Loading...
HomeMy Public PortalAbout5757 GOLDEN WEST AVE_Building__ APPLICATION FOR, BUILDING PERMIT i1 COUNTY OF LOS ANGELES BUILDING_A_N_D_SAFETY__ __----- WORKER'S COMPENSATION DECLARATION ------FOR-APPLICANT-TO-FILL-IN --—_ -BUILDING ADDRESS y BUILDING ADDRESS I herebaffirm that I have a certificate of consent to self insure, or a certificate of Workers'Compensation Insurance,or a certified CITY ! ZIP copy thereof(Sec.3800,Lab.C.) --� LOCALITY PolicyNo. Company y SIZE OF LOT NO.OF BLDGS.NOW ON LOT ❑ Certified copy is hereby furnished. <S� .�. r NEAREST CROS I ST. ❑ Certified copy is filed with the county building inspection TRACT BLOCK LOT NO. USE ZONE MAP NO. department. ASSESSOR MAP BOOK PAGE PARCEL Date Applicant SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER TEL.No. COMPENSATION INSURANCE GL O l� WITHIN 1000 FT OF SCHOOLS YES No ADDRESS (This section need not be completed if the permit is for one hundred ��IZ7 DISTRICT GR OUP TYPE CONST.' FIRE ZONE ROCES D BY dollars($hat or less.) CITY ZIP 5 0 (� T 3 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 ARCHITECT OR ENGINEER TEL.NO. become SUN t to the Workers'Compensation Laws.` STATISTICAL CLASSIFICATION APT CONDO Date.�Applicant �/�' 2y,42 ADDRESS CLASS NO. DWELL UNITS NOTICE TO APPLICANT. If, after making this Certificate of CONTRACTOR TEL.NO. REQUIRED TOTAL SETBACK FROM EXIST Exemption, you should become subject to the Workers' SETBACK YARD HWY, PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith FRONT comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC.NO. PL LICENSED CONTRACTORS DECLARATION CITY LIC.CLASS SIDE a PL a O I hereby affirm that I am licensed under provisions of Chapter 9 SEWER MAP c-D (commencing with Section 7000)of Division 3 of the Business and SO I NO.OF STORES NO.OF FAMILIES Professions Code,and my license is in full force and effect. NEW ❑ BK PG CD CD License Number Lic.Class DE I T NOF WORK ADD ❑ VALUA a Contractor Date / r ALTER Jq $ �® Z f 15 i1 'y REPAIR ❑ $ — ❑ I am exempt under Sec. B.BP.C.for this reason !, DEMOL ❑ LDMA P/C# Date: USE OF EXIST G BLDG. URM ❑ Signature APPLICANT(PRINT) T L.NO. LDMA Perm# 3 Z e•T E I, as owner of the property, or my employees with wages as p ;. their sole compensation,will do the work and the structure is ADDRESS not intended or offered for sale (Section 7044, Business and FINA TE Q `.::I; Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL j r �c( ❑ 1, as owner of theproperty, am exclusive) contracting with OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN Q I Elf 3 Y g THE AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL licensed contractors to construct the project (Section 7044, YES E] NO T TAI 93 - 63 Business and Professions Code.) rr1� ; WILL THE INTENDED USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDINGVVV "'HECK •�it•[7 OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH ..._. • ' CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST I �•�h� F r3NGE FOR GUIDELINES. 1i•£� R Oct I hereby affirm that there is a construction lending agency for YES❑ NO K the performance Of the work for which this permit Is Issued(.Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD ('� �'y 3097,CIV.C.). PERMITTING CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES ��'??i �. COUNTY CODE,TITLE 2,CHAPTE .20 SE NS2.20.100 THROUGH 2.20.140 CONCERNING is Lender's Name HAZARDOUS MATERIALS REPOR NG A R OBTAINING A PERMIT FROM THE SCAQMD. n� Lender's Address ( 1 i 3 OWNER OR AGENT o I certify that I have read this application and state that the above PC.FEE PERMIT FEE �.�t information is correct. I agree to comply with all county 52sG� ordinances and State laws relatin building construction,and hereby authorize repreS rltativ this County to enter upon ISSUANCE FEE the above-mentioned pr pert inspection purposes. ' 3, 00 / INVESTIGATION FEE TOTAL FEE SlgnaWre of APPII for Agan; Date SEE REVERSE FOR EXPLANATORY LANGUAGE APPLICATION FOR BUILDING PERMIT COUNTY OF LOS ANGELES ------BUILDING AND-SAFETY __.WORKER'S-COMPENSATION-DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS r S, � I hereby affirm that I have a certificate of consent to self insure, BUILDING ADDRES7�� ,(0 or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec.3800,Lab.C.) CITY,---- '` ZIP �® LOCALI /0 Policy No. Company SIZE OF LOT NO.OF BLDGS. ❑ Certified copy is hereby furnished. NEAREST CROSS ST. ❑ Certified copy is filed with the County building inspection TRACT BLOCK LOT NO. USE ZONE MAP NO. department. Date Applicant ASSESSOR MAP BOOK PAGE PARCEL SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER JAL.NO. YES NO COMPENSATION INSURANCE G !/ WITHIN 1000 Fr.OF SCHOOL? A15DREST (This section need not be completed if the permit is for one hundred DISTRICT G����RttttOUP TYPE CONST.' FIRE ZONE P CESSE Y dollars that or less.) , CITY ZIP Or A� I I certify that in the performance of the work for which this permit _ is issued, I shall not employ any person in any manner so as to ARCHITECT OR ENGINEER TEL.NO. become subject to the,Workers'Compensation Laws. �" STATISTICAL CLASSIFICATION APT CONDO Date Applicant ADDRESS CLASS NO. DWELL UNITS NOTICE TO APPLICANT. If, after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST Exemption, you should become subject'to the Workers' CONTRACTOR TEL.NO. SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith FRONT comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC.NO. PL SIDE LICENSED CONTRACTORS DECLARATION CITY LIC.CLASS PL c I hereby affirm that I am licensed under provisions of Chapter 9SEWER MAP V (commencing with Section 7000)of Division 3 of the Business and SQ.FT SIZE NO.OF TORES NO.OFF MILIES C Professions Code,and my license is in full force and effect. NEW ED BK PG E3License Number Lic.Class OF WORK ADD VACUA O wa Contractor Date ��i ALTER ❑ �� z ❑ I am exempt under Sec. REPAIR ❑ B.BP.C.for this reason DEMOL ❑ LOMA P/C# Date: USE OF EXISTING BLDG. URM Cl J Signature APPLICANT(PRINT) JNO. • LDMA Perm# as owner of the property, or my employees with wages as tA ! O H(.'v 3=v heir sole compensation,will do the work and the structure is ADDRESS H not intended or offered for sale (Section 7044, Business and J _ _NAL DATE 9 Q �r—,s(_ Professions Code.) WILLTHE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS M461AL (6 GREAT THAN i El I, as owner of the property, am exclusively contracting with OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR tTHE AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY > licensed contractors to construct the project.(Section 7044, YES❑ Nq� 1_IE;3� 53 m 75 Business and Professions Code.) `�� WILL THE INTENDED USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING 'HEIC,K OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH CONSTRUCTION LENDING AGENCY -COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR GUIDELINES - CHANGE 1 hereby affirm that there is a construction lending agency for YES ElNOX the performance Of the Work for Which this permit IS ISSUed(SBC. I HAVE READ THE HAZARDOUS MATERIAJ INFORMATION GUIDE AND THE SCAOMD _ 3097,Civ.C.). PERMITTING CHECKLIST.1 UNDERSTAND EQUIREMENTS UNDER THE LOS ANGELES L E`i m - Ill-:ItILI j m. COUNTY CODE,TITLE 2,CHA R 20 SE 5220.100 THROUGH 220.140 CONCERNING o Lender's Name HAZARDOUS MATERIALS REPORI A OBTAINING A PERMIT FROM THE SCAOMD. .=C 5 Jh ly L Lender's Address owraEnos AGENT o 1 certify that I have read this application and state that the above RC.FEE PERMI FEE information is correct. I agree comply with all county ordinances and State I s relatin building construction,and a.' hereby authorize repr se tatty o this County to enter upon ISSUANCE FEE /'� . the above-mentions pr r spection purposes. /�i�V j INVESTIGATION FEE TOTAL FEE SigmWm of App1I=M a one SEE REVERSE FOR EXPLANATORY LANGUAGE . APPLICATION FOR- BUILDING PERMIT COUNTY OF LOS ANGELES _— - --BUILDING-AND-SAFET-Y— -- - ---- WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS ��f BUILDING ADDRESS I hereby affirm that I have a certificate of consent to self insure, or a certificate of Workers'Compensation Insurance,or a certified G copy thereof(Sec.3800,Lab.C.) CI C y ZIP LOCALITY Policy No. Company SIZE OF LOT NO.OF BLDGS.NOW ON LOT ❑ Certified copy is hereby furnished. 15 f) NEAREST CROSS T. ❑ Certified copy is filed with the county building inspection TRACT`, _ BLOCK LOT NO. «-S department. p 5 - � USE ZONE MAP NO. ASSESSOR MAP BOOK Data Applicant PAGE PARCEL f so -/a q pp �� /1 SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER,:. TEL.NO. COMPENSATION INSURANCE /� 'y��✓� WITHIN 1000 Fr.OF SCHOOL? YES No ADDRESS (This section need not be completed if the permit is for one hundred DISTRICT GROUP TYPE CONST.' FIRE ZONE PROCESSED BY dollars($100)or less.) CITY ZIP I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to ARCHITECT OR ENGINEER TEL.NO. become subject to the Workers'Compensation Laws. STATISTICAL CLASSIFICATION APT CONDO Date Applicant ADDRESS CLASS NO. LNZL DWELL UNITS NOTICE TO APPLICANT. If, after making this Certificate of CONTRACTOR TEL.NO. REQUIRED TOTAL SETBACK FROM EXIST Exemption, you should become Subject to the Workers' SETBACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith FRONT comply with such provisions or this permit shall be deemed revoked. ADDRESS V LIC.NO. PL LICENSED CONTRACTORS DECLARATION CITY _ LIC.CLASS PILDE o I hereby affirm that I am licensed under provisions of Chapter 9 SEWER MAP r, (commencing with Section 7000)of Division 3 of the Business and So.Fl.SIZE NO.OF STORES NO.OF FAMILIES Professions Code,and my license is in full force and effect. NEW BK PG //7pop. CD N OF WRK License Number Lic.Class DES RIP IOOADD ❑ VALU_AT11ON O� a Contractor Date ALTER ❑ $ "�- z ❑ El REPAIR I am exempt under Sec. $ B.BP.C.for this reason edl!' .�`� DEMOL ❑ LDMA P/C# Date: USE OF EXISTING BLDG. UEl Signature APPLICANT(PRINTS TEL.NO. LDMA Perm# - G`'; �. . S Z ti g I, as owner of the property, or my employees with wages as / p their sole compensation, will do the work and the structure is ADDRESS --- �• f not intended or offered for sale (Section 7044, Business and v ¢w F� !: /�% �[f FINAL DATE Q Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE RDOUS MATERIAL ®`l �� � a S I tie is OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN ❑ I, as owner of the property, am exclusively contracting with THE AM UNTS SPE FIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY i D'i ^., �r 1 C`40 licensed contractors to construct the project.(Section 7044, }- - VES NO Business and Professions Code.) •• i- ""!'�tt% - WILL THE INTENDED USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING °=HE='i'` -•�---OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH _..•Li._,1 ,... CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)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 ISSU@d(Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD - +�• 4 4 -- 3097,Civ.C.). PERMITTING CHECKLIST.I LINDERST D MY REQUIREMENTS UNDER THE LOS ANGELES .l.!•a.�=:si'i COUNTY CODE,TITLE CHAPTER 6ECTIONS 2.2=.THROUGH 2.20.140 CONCERNING e a Lender's Name HAZARDOUS MATERIA�REPORTI D FOR OBTAINING A PERMIT FROM THE SCAQMD. St ;s a Lender's Address OWNER OR AGENT o 1 certify that I have read this application and state that the above information is correct. I agr a to comply with all county P.C.FEE PERMIT FEE e ordinances and State laws rel ing to building construction,and Q. hereby authorize represent s of this County to enter upon ISSUANCE FEE /s) the above-menti ned prop for inspection purposes. �) INVESTIGATION FEE TOTAL FEE �� sgnaw�a a Appllwil Date SEE REVERSE FOR EXPLANATORY LANGUAGE _ COMPENSATION DECLARATION tteof consentInsurance, self APPLICATION t FOR BUILDING i PE`�R/M� _I-Tcate4of Workers' Con'ensaton pycert; ledcothereof (Sec. 3800, b'. Policy N -COUNTY OF-LOS ANGELES-- - -- -BUILDING AND SAFETY Company, --- -- —- Certified copy is hereby furnished. BUILDING //�� � Tl� FOR APPLICANT TO FILL IN ADDRESS iG �pZ, wllW[�. Certified copy is filed with th county building inspec- BUILDING /1� ) tion department. ADDRESS ,5 � l� Date App co lriL CIT G �Gb— ZIP e LOCALITY NO. OF BLDGS. NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NOW ON LOT CROSS ST. .,, . COMPENSATION INSURANCE (This section need not be completed if the permit is for one TRACT �© BLOCK LOT NO. ASSESSOR MAP BOOK PAGE PARCEL hundred dollars ($100)or less.) TEL. USE ZONE MAP I certify that in the performance of the work for which this OWNER � _ NO. NO. — SPECIAL permit is issued, I shall not employ any person in any manner ADDRESS _ �_ -- �/ CONDITIONS so as to become subject to the Workers'Compensation Laws. U Date Applicant CITY ZIP NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL DISTRICT GROUP TYPEFIRE SSED BY Exemption, you should become subject to the Workers' ENGINEER _ NO. D CONST. ZONE U Compensation provisions of the Labor Code, you must forth- ADDRESS with comply with-such provisions or this permit shall be deemed revoked. r TEL'6,'175- STATISTICAL CLASSIFICATION APT. CONDO. N CONTRAC i „ ) NO. LICENSED CONTRACTORS DECLARATIONIC CLASS NO. DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRE NO �� SEWER MAP (commencing with Section 7000)of Division 3 of the Business and v' LIC. /7•-� Professions Code, and my license is in full force and effect. CITY CLASS 6:7 - BKS �;��- VALIDATION ,_ SQ. FT NO. OF NO. OF CHECK License 114.1-bal ��Lic.Class SIZE STORIES FAMILIES ONE �. VALUATION _ Contras j �% �� _ Date �v/ DESCRIPTION OF WORK A $ ` I am exempt under Sec. ���f ALTER a R {, B.BP.C. for this reason �'sli4�f'l REPAIR Ll $ 2f p Yf Date: USE OF / J ❑ o O h EXISTING BLDG. ( DEMOL a a O LL YY c� Signature APPLICANT TEL. FINAL rn OWNER-BUILDER DECLARATION PRINT 2,S NO. 5 DATE 1 -8 8 1 hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and ADDRESS FINAL L Professions Code): MRNT By � � . I, as owner of the ptoperty, or my employees with BUILDING 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- A DDRESS tion 7044, Business and Professions Code). TOTAL SETBACK CONSTRUCTION LENDING AGENCY YARD HWY PROP. LINE WIDTH I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). Lender's Name Permit Fee a LDMA Ref. # Lender's Address 3 1 certify that I have read this application and state that the _� o Y PP Issuance Fee i� LDMA P/C N o above information is correct. I agree to comply with all County Fee 0 ordinances and State laws relating to building construction, �- LDMA Perm. N dTotal Fee v and hereby author4reKseAtatives of this County to enter // above- p y for inspection pur ores. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Aent If Date APPLIQATION FOR BUILDING. PERMIT COUNTY OF LOS ANGELES 7 BUILDING AND SAFETY —---------WORKER'S-COMPENSATION"DECL"ARATION--- —` — —FOR APPLICANT TO FILL IN BUILDING ADDRESS I hereby affirm that I have a certificate of consent to self insure, BUILDING ADDRESS G /y'�`C• or a certificate of Workers'Compensation Insurance,or a certified `1. �,7 copy thereof(Sec.3800,Lab.C.) CITYY ZIP *Policy ����� LOCALITY 'Policy No. Company SIZE OF LOT NO.OF BLDGS.NOW ON LOT ❑ Certified copy is hereby furnished. NEAREST CROS T. 100, ❑ Certified copy is filed with the county building inspection TRACT BLOCK LOT NO. department. USE ZONE MAP NO. Date Applicant ASSESSOR MAP BOOK PAGE PARCEL . SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER COMPENSATION INSURANCE1�/ - �hv �l rJ WITHIN 1000 FT.OF SCHOOL? YES NO (This section need not be completed if the permit is for one hundred ADDRESS r �� dollars($100) or less.) / DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED EY /S I certify that in the performance of the work for which this permit CITY -_ ZIP �_C P��di� is issued, I shall not employ any person in any manner so as to ��� _ .3 become subject t0 the Workers'Compensation Laws. ARCHITECT ORENGINEER TEL NO. STATISTICAL CLASSIFICATION APT CONDO Date Applicant ADDRESS CLASS NO. DWELL UNITS NOTICE TO APPLICANT If, after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST Exemption, you should become Subject to the Workers' CONTRACTOR �� TEL NO, SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith FRONT comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC.NO, PL } SIDE a' LICENSED CONTRACTORS DECLARATION CITY LIC.CLASS PL 0 1 hereby affirm that I am licensed underprovisions of Chapter 9 1 SEWER MAP (commencing with Section 7000)of Division 3 of the Business and SO.FT.SIZE NO.OF STORIES N0,OF FAMILIES Professions Code,and my license is in full force and effect. NEW ❑ SK PG, O License Number Lic.Class DES IPTION OF WORK L ADD El VALUATION ► W � Contractor Date DK9640rRt4ALTER $. 500 ,� CL ❑ I am exempt under Sec. ° REPAIR t4_ $ Z i BAP.C.for this reason DEMOL ❑ LDMA P/C# ACCT Date: USE OF EXISTING BLDG. o URM ❑ !'tC•L•I 'a Signature APPLICANT(PRINT/. 1 TEL O. LDMA Perm# 43`-3 � 7008 c / 0 XI, as owner of the property, or my employees with wages as G G S_kA O 1 ITEM00 their sole compensation, will do the work and the structure is ADDRESS _qf not intended or offered for sale(Section 7044, Business and .J� A/ E �'� FINAL DATE 3t/_ Q I CIAL 70 = 80 Professions Code.) WILL.THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL /�r y Li/ O ❑ 1, as owner Of the y, Y g OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE ' J CHECK 70.80 j I,flf1 property, am exclusive) contracting with AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY L� Cr (l rJ licensed contractors to construct the project (Section 7044, YES❑ No❑ r ` L.-HA IGE .00 Business and Professions Code.) WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING �t OCCUPANT REQUIRE A PERMIT,FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH `�✓ CONSTRUCTION LENDING AGENCY COAST AIR OUAUTY MANAGEME T,DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FOR ii r} •• J GUIDELINES. 01300-000 1 2 ,/96 I hereby affirm that there is a construction lending agency for YES❑ No❑ jI�fyLtyrj � a i� the performance Of the Work for which this permit IS Issued(SBC. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING 3097,CIV.C.) CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, TITLE 2.CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 C rn Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMDNCERNING HAZARDOUS m '¢ Lender's Address OWNER OR AGENT 3 I certify that I have read this application andstate under penalty 0 of perjury that the above information is correct.I agree to comply P.C.FEE PERMIT FEE ro with all county ord' ances d State laws relating to building m construction, and h eby Vu representatives of this County ISSUANCE FEE /► gto enter upon thea v - e property for In purposes. ,j V INVESTIGATION FEE TOTAL FEE NGgnaNre of Ap I.—or Date 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 1105180032 PHONE: (626) 285-0488 EXT: LEGAL ID: NO. OF .CONST BUILDING ADDRESS: ITR: 6561 LT: 465 UN: .002 SQ. FT STORIES TYPE 5757 GOLDEN WEST AV I (STRUCTURE: 2900 V-B TEMP CA 917802504 ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET: WORKMAN 18587-023-013 THOMAS PAGE: 597 GRID: A3 LOCALITY: TEMPLE CITY, Cl TENANT: (EXIST BLDG USE: RESID USE ZONE: R-1 JISSUED ON: PROCESSED BY: I 1EXIST OCC GRP: 105/1-8/11 SR OWNER: TEL. NO: IBLDGS. NOW ON LOT: VALUATION: IF D E r FINAL BY: CODE: ICHU EDDIE;BETTY (626) 285-6053- 1 7,100 1 �1 15757 GOLDEN WEST AV TEMP 917802504 FEES PAID IDESCRIPTION OF WORK REMOVE EXISTING ROOF INSTALL 30 YEAR COMP SHINGLE I IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT: ( I (APPLICANT: TEL. NO: I I I IKEEFER ROOFING (626) 279-1224- IAA BLDG PERMIT ISSUANCE 27.80 I I 11216 BEGONIA COURT IAB STATE GREEN BLDG FEE 7100.00 VAL 1.00 ISPECIAL CONDITIONS: I 1UPLAND CA 91784 1AC STRONG MOTION RESID 7100.00 VAL 0.70 1 1 1 ID2 PERMIT W/O EN-HC 7100.00 VAL 183.40 1 1 1 I TOTAL FEES 212.90 1 I (CONTRACTOR: TEL. NO: I (APPROVALS DATE INSPECTOR SIGNATURE 1 IKEEFER'S ROOFING (909) 608-0622- I 11216 BEGONIA COURT LIC. NO L=\TION AND SETBACKS UPLAND CA 91784 760903 C39 SOILS ENGINEER APPROVAL 1 (ARCHITECT OR ENGINEER: TEL. NO: I IFOUNDATION/TRENCH FORMS I LIC. NC: 1 ISLP.B/UNDER FLOOR I I 1 1 (RAISED FLOOR FRAMING 1 I IMAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP: I (UNDERFLOOR INSULATION 1150H269 3 001 1 I 1 I I IFLOOR SHEATHING 1 INO. OF FAMILIES: DWELLING UNITS: APT/COND: STAT CLASS: 1 I-- 0 -_0 NO 21 1 IROOF SHEATHING 1 SCHOOL WITHIN HAZARDOUS ISHEAR PANELS (AIR QUALITY: 1000 FEET MATERIALS I 1 NO NO NO IFRAME INSPECTION 1 I IFIRE SPRINKLER HANGERS 1 I (INSULATION/WEATHER STRIP( I (INTERIOR LATH/DRYWALL I I 1 I EX'=ERIOR LATH 1 I 1 IRATED FLOOR/CEIL ASSEM. 1 IRATED WALL ASSEMBLIES 1 1 I IRATED SHAFTS/OPENINGS I 1 IT-BAR CEILINGS I I 1 1 ILOT DRAINAGE 1 1 1 IREPORT ID: DPR261 ROUTE TO: BS0508 I I I I