HomeMy Public PortalAbout5939 KAUFFMAN AVE_Building__ • . APPLICATION FOR BUILDING PERMIT
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COUNTY OF LOS ANGELES BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION
FOR APPLICANT TO FILL IN BUILDING DRES
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I hereby affirm that I have a certificate of consent to self insure, BUILDING ADDRESS
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or a certificate of Workers'Compensation Insurance,or a certified ZIP
copy thereof(Sec.3800,Lab.C.) G y 71 LOCALITY PL
Policy No. Company SIZE OF LOT NO.OF B GS.NOW ON LOT /
❑ Certified copy is hereby furnished.
NEAREST CROSS ST.
❑ Certified copy is filed with the county building inspection TRACT BLOCK LOT NO.
department. USE ZONE MAP NO.
PAGE PARCEL
ASSESSOR MAP BOOK
Date Applicant SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' ER TEL.NO.
YES NO
COMPENSATION INSURANCE �� Y� WITHIN 1000 FT.OF SCHOOL?
ADDRESS
(This section need not be completed if the permit is for one hundred Z O m�d DISTRICT GROUP TYPE CONST.' FIRE ZONE PROCESSED BY
dollars($100)or less.) I
c TY ZIP o
I certify that in the performance of the work for which this permit /y0 G -e-76
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. ,l STATISTICAL CLASSIFICATION APT CONDO
Date) ApplicanK ADDRESS CLASS NO. DWELL UNITS
NO/I'CE TO APPLICANT. If, after makingthis Certificate of
CONTRACTOR TEL.NO. REQUIRED TOTAL SETBACK FROM EXIST
Exemption, you ShOUId become Subject t0, the Workers SET BACK YARD HWY, PROP LINE WIDTH
Compensation provisions of the Labor Code, you must forthwith 41FRONT
comply with such provisions or this permit shall be deemed revoked. ADDRESS IV LIC.NO. PL
LICENSED CONTRACTORS DECLARATION CITY LIC.CLASS FIDE o
I hereby affirm that I am licensed under provisions of Chapter 9 SEWER MAP v
(commencing with Section 7000)of Division 3 of the Business and SQ.FT.SIZE NO.OF STORES NO.OF FAMILIES I=
Professions Code,and my license is in full force and effect. I NEW ❑ BK PGpoll". o
DESCRIPTION OF ORK ADD ❑ VALUATION
License Number Lac.Class lR eOC L✓'4h r c -it $ ;2 ��, •-v rn
Contractor Date ALTER ❑ Z
P 30 ys►►' REPAIR C3 $ —
❑ I am exempt under Sea
B.&P.C.for this reason DEMOL C3 LOMA P/C#
Date:
USE OF EXISTING BLDG. URM. 13a
Signature APPLICANT(PRINT) TEL.NO.
� LDMA Perm#
as ow er of the property, or my oyees with wages as ZO
their sole compensation,will do the ork and the structure is ADDRESS
not intended or offered for sale (Section 7044, Business and FINAL DATE Q �.,_ _ _
Professions Code.) I "5 0 j I!3 R
WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL +'
OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN i+-;•-yv«
1, as,owner' of the property, am exclusively contracting with THE AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL ( ' 14 �U I .4 Z
licensed contractors to construct the project.(Section 7044, � �
YES❑ NO❑
Business and Professions Code.) j _ 0 .�
WILL THE INTENDED USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH
• CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST 70.• e,:�
FOR GUIDELINES.
I hereby affirm that there is a construction lending agency for YES El NO❑ f' AME*
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the 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
COUNTY CODE,TITLE 2,CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING'
Lender's Name HAZARDOUS MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD. L!"?l¢«fl [ I -
3 - -
a EL
Lender's Address -r
OWNER OR AGENT �;�• L �
o 1 certify that I have read this application and state that the above P.C.FEE PERMIT FEE
$ information is correct. I agree to comply with all county .
N ordinances and State laws relating to building construction,and
a hereby authorize representatives of this County to enter upon ISSUANCE FEE
the�abqv.,,I.-nentiond pr�@ forins ction purposes. INVESTIGATION FEE TOTAL FEESgneor Agent D.�
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 1011240033
PHONE: (626) 285-0488 EXT:
ILEGAL ID: BUILDING ADDRESS:
I NO. OF CONST
ITR: 6561 LT: 120 BL: .001 I SQ. FT STORIES TYPE I 1
1 5939 KAUFFMAN AV 1
I (STRUCTURE: 30 V-B I TEMP CA 917802235
(ASSESSOR INFORMATION NUMBER: 1 _ I NEAREST CROSS STREET: .
18587-020-004 I THOMAS PAGE: 597 GRID: A2 LOCALITY: TEMPLE CITY, Cl
(TENANT: IEXIST BLDG USE: RESID USE ZONE: R-3 (ISSUED ON: PROCESSED BY: 1
IEXIST OCC GRP: 111/24/10 SR 1
1 1 I I
(OWNER: TEL. NO: 1BLDGS. NOW ON LOT: VALUATION: IFINAL DATE FINAL Y: CODE:
IJENSEN CHARLES R;DOROTHY - 1 13,000 1
15939 KAUFFMAN AVE. 1 1
ITEMPLE CITY CA 91780 FEES PAID JIMSCRIPTION OF WORK 1
I IREMOVE EXISTING REPLACE W/3 YEAR ROOF INSTALL 1/2" CDX PLYWI
I IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT: ( I
(APPLICANT: TEL. NO: I I I
IBILT-WELL ROOFING (323) 254-2888- IAA BLDG PERMIT ISSUANCE 27.80 1
13310 VERDUGO ROAD IAB STATE GREEN BLDG FEE 13000.00 VAL 1.00 ISPECIAL CONDITIONS: 1
ILOS ANGELES CA 90065 IAC STRONG MOTION RESID 13000.00 VAL 1.30
ID2 PERMIT W/O EN-HC 13000.00 VAL 267.70 1 1
1 TOTAL FEES 297.80 1 I
ICONTRACTOR: TEL. NO: 1 (APPROVALS DATE INSPECTOR SIGNATURE 1
IBILT-WELL ROOF AND MATERICAL CO. (626) 444-2422- 1 1 I
13310 VERDUGO ROAD LIC. NO 1 (LOCATION AND SETBACKS I 1 '
ILOS ANGELES, CA 90065 458005 C39 I I I I I
I 1 ISOILS ENGINEER APPROVAL
(ARCHITECT OR ENGINEER: TEL. NO: 1 IFOUNDATION/TRENCH FORMS I I I
1 LIC. NO: 1 1SLAB/UNDER FLOOR
I 1 IRAISED FLOOR FRAMING 1 1 1
IMAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP:( 1UNDERFLOOR INSULATION I I I
1150H269 3 001 I 1-1 I
I I IFLOOR SHEATHING I I I
INO. OF FAMILIES: DWELLING UNITS: .APT/GOND: STAT CLASS: _J I I' I
1 NO 21 1 1ROOF SHEATHING
1 SCHOOL WITHIN HAZARDOUS 1 ISHEAR PANELS
(AIR QUALITY: 1000 FEET MATERIALS 1 I I I I
1 NO NO NO IFRAME INSPECTION
I I I
I (FIRE SPRINKLER HANGERS 1 1
(INSULATION/WEATHER STRIPI I I
I 1 11NTERIOR LATH/DRYWALL 1 I
I I I
1 1 1EXTERIOR LATH I I
I I I
RATED FLOOR/CEIL ASSEM. I I
1 (RATED WALL ASSEMBLIES I I I
I I I
IRATED SHAFTS/OPENINGS 1 I
I I I
I I IT-BAR CEILINGS I I
I I I
I I ILOT DRAINAGE I I
I I I
IREPORT ID: DPR261 ROUTE TO: BS0508
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