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HomeMy Public PortalAbout5402 LOMA AVE_Building__ I:EP 44f!:TMENT OF BUILDING AND SAFPLICATI011-r vti PERMIT BOUNTY OF LOS ANGELES I I, " WM. J. FOX. CHIEF ENGINEER FOR APPLICANT TO FILL IN � FOR OFFICE USE ONLY AODRE'SM ' 2, - IaoVw >' le DIHTRIC7'NO. PLAN CK NO. PERMIT 0. LOCALITY ,�/ RECEIVE/DRY cDATE OF APPL, DATE ISSUED NEAREST Cr74 o5 CROSS ST. BUILDING _OWNER_ �_� ��� �� ADDRESH MAILe ! r LOCALITY A� /�7" .!✓/ ADDRESS •- NEAREST /vJ TEL. CROSS HT. CITY � NO. , FIRE NO.OF TYPE r �/= GROUP/ / ARCHITECT OR 7EL. ZONE PLANS ENGINEER NO BLDG. ORD.NO. �D,7(RJEJBS SETBACK LINE CONTRA CyT isyy'� •"��"`"'�ft$Y NO. AliVp/dt APPROVED TEL. j BY DATE USE AD RE . �/ / �/Ey.�/ �,t ZONE ABYPROVED DATE LEGAL I 4 ,'', 3 CORRECTIONS DESCRIPTION LOT NO. BLOCK )/� _TRACT —9- /t} NO.OF SLOGS. _ SIZE OF LOT C� I NOW ON LOT ^',),,,��•{a UBE OF I NO.OF NO.OF LX{9TINO BL66. FAMi LIIE I ROOMS /Jy�.rm �/�,�,�y-• CR?M.rJ DESCRIPTION OF WORK NEW ALTERATION ADDITION O REPAIR .1 MOVING DEMOLIHH p BQ.FT. 4,e r NO.OF Z SIZE �,,,.pp��j ROOMS � STORIES �a� �AA D WA�L ROOF CUVERING ++. WAe� I COVERING r USE OFNEW ,g BUILDING �`' [[�� udoa G 1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPROVALS' APPLICATION AND STATE THAT THE ABOVE IS CORRECT FOUNDATION,: LOCATION --J!4B13EMTDR DATE AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES ' FORMS,MATERIALS AND STATE LAWS REGULATING BUILDING CONSTRUCTION.- op FRAME: FIRE STOPS, SIGNATURE OF BRACING,BOLTS PERMITTEE--- 7 LATH, INT. AUTHORIZED AOT ,me46� LATH, EXT. i 76A636A-3 z-sar p,C,S PLASTER,INT. _ 1�r-j � cy 0 FEE / / PLASTER.EXT. ✓/�/! VALUAT ON FEE -� FINAL ,Y,6A638S1 -�" PPLICATION FOR BUILDI G .PERMIT CO Y OF LOS ANGELES BUILDING DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION LOCALITY c JOHN A. LAMBIE. COUNTY ENGINEER NEAREST COLEMAN W JENKINS,SUP T OF BUILDING CROSS ST o ;I RI CO NQ,�� GR P -TYPE RO Y FOR APPLICANT TO FILL IN C-jJ/ `�J CONST BUILDING STATISTICAL C A SIFICATION SEWEAR MAP .� 1 ADDRESS e CLASS NO * DWELL UNITS BK �/ f` vPG S LOT NO I BLOCK - USE ZONE I MAP �17 NO V TRACT � "y/ '/ SPECIAL NO OF BLDGS lll�_ CONDITIONS SIZE OF LOT Q 170 Q NOW ON LOT USE OF EXI TING BLDG �A, 'BLDG SETBACK FROM /� 7 TEL i/ FRONT PROP LINE OF (STREET) OWNE h, SJ C V4 NO T TYPE OF EXISTING SETBACK HIGHWAY + YARD = -TOTAL ADDRESS�J L 0 4Y • O YY��I' , Ute- HIGHWAY WIDTH FROM C L A! /Z CITY �_V" ct-r BLDG SETBACK FROM _ ARCHITECT OR TEL ENGINEER NO SIDE PROP LINE OF (STREET) TYPE OF EXISTING SETBACK HIGHWAY + YARD = TOTAL ADDRESS" HIGHWAY WIDTH FROM C L TEL + _ CONTRACTOR NO O LIC V ADDRESS LINo CORNER CUTOFF YES NO CITY IL SEE EVERSE`SIDE FOR SPECIAL APPROVALS ' O DESCRIPTION OF WORK v NEW ADD ALTER REPAIR DEMOLISH 'S�. �, ,•.,r z FT NO OF NO OF /�,�' SIZE C9 STORIES FAMILIES ` �z- USE OF e� STRUCTURE SIGNATUREO n !LID1,'" •yA PP L I C A N T T:Q_, VALUATION$ APPROVALS DATE INSPECTOR'S SIGNATUI " qq FOUNDATION, LOCATION �/�?�//i_ •< FEE$ FEE$ V h FORMS, MATERIALS r w�( FRAME, FIRE STOPS, I HEREBY ACKNOWLEDGE THAT-I,HAVE READ THIS APPLICATION BRACING BOLTS AND•STATE THAT THE ABOVE IS CORRECT-AND AGREE TO COMPLY FURNACE LOCATION a _ WITH ALL COUNTY ORDINANCES AND'STATE LAWS REGULATING GAS•VENT DUC-.TSk- 9UILD INGCONSTRUCTION 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 O CALIFORNIA RELAT- 'INGTOWORKMENSCO ENSATION INSURA E - LATH EXT SIGNATURE O - ;HOUSE NUMBER COR- PERMITTEE RECT AND POSTED ADDRESS �44A ' V o- • Fl NAL ` LAN CHECK VALIDATION cK M o CASH JOHN F LEWIS PRINCIPAL STR URAL ENGINEER PERMIT VALIDATION CK M C. CASH LAC91 & 1JAN 27 1 D 15.00- = APPUCAMON, FOR BULONG PERNT COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS I hereby affirm that I have a certificate of consent to self Insure, BUILQJpI qI�E �M ��y/O or a certificate of,Workers' Compensation Insurance,or a certified f� 111 �7I Ale- copy thereof(Sec 3800,Lab C) C s ZIP n/C/`� 04;�O' LOCAUT �f Policy NO Company• SIZE OF L T NO OF BLDGS NOW ON LOT ❑ Certified copy Is hereby furnished- NEAREST CROSS S ❑ Certified copy Is filed with the county budding Inspection - TRACT BLOCK LOT NO department USE ZONE MAP NO Date Applicant ASSESSOR MAP BOOK PAGE PARCEL SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' /} 4 Q G - b/ COMPENSATION INSURANCE Q 0 r_a1gng AIL �V — / 4�O WITHIN 1000 FT OF SCHOOLS YES NO This section need not be completed if the AD,gg ( p permit is for one hundred q Q / Omq DISTRICT GROUP TYP ,CONST FIRE ZONE', PROCESSED BY dollars ($100)or less) [�.— C ZIP I certify that in the performance of the work for which this permit 7 i is Issued, I shall not employ any person in any manner so as to beco bject f the rkers'Compens n Laws ARCHITE OR ENGINEE TEL ^ fiir, %-- C.� STATISTICAL.CLASSIFICATION APT CONDO Kant ADDRESS CLASS NO DWELL UNITS NOTICE TO APPLICANT If, after ma i g this Certificate of REQUIRED TOTAL SETBACK FROM EXIST Exemption, you Should become subj ct t0 •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 LICENSED CONTRACTORS DECLARATION SIDE CITY - - LIC CLASS PL , I hereby affirm that I am licensed underprovisions of Chapter 9 SEWER MAP CL (commencing with Sion 7000)of Division 3 of the Business and SQ T SIZE NO OF STOES NO OF FAMILIES d Section RI 'Professions Code,and my license is,in full force and effect NEW BK PG v License Number Lic Class " DESCRIP ON F RK ADD. ..❑ VALUATION O Contractor Date ALTER 'Cl. $ �3 LLJ. REPAIR ❑ ti C1 am exempt under Sec $ z B&PC for this reason /�G%G-e.r..P� DEMOL ❑ LDMA P/C# Date SE OF EXISTING BLD URM ❑ " Signature - APP (CANT(PRINT)Al. :r L N11LDMA Perm# property, or my employees with wages as j� �ti.r.. ❑ I.as owner of the ro � �/ Z - their sole compensation, will do the work and the structure Is ADDS 0 _ not Intended Or offered for sale (Section 7044, Business and / is• FINAL DATE Q '.i)�� 1 +',•=1= Professions Code) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT`HANDLE A HAZARDOUS MATERIAL - p t 'M/ OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE J +• f T '' yep I, as owner of the property, am exclusively contracting with AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY y ,licensed contractors t0 Construct the project (Section 7044, .,YES El NO 1:1 - i , :0 1 AL 10_3 m L Business and Professions Code) 77_� WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING !-!{ n•.IJ _ OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH y_j•__ CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR -- GUIDELINES (.•HsftIGLE.. I hereby affirm that there Is a construction lending agency for YES ElNo El - N the performance of the Work for'Which this permit Is Issued(Sec `I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING 3097,Civ C) CHECKLIST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS.ANGELES COUNTY CODE, —00,!_ ;— TITLE 2 CHAPTER 2 20 SECTIONS,2 20 100 THROUGH 2 20 140 CONCERNING HAZARDOUS L'31E 1=1�s 'LIS 71j26''9 fT' Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD I _— Lender's Address 6`_. - OWNER OR AGENT ' o 'I certify that I have read this application and state under penalty O of perjury that the above Information Is correct I agree to comply PC FEE - PERMIT FEE N with all county ordinances and State laws relating to building m construction, and hereby authorize representatives of this County ISSUANCE FEE / O � to ;ter upon the e- boned r y for inspect pur es CO (0 tTA INVESTIGATION FEE TOTAL FEE D Jr T ON a a nl w Ap C/ SEE REVERSE FOR EXPLANATORY LANGUAGE l q COUNTY OF LOS ANGELES , A BUILDING AND SAFETY WdRKER'S COMPENSATION DECLARATION �yq�_E _.•-FOR APPLICANT TO FILL IN , � BUILDING ADDRESS BUILDJpIG PV Ss� + C/'Tt-71-G/✓ "thereby affirm that I•have a certificate of consent to self Insure, {� 11 LO G � or a certificate of Workers' Compensation Insurance,or a certified, .� copy thereof(Sec 3800,Lab C) CIT](��� �, ZIP �� II U LOCALITY , Policy No Company SIZE OF LOT _ NO OF,BLDGS NOW ON LOT ❑ Certified copy Is hereby furnished ;)20 NEAREST CROSS 02 / ❑ Certified copy is filed with the county building Inspection TRACT BLOCK ^� LOT NO 0�(3'I)GJR b o� department 1-7 taZI USE ZONE MAP NO - Date Applicant ASSESSOR MAP BOOK PAGE PARCEL EO - _ SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER TES COMPENSATION INSURANCE avk� We,<a CIGGlloAe- o1i��-�� WITHIN 1000 FT OF SCHOOLS YES No ADDRESS (This section need not be completed If the permit Is for one•hundredr\ O DISTRICT GROUP TYPE CONST FIRE ZONE PROCESSED BY dollars($100)or less) (,certify that In the performance of the work for which this permit p Is issued, I shall not employ any person in any manner so as to >�`L �i C I. ZIP beCORle subject to the Workers'Compensation Laws ARCHITE TIORR REENGINEER 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, your 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 ow zi— FRONT comply with such provisions or this permit shall be deemed revoked ADDRESS LIC NO PL LICENSED CONTRACTORS DECLARATIONSIDE CITY LIC CLASS P L I hereby affirm that I am licensed underprovisions of Chapter 9 SEWER MAP >- (commencing with Section 7000)of Division 3 of the Business and SO F+T,SIZk I NO OF STORIES NO OF FAMILIES Professions Code,and my license Is In full force and effect -1-:>— � NEW El PG O License Number LIC Class DESC IPTION OF WORK App VALUATION n (�P ^1:r. r O Contractor Date ALTER 1:1 $ 3� 7 5' a0 '- ' ig ~ �7M C-- I c_•:3 W ❑ CL 1 am exempt under Sec REPAIR ❑ $ i z BBPC for this reason ' DEMOL ❑ LDMA P/C# Date U OF EXISTING BLDG URM ❑ AC— X Signature A/PPl„IC-A T(PRNT) TEL NO �7 LDMA Perm# _ + 1,as owner of the property, or my employees with wages as IY�► d a loe d 3 Q Z 2 I'Ert their sole compensation, will do the work and the structure Is All E SO _3 . 4 not Intended or offered for sale (Section 7044, Business and a FINAL DATE a I t j= 6894 Professions Code) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL rli-, .� El,1, as owner of the property, am exclusively contracting with ORA MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE Q AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDES FINAL BY > i-.��!.^-• '>Ilcensed contractors to construct the project (Section 7044, VES 1:1 No Business and Professions Code) ❑ -WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH < +.•' - r -'Y,„ - CONSTRUCTION LENDING AGENCY COAST AIR QUAUTY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKGUIOEUNELIST I hereby affirm that there Is a construction lending agency for VES❑ NO❑ a the performance of the work for which this permit Is Issued(Sec ° 3097,Civ C IHAVE ECKLISD I HE UNDERSTAND MY INFORMATION GUIDE AND ANGELHE ES COUNTMD YITTING a ) 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 HAZARDOUS 2 Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD o Lender's Address Ct OWNER OR AGENT 0 1 certify that I have read this application and state under penalty o of perjury that the above Information IS correct I-agree to comply PC FEE �D,�T PERMIT FEE �� h a with all county ordinances and State laws relating to building (/ !/ CO construction, and hereby authorize representatives of this County ISSUANCE FEE co to enti ned ter upon the above mproperty for inspection purposes �6O a m / ��Z” INVESTIGATION FEE TOTAL FEE 'L ^ I/ Dine 7 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 1207020048 PHONE (626) 285-0488 EXT ILEGAL ID NO OF CONST BUILDING ADDRESS ITR 7796 LT- 21 SQ FT STORIES TYPE 5410 LOMA AV ISTRUCTURE V—B TEMP CA 917803003 ASSESSOR INFORMATION NUMBER NEAREST,CROSS STREET 15388-001-021 THOMAS PAGE 596 GRID H4 LOCALITY TEMPLE CITY, Cl ITENANT j.ZXTST BLDG USE RESID USE ZONE: R-1 ISSUED ON PROCESSED BY EXIST OCC GRP 107/02/12 SR (OWNER TEL NO IBLDGS NOW ON LOT- VALUATION IFINAL ATE FINAL BY CODE JACALONE MARK,TERESA M — 2,000 - 15410 LOMA AV ITEMP 917803003 FEES PAID II)tSCITIPTION OF WORK v1 REPLACE 3 (E) WINDOWS @ FRONT OF HOUSE 1 IFEE DESCRIPTION QUANTITY UOM AMOUNT 1 1 (APPLICANT TEL NO I 1 1 IBROTMAN, IFAT (818) 987-7277— IAA BLDG PERMIT ISSUANCE 27 80 1 1 IAB STATE GREEN BLDG FEE 2000 00 VAL 1 00 ISPECIAL CONDITIONS IAC STRONG MOTION RESID 2000 00 VAL 0 50 1 ID2 PERMIT W/O EN—HC 2000 00 VAL 82 20 1 1 1 IFR INV WORK W/O PERMIT 342 20 DOL 342 20 1 1 ICONTRACTOR TEL NO I TOTAL FEES 453 70 (APPROVALS DATE INSPECTOR SIGNATURE 1 IGOLD REMODELING (213) 908-7135— I 1430 S WESTERN AVE LIC NO 1 (LOCATION AND SETBACKS 1 1 1 ILOS ANGELES CA 90020 955584 B ' 1 I 1 I ISOILS ENGINEER APPROVAL 1 1 (ARCHITECT OR ENGINEER TEL NO: (FOUNDATION/TRENCH FORMS I I I LIC. NO I ISLAB/UNDER FLOOR I I I 1 11 1 1 IRAISED FLOOR FRAMING 1 IMAP NO SEWER MAP BOOK PAGE FIRE ZONE CMP 1 1UNDERFLOOR INSULATION I I I 1147H265 3 001 1 1 1 1 I I , IFLOOR SHEATHING 1 1 1 INO OF FAMILIES DWELLING UNITS APT/COND STAT CLASS I 1 1 0 NO 21 IROOF SHEATHING 1 1 SCHOOL WITHIN HAZARDOUS ISHEAR PANELS I (AIR QUALITY 1000 FEET MATERIALS 1 1 1 1 1 NO NO NO IFRAME INSPECTION I I I I I i IFIRE SPRINKLER HANGERS I I 1 I I I I I I (INSULATION/WEATHER STRIPI I I 1 _I 11NTERIOR LATH/DRYWALL I 1 1 I I I I I I 1 1 IEXTERIOR L 1 �" 1 IRATED.FLOOR/CEIL'ASSEM. I (RATED-WALL ASSEMBLIES I I I I I I I I I IRATEDSHAFTS/OPENINGS � I I I IT—BAR CEILINGS I 1 1 I I I ILOT DRAINAGE I I I I I 1 IREPORT ID DPR261 ROUTE TO- BS0508 1 I a ' ANPUCAYMM FOR ULONG [PEIR 7 . COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS d hefeby affirm that I have a Certificate of consent to self Insure, BUILDING ADDRESSN�MR R �� •or a certificate of Workers'Compensation Insurance,or a certified 0,23 Cm ZIP copy thereof(Sec 3800,Lab C) `r tY Policy No Company LLOCALI Z SIZE OF LOT O �O NO OF�LDGS NOW ON LOT Certified copy is hereby furnished NEAREST CROSS ST 1:3 ❑ Certified copy Is filed with the county building Inspection TRACT BLOCK LOT NO department - USE ZONE MAP NO ASSESSOR MAP BOOK PAGEPARCEL Date Applicant ^ SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' /1nJ OWNER TEL NO COMPENSATION INSURANCE A&za WITHIN IODD FT OF SCHOOL? YES NO (This section need not be completed ifthe permit Is for one hundred ADDR%33 J li� I DISTRICT GROUP TYPE CONST' FIRE ZONE PROCESSEDBY dollars($hat or less) CITY ZIP D �O�/ � ]� I certify that In the performance of the oris or which this permit o j1>��J`1l Is Issued, 1 Shall not employ any pe n in a erne s0 as t0 ARCHITECT OR ENGINEER TEL NO become suub2ect�Onthe Workers'C STATISTICAL CLASSIFICATION APT CONDO Date 11�.�L]LApplicant 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' — 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 CL LICENSED CONTRACTORS DECLARATION CITY uc CLASS SIDE ddoPL p I hereby affirm that I am licensed under provisions of Chapter 9 'IT — SEWER MAP v (commencing with Section 7000)of Division 3 of the Business and SO SIZ NO OF STORES NO OF FAMILIES Professions Code,and my license Is In full force and effect NEW ❑ BK PG v D RIPTION F WORK - ADD ElVALUATK)N - �W License Number Llc Class Contractor Date `. ALTER - ❑ $ z_ ❑ I am exempt under Sec REPAIR ❑ B&PC for this reason J L DEMOL Date USE OF EXISTING BLDG LJRM ❑ LDMA P/C# Signature APPLICANT(PRINT) TEL NO LDMA Perm# ❑ I, as owner of thero Z p party, or my employees with wages as O their sole compensation, will do the work and the structure IsADDRESS • _ i iTE j not Intended or offered for sale (Section 7044, Business and FINAL DA Prof@SSIOfIS Code) WILLTHEAPPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL // O TOTAL 313 00 OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN 11 (, 1, as owner of the property, am exclusively contracting with THE AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY /� C i i_H JV e t I_I licensed contractors to construct the project (Section 7044, YES❑ No❑ Business and Professions Code.) i_H'ANGE ,LII WILL THE INTENDED USE OF THE OUILDING 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 FOR GUIDELINES I hereby affirm that there Is a construction lending agency for YES 1:1NO 1:1 the performance of the work for which this permit Is Issued(Sec 3097,CIV C I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE ANGELES '4�i'ti i AM 9:2 ) PERMITTING CHECKLIST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES i+ + 1 L'fl t °i-° COUNTY CODE,TITLE 2,CHAPTER 2 20 SECTIONS 2 20100 THROUGH 2 20140 CONCERNING Lender's Name HAZARDOUS MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD Lender's Address � OWNM OR AGENT o I certify that I ave read this application and state that the above PC FEE PERMIT FEE �"1 Information I cc ct I a ree to comply with all county V ordinances' d S in to budding construction,and hereby a nze re f this County to enter upon ISSUANCE FEE th v ei tion purposes a // INVESTIGATION FEE TOTAL FEE a wAprV 0w 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 1 hereby affirm that I have a certificate of consent to self insure, BUIL /pD ES t� O��l�/a k �sC� or a certificate of Workers' Compensation Insurance,or a certified V41• v/0 Copy thereof(Sec.3800,Lab.C.) R c��C7�� Policy No. Company C M r ZIP / c V�.d LOCALITY C SIZE C L T NO.OF BLDGS.NOW ON LOT ❑ Certified copy is hereby furnished. NEAREST CROSS S 11Certified 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' OAR jy)ark -7 �;�Ga COMPENSATION INSURANCE Jae-gione J J WITHIN 1000 FT.OF SCHOOL? YES No (This section need not be completed if the permit is for one hundred AQ4 9 L `QQm� e DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY dollars($100)or less.) C ZIP I certify that in the performance of the work for which this permit is issued, I shall not employ any person in an manner so as to becoW s bject t the Mrkers'Compens n Laws. ARCHITE OR ENGINEEg EL QAC/A� /� �--- � � STATISTICAL,C..L�A2SS�IFICATION APT CONDO Da 1 ant ADDRESS CLASS NO.�_ DWELL UNITS NOTICE TO APPLICANT. if, after mai g this Certificate of REQUIRED TOTAL SETBACK FROM EXIST Exemption, you Should become subJ Ct to the Workers' CONTRACTOR / TEL NO. SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith permit shall be deemed revoked. FRONT comply with such provisions or this P ADDRESS LIC.NO. � PL LICENSED CONTRACTORS DECLARATIONSIDE CITY LIC.CLASS PL I hereby affirm that I am licensed underprovisions of Chapter 9 SEWER MAP >• (commencing with Section 7000)of Division 3 of the Business and SQ,�T.SIZE NO.OF STORIES NO.OF FAMILIES a' Professions Code,and my license is in full force and effect. NEW BK PG v DESCRIP ON OF• RK VALUATION , License Number Lic.Class ADD ❑ O Contractor Date ALTER El $ 1-5 W M -hI, I) wr REPAIR El V)❑ 1 am exempt under Sec. $ z_ BAP.C. for this reason /��L.Ga[r�� DEMOL ❑ LDMA P/C# Date: - Z.dSEEXISTING BLD URM ❑ Signature APP ICANT(PRINT) TEL N LDMA Perm# '• Al �i r. ❑.I,:as owner of the property, or my employees with wages as a �1 ZO _a.c a their sole compensation, will do the work and the structure is ADD SS �. fl-i.- not intended or offered for sale (Section 7044, Business and FINAL DATE R j•_1:. Krofessions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT`HANDLE A HAZARDOUS MATERIAL OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE J � ' (f aS OWRef of the property, am exclusively contracting Wlttl AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY ` 5 _I censed contractors to construct the project (Section 7044, YES❑ No❑ -`I }= 03:-- =0 .Business and Professions Code.) _ WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING •' '0•''• I` OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH i_.?";Wi,; 1.t'•.�.•.1°.: CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FORIF-: GUIDEl1NES. CHANGEf3e n I hereby affirm that there is a construction lending agency for YES❑ No❑ C4 the performance of the work for which this permit is issued(Sec. p1 I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING _ 3097,CIV.C.) CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, ''jf�'. TITLE 2.CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING HAZARDOUS '3-fra �U*-;-1 + �•••-• •'• Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD. o Lender's Address O OWNER OR AGENT o I certify that I have read this application and state under penalty O of perjury that the above information is correct. I agree to comply P.C.FEE PERMIT FEE N with all county ordinances and State laws relating to building / m construction, and hereby authorize representatives of this County ISSUANCE FEE to ter upon the e- tioned r p ty for inspect' n pur oses. !!� 10 ,It Ar, M a INVESTIGATION FEE TOTAL FEE atuao Aoo nr or-Awl' (/ G/ SEE REVERSE FOR EXPLANATORY LANGUAGE COUNTY-OF LOS ANGELES BUILDING AND SAFETY FOR APPLICANT TO FILL!J' • 'WORKER'S COMPENSATION DECLARATION BUILDING ADDRESS , BUILDIN AD 4 E hereby affirm that I have a certificate of consent to self Insure, O S ,or a certificate pf Workers'Compensation Insurance,or a certified 'copy thereof(S6c 3800,Lab C) CIT yTE/l� � G/ ZIP / �O LOCALI ZI Policy No Company SIZE OF LOT770 ' NO OF B4DGS NOW ON LOT 12 certified copy is hereby furnished 7/,� 7. e2 ! NEAREST CROSS ST ❑ Certified copy is filed with the county building Inspection TRACT BLOCK LOT N© department 77 ` USE ZONE MAP NO D ' Date Applicant ASSESSOR MAP BOOK PAGE PARCEL SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' OWN�•V� �Da TEL 8S� r\ YES NO COMPENSATION INSURANCE WITHIN 1000 FT OF SCHOOL? ADDRES (This section need not be completed if the permit is for one hundred S ��� S DISTRICT GROUP TYPE CONST' FIRE ZON PROCESSED BY dollars($hoo)or less) CITY / _ zlPq �` (� ``3 I certify that In the performance of the ork for which•this permit �7C� C /��ov a �o J J is issued, I shall not employ any I. InWymer so as to ARCHITECT OR E GINE TEL NOPE become SU t to�e Workers' tl �• �iQ�`�/ 7 STATISTICAL C IFICATION APT NDO Date�ApplicantYN ADDRESS DaD �s /TL/• �`�iliPl{/�� C/7• CLASS NO DWELL UNITS NOTICE TO APPLICANT. If, after making this Certificate of CONTRALTO TEL NO REQUIRED TOTAL SETBACK FROM EXIST ' fr/� Exemption, you should become SUbJBCt to the Workers' SETBACK YARD HWV PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith 2^r -- comply with such provisions or this permit shall be deemed revoked ADDR SS �- LIC.NO FRONT 02 0W s/ SIDE 0- LICENSED CONTRACTORS DECLARATION CITY LIC CLASS PL o I hereby affirm that I am licensed under provisions of Chapter 9 SEWER MAP v 3 � (commencing With Section 7000)of Division NO OF STORES NO OF FAMILIES �rslon 3 of the Business and ���.Ia Professions Code,and my license Is In full force and effect ? Z / NEW BK PG D � n s U 1 DES RIPTION OF Vyj3jjlL ADD ❑ VALU l�l�J1 Q ❑ n-w License Number Lo Class Q� rN U �ti-f 7 Contractor Date ALTER ❑ ��1 - 1 s' Z (/ ITEMS IeEiib G 2 REPAIR ❑ 1 ❑ 1 am exempt under Sec TOTAL 750 - 98 B&PC for this reason DEMOL ❑ LDC# USE OF EXISTING BLDG c; e 9.,_,; Date. URM 1:1 4rECK tL{rC Ignature AP LI ANT(PRINT) TEL NO , LDIAAA rm# t)0 CHANGE ul� as owner of the property, or my employees with wages as O the rintewill do tstructure Ess intended or offered forsa a (Section Business 7044, Buness and r not Z y �/3 %. FINATE C1000-000 Professions Code) G 4 # WILLTHEAPPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL AL — 9J 01312 j Ali ?:4V ❑ I, as owner of the property, am exclusive) contracting With OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN Y g THE AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY `y licensed contractors to construct the project (Section 7044, YES❑ NO❑ �` Business and Professions Code) l WILL THE INTENDED USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING IY OCCUPANT REQUIQUALITY MANAGEMENT TDICONSTRUCTION(S OR MODIFICATION FROM THE SOUTH VV CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST J FOR GUIDELINES I hereby affirm that there Is a construction lending agency for YES❑ NO 1:1 the performance of the work for which this permit Is issued(Sec F-. r-, -, -{ �,( �.,, ,�T g 1 HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD _ _ }',i W97,CIV.C) PERMITTING CHECKLIST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES '—I '�' Lam! sIC,. v F COUNTY CODE,TITLE Z CHAPTER 220 SECTIONS 2 20 100THROUGH 220740 CONCERNING M r'7 j Lender's Name HAZARDOUS MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD r 7 �'� �'i 1_!f 1131 q 1''6' Lender's Address ���� L- M w 4r° 1 ITEMS o I certify that I have read this application and state that the above FL .I 1 rj A PC FEE PERMIT FEE I L 1 0 1 -_ 36 information is corre t I agree to comply with all county �,5 94 C! '- j f ��' ordinances d Stat s lating to building construction,and CHECK fE`.�� �� o�_, hereby But nze r r vas this County to enter upon ISSUANCE FEE th e#enti n tion purposes 3 3> t �� I�-_I I ,Il i I INVESTIGATION FEE TOTAL FEE t_1 � ��3 d 0m •�O '� rcl I:LI CCI _ 0- SEE REVERSE FOR EXPLANATORY LANGUAGE I -I I l�