1S MSL EQUAL TO OR QW-CEn THAN T}f f h'rI I TEM
�'�+
Pro}eC (Section 7044, AAIOlNTB BPECFEO ON TFE FIAZAH7oUB MA7iEFiAL&lFOFMQION oUoeT FAL�' TOTAL . 10-- - 30
f{cerr&ed c6 d RDf rs 1d Code) the res❑ mo❑
Buelrree&end PrOfeeasare Code.) � i 1� 1
wa L rHE OfFENDED � OF rHE euoL►a BY THE APPLXANr OR FUTURE �+.�
OCCLFANT A FOR CONSTRUCTION OR WDFICAION FROM THE 8OUTH
CONSTRUCfiION LENDING AGENCY QST An QL USM&7 WAQ14))ME PB44TTM C Ea FOR .'
or rte+pEa
I heraby afilrm that there Is a corsbTlctlon leading agency for yEs❑ NO❑
n the performance of the work for which thla permit is Issued(Sec. IPMEn'EAOTHE wArm:ALsrcaRi L41 augDEAmTHE ecAnormrrm
3087,Civ.C.) i ` Mr u► r Tr1aLoQ ca,N,Y soot
n �Z APT6r z2o&ECTIONS zsa r TFFI0UOF1 2-a140a+o HvzAroous
LervJWs Name WU'EFIAL8 R1P0Fr k%3 Alit FOR 06VM1Q A PERWT FROM THE 8GAQ a
Lander'&,Address �6 � 7626 1 PN 5:16
p
I certify ttmt l have read this apolldatbn and elate under penalty
of perjury that fie abotie YTforrrration Is correct I agree to comply PDv FEE PEF!•Tf FEE
with all county ordlnancee and State.Tawe reUrHF g to bub±w
corratrtlotiorr, and hereby &unionize mprwmrrtativee of this Canty B8l1ANOE FEE
�t0"upon
on the above- property for Inspection
-_�•� / f - NVEMXWlCN FEE TOZ,L FTS
Ae.
SEE REVERSE FOR EXPLANATORY LANQ A13E
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COUNTY OF LOS ANGELES TEMPLE CITY 0508 BUILDING PERMIT
(DEPARTMENT OF PUBLIC STORKS 9701 LAS TUNAS ALTERATION/REPKIR
BUILDING AND SAFETY / LAND DEVELOPMENT TE]PLE Cr TY CA 91780 BL 0508 1204050033
PHONE: (626) 285-0488 SIT:
LEGAL ID: 190. OF CONST BUILDING ADDRESS:
TR: 6561 IT: 209 UN: .002 SQ. FT STORIES TYPE 9616 GARIBALDI AV
STRUCTURE: 1200 V-B TEMP CA 917801735
ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET: TEMPLE CITY
5385-014-022 T AIik,S PAGE: 596 GRID: J2 LOCA=: TEMPLE CITY, C
TENANT: =AT BLDG USE: RESID 0.4E ZONE: R-3 ISSUED ON: PROCESSED BY:
EKIST OCC GRP: 04/05/12 SR
TEL. NO: BIDGS. ON LO-T: VALIDATION: FINAL DATE FINAL BY: CODE:
LANE BERNICE (618) 286--5523- 2,900
9616 GARIBALDI AV
TEMP 917801735 FEES PAID DESCRIPTION OF WORT
INSTALL CLASS A FIBER RATED 9H15GLES OVER EZTSTIW ONE LAYER
FEE DESCRIPTION: QUANTITY: CC&(: ANUUNT: OF SRI2A31,F_q
APPLICANT: TEL. NO:
KEEFER, BRIAN - AA BLDG PERMIT ISSUANCE 27.80
AB STATE ¢REEK BLDG FEE 2900.00 VAL 1.00 SPECIAL CONDITIONS:
AC STRONG [37TTON RFi9ID 2900.00 VAL 0.50
D2 PERMIT W/O EN-HC 2900.00 VAL 99.00
TOTAL FEES 128.30
CONTRACTOR: TEL. NO: APPROVALS DATE INSPECTOR SIGNATURE
KEEFERIS ROOFING (909) 608-0622-
1216 BEGONIA COURT LIC. NO L)=ON AND SETBACR.9
UPLAND CA 91784' 760903 C39
SOILS ENGINEER APPROVAL '
ARCHITECT OR INFER: TEL. N0: TION/TRENCH FORMS
LIC. NO: UNDER FLOOR
RAISED FLOOR FRAMING
_ MAP NO: SWWRR MAP BOOK: PAGE: FIRE ZONE: C1P- ERFIOOR INSULATION
15OH269 3 00
_ FLDOR SHEATHING .
NO. OF FAMIT.IF'.la: DWE J-119G UNITS: APT/COND: STAT CLASS:
0 NO 21 ROOF SEDLATHING .
SCHOOL WITHIN HAZARDOUS SHEAR PANELS
AIR QUALITY: 1000 FEET )UTE IALS -
NO NO NO FRAME INSPECTION
FIR� SPRINKLER ER HANGERS
INSULATION WEATHER STRIP
IFTSRIOR.LATH DS2YW\LL
EZTERIOR LATH
CA
/� -+���® RATED FIGO = ASSEM.
���///���1RATED W1L L AS._gE Ca tta
—osRATED SHAFTS OPENS
T-BAR CEILINGS
IAT DRAINAGE
REPORT ID: DPR261 ROUTE TO: BS0508