HomeMy Public PortalAbout4970 LOMA AVE_Building__ TEMPLE CITY J
7eAe3eACE geol. "I ARRUCATION FOR E3lu' R _®INN PERMIT �.
COUNTY OF LOS ANGELES BUILDING / AA
DEPARTMENT OF COUNTY ENGINEER ADDRESS 4 -6
BUILDING AND SAFETY DMSION LOCALITY T+----A4 PL E Gf T .
JOHN A. LAMBIE, COUNTY ENGINEER NEAREST E1Li�ND D.,2'
'WILLIAM A JENSEN BUP'T OF BUILDING CROSS ST S
DISTRICT N GROUP �.pE PROCESSED BY
FOR APPLICANT TO FILL IN SU T; T coNST �- 6 o Lo✓Kc3
BUILDING _ -70 ` STATISTICAL CLASSIFICATION SEWER MAP
ADDRESS _ DWELL UNITS BK PG'
D CLASS NO
LOT NO Pal'6el 19' _ '- BLOCK WATER NOT REQUIRED1:1RECEIVED
..,d i _D- CERTIFICATE
TRACT Record of Sul7e Bo MAP rl „- I HIGHWAY STATE MAJOR SECOND, OCA
p�y,� No OF BLDGS.� NO C-0 (CIRCLE)
SIZE OF-LOT piX NOW ON LOT USE ZONE SPECIAL
USE F
EX STOING BLDG D e,�f. 7�inn & Dot, Gaza e Aw �' CONDITIONS
OWNER Mr, Dana�-d v 'pNO BUILDING YARD HWY STREET NAME EXIST
ADDRESS 1015 McAdian So* Pasadena SETBACK WIDTH
ARCHITECT OR TEL. FRONT
ARCHITECTO
ENGINEER mane NO SIDE
P L
ADDRESS ( TEL ` / INSPECTIONIRECORD CL
O
CONTRACTOR Santa Anita rC,6n8 10 •-A'Y797L'�G. 7/ / yr ,,� V
ADDRESS Z E 1 '9`'
f W O
DESCRIPTION OF WORKIL
�� • �- `
NEW Yy ADD ALTER REPAIR DEMOLISH -j - ,,{{///✓�,�{U/jff l r,/,�,,i h
SOFT., NO'OF' NO OF
IZE Q - - STORIES r FAMILIES
SUSE OF
TRUCTURE _.w I a`I R !/L' � /�/�G29 +C^3��✓�V /I��. �llG�r
SIGNATUR� -
APPLICANT �E t
a VALUATION$ '!s�ZO 0 a `
fie/ APPROVALS 'I6AT/E INSPECTOR'S SIGNATURE
PMTFEE $"�'�FQ', FEE $' V '-� FO FORMS,MATERIALS
UNDATION PC
ON
FRAME• FIRE STOPS,
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION BRACING, BOLTS e, _ ✓.s r7I'3"/71"
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY FURNACE LOCATION, �'J( ✓�`�/ I�
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING GAS VENT DUCTS
BUILDING CONSTRUCTION I CERTIFY THAT IN DOING THE WORK
AUTHORIZED HEREBY I WILL NOT EMPLOY ANY PERSON IN VIOLA- LATH,INT. . .
TION OF THE LABOR CODE OF THE STATE OF CALIFORNIA'RELAT= /y
INC TO WOR MPENSATJ,PJ�J INSURANCE y�v/ Y `•� �a'
"���Q)_ C�, LATH,EXT. , t
SIGNATURE HOUSE�.�- HOUSE NUMBER COR-
PERMITTEE -�- RECT AND POSTED
•ADDRESS ?.1-7 4--/- FINAL
CLYDE N DIRLAM, PRINCIPAL STR RAL ENGINEER
PLAN CHECK VALIDATION cK e,.o. CASR PERMIT VALIDATION cK. m.o. cwsm
• I
G C WIS i'iAl 13' 2 3 D 5 0.2 5 u
�€^1,c� 5' : 3 5^ i'1AY j 1 1 D 60.50-
• r J
1 ' - • ' • ` lv 1 A
D ARTMENT OF BUILDING. AND SAFETY APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES
WM. J. FOX. CHIEF ENGINEER RUMLDMNU
FOR APPLICANT TO FILL IN FOR OFFICE USE ONLY
BUILDING DISTRICT NO. PLAN CK.NO.- PERMIT NO.
ADDRESH �„ 36q-3
LOCALITY RECEIVED 19Y DATE APPL. DATE ISSUED
NEAREST -2- S-0
CROHB T
BUILDING
OWNER may � u ADDRESS C/ U
MAILGJ •�'^'V •
r � '�� LOCALITY / i 4
ADDRESS
i
- NEAREST
CITY
NO. CROSS ST.
ARCHITECT OR TEL. ZONE PLAN FIRE No. T1/PE GROUP
ENGINEER .%L
� BLDG. ORD.NO.
ADDRESS SETBACK LINE
APPROVED
CONTRACTOR m Np- 1, /',. BY DATE
USE APPROVED
ADDRESS ZONE BY DATE
LEGAL �2-0 -7 CORRECTIONS
DESCRIPTION ,LOT NO. BLOCK
TRACT -
�] NO.'OF BLDG9.
SIZE OF LOT M.S.6/ I NOW ON LOT
USE OF NO.OFNO.OF
EXISTING BLDG. FAMILIEa ROOMS
DESCRIPTION°OF WORK
NEW ALTERATION ADDITION Y O
REPAIR MOVING DEMOLISH
IS0
S .FT. �V ROOMS STORIES r
912E
WALL
G COOF��O
COVERING COVaaERING
USE OF NEW
BUILDING
Yee bl/eenji-led Ir
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPROVALS?
APPLICATION AND STATE THAT THE ABOVE IS CORRECT INSPECTOR DATE
AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES FOUNDATION: LOCATION'
FORMS, MATERIALS
AND STATE LAWS REGULATING BUILDING CONSTRUC
FRAME: FIRE STOPS, J V
SIGNATURE OFU�t BRACING,BOLTS
PERMITTE ► -
LATH, INT.
AUTHORIZED AGT
i LATH, EXT. �
76A639A-3 7-49 P.C. �y� PLASTER, INT. 44
l/ FEE PLASTER,EXT. 3 I
`a
VALUATION FEE FINAL v
,DEP,ARTMENT OF BUILDING AND SAFETY APPLICATION FOR PERMIT
'COUNTY OF LOS ANGELES
WM. J. FOX, CHIEF ENGINEER
FOR OFFICE USE
FOR APPLICANT TO FILL IN UILDING J . ONLY
DISTRICT NO. PLAN CK.NO. /P'ERMIT NO.
ADDRESS D,:/ _l o_
LOCALITY• ( ; RECEIVED 1BY DATE OF APPL. DATE ISSUED
NEA
CROB9 BT. BUILDING
• /� / ADDRESS
HER/
MAIL \ ij a LOCALITY RdSc- 0-" cd of
ADDREB Q�' Gf NEAREST LDD
TEL CROSS HT. QI.J�I �' S CZ /fie
CITY NO.
FIRE NO.OFTYPE GROUP
ARCHITECT OR TEL ZONE _� PLANS
-ENGINEER',
BLDG. As ORD.NO.
SETBACK LINE
ADDRESS v�-
APPROVE /J�f
TEL. BY a�f _ _ •%q,/�� DATE
CONTRACTOR NO. _
UBEG APPROVED
ADDREHH ZONE � I BY DATE
DESCRIPTION LOTNO. ( f-- BLOCK _LEGAL CORRECTIONS
TRACT /V / ,�ica�.. v ,t t-�en
X �� I NO.OF BLOTS.
SIZE OF LOT � 1 NOW ON LOT
USE OF NO.OFNO.OF
_EXISTING BLDG. FAMILIES ROOMS
DESCRIPTION OF WORK
NEW I I_rALTERATION ADDITION `
O
.0
REPAIR MOVING DEMOLISH p
Sq.FT. y� NO.OF 2 Z
SIZE [/ o ROOMS �7 STORIES / -
WALL / ROOF
COVERING S'�c�( COVERING C .
USE DI NEW �/ J , �.a7�
BUILDING /. V//'(.Ir-... p e Qa
,_ I P
�e-s7. {7 -emsy /tet t, LA d l.Du s
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIB' APPROVALS
APPLICATION AND STATE THAT THE ABOVE IH CORRECT FOUNDATION: LOCATION INSPECTOR DATE
AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES FORMS,MATERIALS
AND STATE LAWS R BULATIN13 BUILDING CONSTRUCTIONS r•
FRAME: FIRE STOPS,'
SIGNATURE OF S /J BRACING,BOLTS _
PERMITTE ( - LATH,INT.:
AUTHORIZED T__
- LATH,EXT.:
D8S-3 SOM SerS 1-48 $ L
FFEE
PLASTER,INT.
PLASTER,EXT.
VALUATION `� FINAL
r''DIV'ig-ION t OF BUILDING AND SAFETY {
�'= •=<= Department of County Engineer
County of Los-Angeles APPLICATION
WM. J. FOX, COUNTY ENGINEER
FOR APPLICANT TO FILL IN FOR OFFICE USE ONLY
p/ J� DISTRICT NO. PLAN CK. OR RED.NO. PERMIT NO.
UILDING
ADDREBS6 /UD. LD ' �• -- a� 3 d7
RECEIVED BY
DATE OF APPL. DATE IBBU,{ED
LOCALITY
NEAREST
CROSS ST. AUILDING
DDRESS . �•►. /'^]
d
OWNER�/�}"/�tr�- �-• ^
MAIL f /� LOCALITY A -
ADDRESB Z 7 �V U ` 10 114'J4 S`� NEAREST
A / n CRIBS ST.
CITY �/LfLf /D L f�L lHD /4/ (� -P)IO� FIRE NO.OF TYPE / GROUP
ZONE — PLANS
ARCHITECT OR TEL
ENGINEER NO. BLDG. _S � D NO.
SETBACK LINE [_"
ADDREBH USE /� APPROVED
TEL. ZDNE/ I - / BY DATE
CONTRACTOR NO. HOUSE NUMBERING
ADDRRBB MAP NUMBER Q/ - NO. ASSIGNED BY
LEGAL Q CORRECTIONS
DESCRIPTION LOT NO. 7 BLOCK
TRACT `
NO. OF BLDOS.
SIZE OF LOT I,� NOW ON LOTUSE OF rt
EXISTING BLDG. d.� I� I N G I F0.ILLIiES
DESCRIPTION OF WORK °x
0
NEW ALTERATION ADDITION Z
.I D
REPAIR DEMOLITION r
BQ.FT. NO.OF '
SIZE" �l Rooms STORIES
/ O
'LL 'y^�4/7�COVEM OW
USE OF STRUCTURE `
i
INSPECTION FOR APPROVALS
OCCUPANCYAS INBPECTOR'SSIGNATURE DATE
FOUNDATION: LOCATION
FORMS, MATERIALS !Q—w"("
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIN AP-'
PLICATION AND STATE THAT THE INFORMATION GIVEN IS FRAME: FIRESTOPS,
CORRECT. - BRACING, BOLTS yp
1 AGREE TO COMPLY WITH ALL COUNTY ORDINANCES FURNACE: LOCATION,
AND STATE LAWS GULATING BUILDING CON RUCTION. GAS VENT, DUCTS \
SIGNATURE OFe � LATH, INT.
PE R M ITTt `
ADOREATH. EXT.
S � . L
PLASTER, INT. ���
AUTHORIZED AGT. -
PLASTER, EXT.
J P.C.Q HOUSE NUMBER COR-
•% D O '0 FEE RECT AND POSTED
VALUATION FEE O'^� RINAL
b
76A63BA DBS 3 I-S2
DEPARTMENT OF BUILDING AND SAFETY APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES 9 L I
WM. J. FOX, CHIEF ENGINEER
FOR APPLICANT TO FILL IN ,FOR OFFICE USE ONLY
DISTRICT NO. PLAN CK.NO. PERMIT NO.
BUILDING
ADDRESS (�
LOCALITY (' ��C�,._ X�o�3 CI-"• +�5:/1+vll REC 1 D Y DATE OFA PL. DAT IBSUED
NEAREST S— / ��
CROSS ST.
A BUILDING
OWNER \R\ \ iO./1�NA\V•�!/ ADDRESS
MAIL ('1� LOCALITY
ADDRESS -\ t! ,�,4 a }ate
NEAREST
CITYCTE."'�\\' CRO5S ST. -
N O.
FIRE NO.OF TYP ,• GROUF}..,
ARCHITECT OR TEL ZONE PLANS �L��
ENGINEER _ NO. - _
SLOG. � ORD.NO.
ADDRESS SETBACK LINE
APPROVED
TEL. BY DATE
CONTRACTOR NO. - n
USE APPROVED
ADDRESS I �r1 ZONE -/ BY - DATE
LEGAL �'� CORRECTIONS '
DESCRIPTION LOT NO. BLOCK G/,
TRACT aUL /"er/J' �•�' '�!/ 7-C,/`7�i6fi ,�
���� I NOW ON LOTS
SIZE OF LOT LI
USE OFUSE OF vF .O E9 4I ROOMS.O E9 4I ROOMS ,
NO.OF
EXISTING BLDG.
DESCRIPTION OF WORK
NEW ' ALTERATION ADDITION -
O
- A
REPAIR MOVING DEMOLISH
Sq.FT. 1 NO.OFZ
SIZEy� !_) ROOMS "r•�. STORIES _ D
WALL ROOF
COVERING `LIO�4 �A I COVERINGUSE
CA�(I.,LQ �`•'�
BU LDFING W
1 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. T
FRAME: FIRE STOPS,
SIGNATURE OF BRACING,BOLTS
PERMITTEE \'�-�` -�� \ LATH,INT.:
- V
AUTHORIZED AOT
LATH,EXT.:
DBS-3 SOM SETS 7-47 $ P.C III PLASTER,INT.r
FEE PLASTER,EXT.
VALUATION - FEE lf' --7" FINAL
DEPARTMENT OF BUILDING AND SAFETY APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES a
WM. J. FOX. CHIEF ENGINEER
!r
FOR APPLICANT TO FILL IN FOR OFFICE USE ONLY
DISTRICT NO. PLAN CK.NO. PERMIT NO.
BUILDING
ADDRESS QS ✓� Ci �/' �Q �/' '��
LOCALITY { RECEIVED BY DATE OF AiPPL. DATE ISSUED
NEAR EBT• �-
c� �CjZ�/VQ U.S O � S
CROBB BUILD
OWNER �i /V J C Com-v G ADDREIBB d �� �/ e'�� -/✓
MAIL LOCALITY
ADDRESS ,S
NEAREST,
TEL.. CROSSST.
� , D
CITY 7�lIPLaIRE
ARCHITECT OR TEL. ZONE Y , PLANB' SPE GROUP
ENGINEER NO.
BLDG. ORD.NO.
ADDRESS - BETBACK'LINE
APPROVED
!� NO.
BY DATE
CONTRACTOR
USE/ APPROVED ,
ADDRE ZONES BY DATE
DESLEGALCRIPTION LOT NO. LOCK ZQ ` CORRECTIONS -
TRACTNO.OF BLDG
SIZE OF LOT NOW ON LOTS
U9E OF o 7' NO.OF / NO.OF
EX I9TINO BLDG. '¢V FA iLiEe ROOMS
DESCRIPTION OF WORK
NEW J LL ALTERATION ADDITION O
' A
REPAIR MOVING DEMOLISH G
9Q.FT. NO.OF D
91ZE ' j ROOMS STORIES >
WALL ROD
COVERING COVERING6�,J'lfloe
USE OF NEW
BUILDING b'C
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THISR"T APPROVALS
APPANDLAGREE TO COMPLY W TH ALL ON AND STATE THAT HE ABOVE IS CORRECT C COUNTY ORDINANCES FOUNDATION: LOCATION INSPECTOR 0'--' 9 JTE
FORMS, MATERIALS
AND STATE LAWS REGULATING BUILDING CONSTRUCTION.
j��RAME: FIRE STOPS,
SIGNATURE O _ �« BRACING,BOLTS
PERMITTE AUTHORIZED AOT
76A63BA-3 7-4e $ o-C P.C.4 ' PLASTER,INT.
Ll FEE PLASTER,EXT.
VALUATION FINAL r
FEE �
Li
APF'LlC� T'IrOIV FOR BUILDING PERMIT"
APPLICANT TO-FILL IN (Print`or t,Yoe only) ,
BUI LIDI'NG, - COLON L%ANGELES -_
ADDRESS, _ { DEPARTMENT OF COUNTY, "ENGINEER.
� $ Z ? BUILDING AND SAFETY DIVISION b
'° ;; �' p NO OF BLDGS-__ BUILDING
•SIZE"'OFf � ,NOW ON LOT ADDRESS
TR BLOGF(� LOT.NO LOCALITY �• �.,.,,...;/"- f� .�^y
r ,:•Ce"' TEL NEAREST `- -
OWNER',"_ w - f 'F,.r NO CROSS ST tf� •.t:._,Li� '....a`.:!".d ,id'Mr^'• -
-iESS...- _ MAP�BOOK ASSESSOR,-;t-"-',-':r�,. . •� r.+- _ e:
ADDR �•' �' _ - .(• PAGE PARCEL_
DISTRICT IGROUP, TYPE �1 FIRE PROCE%ED; Y, ,
CIT�
ARCHITECT_ ' RS ZIP TEL C O NS T�"•," ..s ZONE
ENGINEER, r 'NO
r ', STATISTICAL CLASSIFICATION i SEWE, P
ADDRESS'•,: .'`�.,$.• _ CLASS NOS• t ;=DWELL UNITS -r BK - 'PG
,.� nv "- TEL -
CONT+RACT_,OR \ NO USE,ZONE MAP
_ LIC N O
ADDRESS•`.S f , ��� NO e� ��- 7,) SPECIAL'".';`• '
y LIC-� I CONDITIONS -
CITY 4 _ CLASS - ROAD DE PAR TM EN T'AIPP ROVA L REQUIRED Y,ES❑ NO`;.❑' y,
CONSTROC•T,ION[L`ENDERs`- - �'- ��� ` _ "
NAMEAND,BRANCH _ BLDG SETBACK FROtv1kf~°' V
' "'�• -`� ° FRONT PROP LINE OF' - IST.REET);_�; r
ADDRESS ,•� CITY 'vr,�_ J ty` TOTAL SETBACK FROM TYPE-OF' 'J
HIGHWAY + YARD �y
„SQ`1=F,T'�� „• NO OF 'a NO. OF_ CHECK ,i _ FRONT PROP LINE HIGHWAYS;•W,IDTH,�
S_I'ZE ��'' ri�"�'STORIES _7 FAMILIfiS u-ONE
+
DES, R'I`PTIONOFW,ORK _ °,- _ "t• NEW
mow;`, - , c vy 's` �k O
BLDG,SETBACK•FROM_ •_
� A'DD [:1SIDEPROP LINEOF ' - (STREET
�'✓, u r - ALTER ❑ TOTAL SETBACK FROM ,TYPE„.,OF% EXISTING , LV
r.
'.��.�, `'"� lC!\ +� '�'a"�>aKr 'r+ m,,.r• -_-- :HIGHWAY + YARD- "; " ''� HIGHWAY,
REPAIR❑ SIDE PROP LINE _,mow
EXISTING;BLDG. -
APPLICANT 'i' TEL CORNER C _'r'OFF YES, ❑ NO ❑
(PRINT) f 'r - -A - NO..
�• F•. IN OPEN SPACE - YES ❑ - NO ❑
t •'B Y'(S I G N ATU R E), - ••_;� ;� g_--
-tr IN COASTAL ZONE ,�- YES [] - NO ❑
VALUATION.�. � _, 1� -�.!' - CATEGORICAL EXEMPTION YES❑ •^•'"a,'q•N O,❑"
y
q , I,HERE BY ACK NOWH
LEDGE-T, AT I HAVE READ THIS APPLICATION -ENVIRONMENTAL
AND STATE THAT THE AOVEb IS'CORRECT AND AGREE TO COMPLY IMPACT EXEM'?JION DECLARATION SIGNED (DATE)
h WITH ALL ORDINANCES'
BAND,` LAWS REGULATING BUILDING CON- „
ST,RUCTION 1 CER,TlFY -THAT','IN DOINGg THE WORK AUTHORIZED IM PAC?d.REPORT PROCESSED (DA•TE)
bx -EMPL'OY�{rANY PERSON�I,N-VIOLATION/OF THE v f
—HERE BYNI WILL N��O,,rrT+�
•LABOR �C06E'AjOF,;f,3�,T HE STATE; OF CALIF,OR'NIA4iIN REL"ATING TO
WO RK MEN:S COMPENSATION INSURAN 1- -
w {..
T. :p
'SI'GNAURE�OF `
-PERMITTEES"`- Q,��° "�y'`�• A
f1' ,�,
LCL ` a! `� lf: = • l•S,y.6n
ADDRESS
.s.•�`�� t.� ,t ��,�.� )' FINAL- BY
''T.d1 �- >
'--� j�,� i tt TEL;gv�I�� �]y DAT •'�#:t ' ' ,'tom '"�'i, �,+ ��1y��
C I T Y�y'vt>a .',WWW I'zF� -.l; ,.`yryNxsOa �i RiA �E
E,
C.'IIE C Ks P.1}'W/3i-'-E /O� -t- , FEE � 3� i g 4� FEE $RMT.
;HARVEY T. BRAND,, COUNTY ENGINIEER `d _ sr
;PLAN CHECK VASLIDATION CK M o CASH m PERMI ;,VALIDATION CK M O CASH
i ma 1 c ana dy c
76A638A CE 4803 12/72
WORKERS'COMPENSATION'DECLARATION _ _-, ,..�,•' `. �+,t"dS,1..,-`p r �_. _. .__. . �t ;;' .,r� i
+ ,I herQb =_affirm that I have a certificate of consent to,self101-
D O A D O O
insure, or a'certificate of'Workers' Compensation Insurance, p p d 0 C�Q�0 O Ill C �00 C Cfl3 M,
or a certified copy thereof (Sec 3800, Lab`C') [/�\�
COUNTY OF LOS ANGELES~ BUILDING-ARID SAFETY
POlicy,No•s Company ---
Pv y FOR APPLICANT IN ~BUILDING � - =
Certified co is hereby furnished „-'. ADDRESS (/ `
Certified copy'rs filed with the"county buildmg7mspeo- BUILDING
hon department ADDRESS
Date-' •Applicant CITY`� Mr - (�f f /• �� ZIP. /� LOCALITY Lecew
`CERTIFICATE OF`EXEMPTION FROM WORKERS -' --,NO-OF BLDGS--- - NEAREST•~
COMPENSATIONI INSURANCE, SIZE OF LOT i•NOW ON LOT CROSS ST
(This�sectton need not,be•completed=if.thetpermit,is,for',one -• - -� - ASSESSORS-'_ �• -- t. /
TRACT BLOCK LOT NO MAP BOOK: ;'( •,t PAGE; PARCEL
hundred dollars ($100) or,less,). TEL ��
1, ^ ;" r , •r, OWNER'•- `O(�► -- - +- l.�f.• __.N USE NE 'MAP
.It certify thdtjm�the performance of the work for which this / NO
permit is issued,I shall not,empl'gy any person'm any manner _ r - -!• - ,SPECIAL-
so as w6ecome"subject to the Workers'Compensation Laws ADDRESS- 7, CONDITIONS" 10
- - CITY_. ../°.kyr - j• - --ZIP- 1 ; - -_ -- _ -
ate-- APPIIL�
NOTICE TO'APPLICANT'If, after`Srnakirig this Cerh c61e,of ARCHITECT OR, TEL _ ,_DISTRICT„ ,GROUP• TYPE.,,,, C• FIRE, r PROC SE' BY:
ENGINEER NO CONST ZONE
ExeriipTion, you' 'should-'becomes subject to 'the Workers' O ;LU
Compensation provisions of the Labor,Code, you must forth- ADDRESS ` �' -- -•- �'« : -.J --- -with comply.with such rovisi_ons or,this,, ermit,shall be
P Y' P P �- TEL STATISTICAL,CLASSIFICATION r j APT CO O"
deemed revoked - •,, '.gY;�,e•} CONTRACTOR �' NO '' // � 4-
LICENSED
-., , -
LICENSEDCONTRACTORSrDECLARATION •,! -- - - - - - - _.._..LIC._:_.c_ _ CLASSNO -DWELL•,UNITS r
I hereby affirm that I am licensed under provisions of Chapter 9 w ADDRESS NO
f
(commencing with Section 7000)of Division 3 of the Business and _•_ __•_, _ _ _ SEWER MAP _
.r-• LIC-T• •y
Professions Code,^and'my license is,,n'full'foice and effect CITY CLASS "i _ "'�"' VALIDATION -'
SBK PG
Q FT 0 NO OF _ NO OF _ _ CHECK
License Number Lic Class" SIZE % STORIES ' FAMILIES:" / ONE' 7
i•. iyi ..u, c , , •au E;' , r='v •tart ., ', .-O VALUATION'- _
Yc' - DESCRIPTION'OF'WORK $
Contractor Date, „
❑ ., r i, -- _ / - _ ADD
I am exempt under Sec -� ��' guT� ALTER
B&P C for this reason „x % -- - - REPAIR
- ^ - - Date -. ,. USE OF
EXISTING BLDG DEMOL
Signature�:r E-`APPLICANT,-, - - TEL i FINAL .� .
OWNER-BUILDERDECLARATION (PRINT) -NO y :DAT1 ,;24560A
-1 hereby affirm that I•am•exempt from the-Co ntractor's LicenseADDRESS T FINA # o,lo,0,-0,o_
d Law for the following'reason•(Section 7031 5, Business and `� _ _ _ • '
.. Professions Code) ":` - '' ," - NT ._.__� __ _ -._. .-. ..__. '_ ._ ' By - - i-'"' c•o s ,
xj-JjgJ( BUILDING
I, as owner of the property_or my;employees with y - A_DD_RESS• _ " •}
wages as their sole compensation,will do the work and _ w ? i-4;98 8 ox ;
the structure is not intended ory ffered;for sale(Section LOCALITY t
" 7044, Business and Professidns'Code) MOVING' ^_" -TEL" -� �' - --" ` :t - - � � 1
1, as owner of the property, am exclusively contracting CONTRACTOR NO
`-with licensed contractors,to'construct the project (Sec- . -
ADDRESS
, i
• . hon 7044, Business and•Professrons-Code) - - _ .. '' ,� 7 ^; •xp: a i ,
_. REQUIRED, _.TOTAL SETBACKFROM EXIST
CONSTRUCTION LENDING AGENCY SET BACK
- 'YARD '"HWY PROP LINE WIDTH'
I hereby affirm that there is a construction lending agency for FRONT s :'Ot`.�r• ,r'y 3'
-the performance of the work for which this permit is-issued -- P•L--•-
(Sec ,3097, Civ C ) SIDE
-P L - - ' - - JM
Lender's Name _-- -- - "( r
S _ - U LDMA Ref #
� - - --• - -- . . _ ._� P C-Fee-$- - -- PermrrFee - - - - - ----' - - - -
Lender's Address �^-- { :{
.1-certify that I have read this.application and state that theIssuance-Fee 1 -O r J Q• LDMA-P/C#,^ -t - ---- -
above information is correct I agree to comply with all County Investigation Fee `.'t ; , •` ' �" �'�
ordinances and State lows relatin to building construction, g x•�`
v__. 9 Total-Fee- t LD"'Perm'=
u and hereby authorize representatives of This County to enter
m upon the above-mentioned pr erty for inspection purposes
o `_ D Tc SEE REVERSE FOR EXPLANATORY LANGUAGE
Signotvre-of44kant or Agent Date
WORKERS'COMPENSATION'DECLARATION 91306111
_
by affirm that I have a certificate of•consenh to self' I O D `� D "O O O
or a certificate of Workers' Compensation Insurance, r, A P P��C �� IJ O N•'•�O Q• B M�d D 'G�] G3G�ri 0�
ertified copy thereof (Sec 3800, Lab C ) I'
COUNTY OF LOS ANGELES_ BUILDING AND SAFETY ,
NoTV83-2251rripcny Fremont Indemnity'
,Certified copy is hereby.furrnshed FOR APPLICANT TO FILL IN -• BUILDING_
ADDRESS
Certified copy is filed with the county building onspec- BUILDING '
o tion,department ADDRESS 4970 'Loma Ae u - '- LOCALITY = -
NEAREST
11/81$3 Applicant Vi rcri n Roof,• CO. CITY Temple City- ZIP CROSS ST
I CERTIFICATE OF EXEMPTION FROM WORKERS' NO OF BLDGS ASSESSOR
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP-BOOK,--, PAGE PARCEL'
�section'need not be completed if the permit is for one USE ZONE MAP
Fred dollars ($100)or less ) TRACT BLOCK LOT NO —4—d NO,
TEL SPECIAL'
ktfy that in the-performance of the work for which this OWNER Donald `Ra NO '� CONDITIONS
nit is`iss'ed, I sholl'not employ any person in any manner DISTRICT GROUP.• TYPE FIRE PROCESSED BY O
s to become subject to the Workers'Compensation Laws ADDRESS '4970 Loma AV enue CONST ZONE V
CITY Temple @it ' ZIP O
Applicant STATISTICAL CIASSIFICATIO APT CONDO V
iICE TO APPLICANT If,- after making this Certificate`of i ARCHITECT OR TEL,
ENGINEER NO` 'r CLASS NOmDWELL UNITS a
ption, you should become subject to the`,Workers;, ,
npensatton provisions become'
Labor Code, you must forth- ADDRESS - SEWER MAP y`/
h comply with-such_provisions_or,this permit shall beTEL �z
med revoked CONTRACTOR Virgin Roof Co. No 287-0507 'BK - PG, VALIDATION
LICENSED CONTRACTORS DECLARATION LIC e
preby affirm that I am hcensed undelr'provisions,of Chapter 9 ADDRESS -P , BOX J NO 640VALUATION
Immencmg with Section 7000)of Division 3 of the Business and i LIC
tfessions Code, and my license is-in full force and effect CITY San Gabriel 917 8 CLASS 51522.00'
'SQ FT" NO OF NO OF CHECK D
ense Number 166650 Lic Class C�� SIZE STORIES FAMILIES ONE
Y11/8/83 DESCRIPTION OF WORK — NEW
ntractor Virgin. Roof Co. Date
ADD O #'
(� I am exempt under,Sec C
of, house With 220�r Class .A ALTER FINAL
2
DATE' 2
B 8P C for this reason ; Fiberglass cam ' shin les �16s ETEPAIR Q _
Date USE OF DEPAIR FINAL
9 EXISTING BLDG dW 1 - By [ C�_! �•Q•-s�.11
Signature -` APPLICANT-'• ' TEL V t
OWNER-BUILDER,DECLARATION t PRINT Vir in Roof-.Co _ -No287-050 - _ ,
hereby affirm,that I am exempt from the Contractor's License
iw for the following reason (Section 7031 5, Business and ADDRESS _ D _
rofesstons Code) PRESENT -
BUILDING
in I,as owner,of.the property, or,my•employees with' ADDRESS'
wages as their sole compensation,will do the,work and 6 8.9. A
•the structure is not intended or offered for sale(Section LOCALITY :# 0 0 0 0 0 1
7044, Business'and Profess Ians'Code) MOVING TEL i .
I, as,owner of the property, am e';clusively contracting CONTRACTOR NO 2o
988'
-with
licensed contractors to-construct the project (Sec-
_ 4 g 88.
tion 7,044, Business and Professions Code) ADDRESS ,h o oJe
REQUIRED TOTAL SETBACK FROM EXIST
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP LINE WIDTH I 1 1,7-83
`hereby affirm,that there is a construction lending agency for FRONT,
fhe performance of'the work for which this permit is issued { P L '
(Sec 3097;Civ C ) ' SIDE
P,L
Lender's Name
�.'
39 38
P C Fee$ Permit Fee .
IlLencler's'Addreis
I certify that I have read this application and state that the Issuance Fee 1.0.50
z. above information is correct I agree to comply with all County Investigation Fee
ordinances and State laws relating to building construction, _ Total Fee 49.88
and eby authorize representatives of this County to enter
upo the out perty pectiioonn purposes
^}] -
' t SEE REVERSE FOR EXPLANATORY LANGUAGE �~ '
r'
t nature of Applicant or Agent Date ^--