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TEMPLE CITY
7GA638A CE#9032/60 APPLICATION FOR BUILDING PERMIT 1
COUNTY OF LOS ANGELES [ADDRESS
UILDING '
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISIONOCALIJOHN A. LAMBIE, COUNTY ENGINEEREAREST
WILLIAM A. JENSEN SUPT OF BUILDING ROSS ST.
DI!>ICT GROUP T1 PE PR CESS BM
FOR APPLICANT TO FILL IN Q CONST, G
BUILDING STATISTICAL CLASSIFICATION SEWER MAP
ADQRE.5S j B
_ CLASS.".-I--DWELL.UNITS_L_
L T _ STATI_ K O MAP NUMBER ClO HWYE YES O
TRACT '57- USE ZONE SPECIAL /7
// NO.OF BLDGS. l CONDITIONS
SIZE OF LOT O 3 x /0 I NOW ON LOT
USE OF
EXISTING BLDG. ;3 Q BUILDINGYARD i+r+nY TREET NAME EXIST.
SETBACK WIDTH
TEL
OWNER �, NO. O FRONT i
Le fil,
ADDRESS7e &4eSIDE
ARCHITECT OR TEL 1'•L•
ENGINEER No. INSPECTION RECORD
ADDRESS
CONTRACTOR /�(/ NO.TEL. >-4a
O
ADDRESS
DtSCRIPTI011 OF WORK fi
E•
NEW ADD ALTER REPAIR DEMOLISH
SC!.FT. NO.OF NO.OF
SIZE / STORIES FAMILIES N
USE OF
STRUCTURE I�
SIGN UREOF S tf ' C�CUP/JNC4
APPLICANTJEZZ
VALUATION$
APPROVALS DATE INSPECTOR'S SIGNATURE
FOUNDATION: LOCATION
FEE $ FEE PMT FORMS, MATERIALS _)_,/ E�
$ ��
FRAME:FIRE STOPS, �.
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS AP- BRACING, BOLTS
PLICATION AND STATE THAT THE ABOVE IS CORRECT AND FURNACE: LOCATION.
AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND GAS VENT,DUCTS
STATE LAWS REGULATING BUILDING CONSTRUCTION.
I CERTIFY THAT IN DOING THE WORK AUTHORIZED I LATH, INT.
WILL NOT EMPLOY ANY PERSON IN VIOLATION OF THE
WORKMEN'S C(C�MPETI/$�ATIONN�LAWS OF CALIFORNIA. LATH,EXT.
SIGNATURE OF1 /�J C `� HOUSE NUMBER CO
PERMITTEE ' Go RECT AND POSTED
ADDRESS FINAL
CLYDE N. DIRLAM, PRINCIPAL STRYCTLIRAL ENGINEER
PLAN CHECK VALIDATION 0... M.O. CASH PERMIT VALIDATION CK. M.O. CASH
90361 'i 15230 2250
®r
L �q u 'r :o tiG-v 3 4 5.0 0
79A999A CE ry801-9 60 APPLICATION FOR
BUI IN PERMIT IJ
COUNTY OF LOS ANGELES BUI '
DEPARTMENT OF COUNTY ENGINEER ADDRR IN ESS
BUILDING AND SAFETY DMSION LOCALITY
JOHN A. LAMBIE, COUNTY ENGINEER NEAREST
WILLIAM A. JENSEN SUPT OF BUILDING CROSS ST.
DKCT N GROU TypEP OCE Y
OR APPLICANT TO FILL IN CONST.
BUILDING _ STATISTICAL CL ION I E13ER MAPP
ADDRESS
CLASS. NO. DWELL. UNITS
LOT N MAP STATE YES NO
NUMBER HWY.
TRACT l USEZONE SPECIAL
NO.OF BLDGS. CONDITIONS
SIZE OF LO I NOW ON LOT ..�
USE OF
EXISTING BLDG. EL/&ZB ILDI G YARD ST T NAM WIDTH
EXIST.
SETBACK
OWNER NO. FRONT ( ' f
P. L. i
ADDRESS / SIDE
ARCHIT R I TEL. P.L.
ENGINE NO. INSPECTION RECORD
CIL}
q ESS
TEL L !1 /'. •� '- 0
CONTRACTOR NO.
ADDRESS O
DESCRIPTION OF WORK w
CL
N
NEW ADD ALTER REPAIR DEMOLISH Z
SNO.OF No.OF
SIZE FT. T� STORIES FAMILIES
T
USE OF
STRUCTURE AZ
y,
SIGNA
ED -�
APPLICANT
VALUATION$ ��
APPROVALS DATE INSPECTOR'S SIGNATURE
PC '`..� PMT (, FOUNDATION: LOCATION
FE FEE FORMS, MATERIALS
FRAME: FIRE STOPS,
I HEREB ACKNOWLEDGE THAT'l HAVE READ THIS APPLICATION BRACING, BOLTS
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY FURNACE: LOCATION, J
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING GAS VENT DUCTS
BUILDING CONSTRUCTION. I CERTIFY THAT IN THE PERFORMANCE �. J
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED I SHALL NOT LATH, INT.
EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBUECT
TO THE WORKMEN' COMPINSATION LAWS CALIFORNIA.
LATH,EXT.
SIGNATURE OF • HOUSE NUMBER C SIGNATURE
RECT AND POSTEDPERMI
ADDRESS FINAL
CLYDE N. DIRLAM, PRINCIPAL ST URAL ENGINEER
PLA�i CHECK VALIDATII,ON CK* M.O. CASH PERMIT VALIDATION cK.Jj M.O. CASH
1 9 1 1 0 2 2.5 0,
xj-1104fv
WORKERS'COMPENSATION DECLARATION..
hereby affirm that I have c.' ComComte of consent ;IfAPPLICATION FOR BUILDING P E RM I T
Insure, or a certificate of Workers' persatlorf'irisurancb,
or a certified copy thereof (Sec- 3800, Lab. C.)
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company -
Certified copy Is hereby fvrnlahed. FOR APPLICANT TO FILL INA r �
Certified copy Is filed with the county building Inupec- BUILDING
tion.department. ADDRESS h t>i AveLOCALITY
NEAREST
Applicant CTTYT (Date ZIP 1 L S 02065 ST.
CERTIFICATE OF DMYJ ON FROM WORKERS' _ y �y` NO.OF BLDGS, ASSESSOR
COMPENSATION INSURAIJCE Sig OF LOT /� V NOW ON I MAP PAGE PAkM
(This section need not be com leted If the permit Is for one USE ZONE MAP
hundred dollars (;100)or less. BLOCK LOT NO.
SPECLAL
I certify thOWNERt In the perforinarice of the work for which this OWI AAVJ�-L 64A A h10.�7- g DCON ITIS CL
TYPE
permit Is Issued, I shall not employ any person In any manner ADDS �IE DISTRICT GROUPT FIRE BY U
�as to become subject to the Work Compersatlon Laws
Dafbo~� Applicant QTY kOrA Lr. rLt� ZIP \ 0 STA F CON
TEL
OR
NOTICE TO APPLICANT: If, after making th Ificate of ARCNffECT
NO. CLASS NO. DWELL UNITS - - W
'Exemption, you should become subject, t&--As WorkersN
Compensation provisions of'the Labor Code, you must fort-h- ADSEWER MAP Z
'with comply with such Provisions cr this permit shall be TEL.
deemed revoked. CONTRACTOR NO. BK, PG, VALIDATION
L,10ENSED CONTRACTORS DECLARATION L1C
I hereby affirm that I am Ilcerned uhder provtsldns of Chapter 9 ADDRESS NO. V WATION
(coSection
(commencing with 7000)of Dlvislon 3 of the Business and LK Gn
Professions Code, and my license is in full force and effect. QTY CLAM , 1 Q 3 A
SQ. FT. NO.OF tJO. CF CHECK
License Number Llc.Class SIZE 00 STORLES' F LIES I ONE f o 0 0 0 2
Cgntractar Dare DESCRIPTION OF WORK NEW ❑ ; A/0" 4mo_____ .2 ° 1 6 Q 0 0
ADD 0
❑ 1 am exempt under Sec 1 6 @. 0 0 H
ALTER ❑ R NAL
B.13P.C. for this reason O REPAIR ❑ DATE 1 9-83
Date: EX ISM OFrIG BLDG. O mma ❑ Fl
Signature A I'Ll'C Ni TEL
OWNER-BUILDER DECLAR �ATION U_g 11 1A NO.a '��
I hergby affirm that I am exempt from the Contractors License T F 6 L1 Q 1 A
Law for the following reason (Section 7031.5, Business and
Professions Cdde): D , ' o ° o • ?
I, as owner of the property, or my employees with �ADSSSS • 'G
waves as their sole compensation,will do the work and L' 2 ? 1 6 1,30
(
the structure Is not Intended or offered for sale ion ��'�''''`�� g
7W4, Business and Prof mmlbns Code}. MOVING TEL /IR s/ ` ° 1 6 1,
I, as owner of the o TRACTOR �' ��
prop", am exclusively contracting ) ,,_8
with licensed contractors to construct the project (Sec- ADDRESS / .
tion 7041, Business and Professions Code} REQU
CONSTRUCTION LENDING AGENCY gi� YARD I WY TOTALPSF�f9 uAdC FROM E�QST. , Ick
I hereby affirm that there Is a construction lending agency for FRONT WIDTH 'I(y.\
he performance of the work for which this permit Is Issued P.
Sec. 3097, Clv. C.).. SIDE
p PL.
? Lenders Name—
P.
ame _
Lenders Address P.0 Fee 6r�• Od Permit F« °
rn
w ,I
I certify that I have read this application and state that the kasuarKe Fee Q ► 5 0 �
above Infomwtlon Is correct. I agree to cbmply with.all County Invite) / Cb
ordimnces and State flaws relating to building construction, ! r 3� Total Fee 8� 7 lJ a� o P
and hereby authorlxe representatives of this County to enter Ln o N
uPon the above-nentloned property for Inspectlon purpcees. 04 CD CD A
sae vvise roe olrL NATOCY LAMKWAGE 't
SFgnature of Applicant or AQent Date