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Home My Public Portal About5737 LOMA AVE_Building__ WORKERS' COMPENSATION DECLARATION , insure, raafcertif carte of Workers' ensuran elf APP L I CAT ION F O R �R U I L D I N G .P E RM I T hereby ' or a certified copy thereof•(Sec, 3800,.LaCb. C.) _ Policy N/ Company • .`�' � t• : ' COUNTY OF LOS ANGELES BUILDING'AND SAFETY Certified co is hereby furnished., FOR APPLICANT TO FILL IN :, BUILDING py y_ ADDRESS Certified copy is filed with the.county building'inspec- BUILDING i ADDRESS /1 • tion depart ent. J d- N,F5ROM T� r // _DateCITY /c �Lc C�/% ZIP ` LOCALITYNO: OF•.BLDGS. _ ,_ NEAREST CERTIFICATE OF EXEM WORK RS'" SIZE OF LOT NOW ON LOT CROSS ST. COMPENSATI'ON'INSURA_ NCE ASSESSOR (Thi sisection need not be completed:tf the per 't s-for one TRACT' BLOCK LOT NO. J MAP BOOK' PAGE PARCEL hundred dollars ($100) or less.)• TEL. OWNER'G yD.//� '�Ox NO.p?��'��I USE ZONE MAP I certify that in the perfoirimance•;of a work for which this NO. permit is issued, I shall not em' any person'in any manner ADDRESS �lK�� /�,BQ�G SPECIAL IL CONDITIONS so as to:become subject tot Workers' Compensation;Laws: O CIN ZIP Date ' pplicant.k' 'ARCHITECT OR_I+ �+ 8 d- TEL. DISTRICT OUP' TYPE FIRE ROCESSED BY O NOTICE TO AP CANT% If after making this.Certificate of ENGINEER NO. // CONST. �f' E HExemption, ou: should become ubject to'the .Workers' O}{ 1/ �// U Compen ion provisions of the tabor Code, you must,forth- ADDRESS d /1�0J�� - Liv vvvJ:G AAA •11YY�" 4�/ w' a_ with om I with, such rovisions or=this TEL. STATISTICAL CLASSIFICATION APT. JCONDO: Z p y p permit shall be' TEL. /P med revoked.- CONTRACTOR — LICENSED CONTRACTORS DECLARATION / �T LIC. CLASS NO. DWELL. UNITS I hereby affirm that I_am licensed under provisions Chapter 9 ADDRESS ��NO, LIC. / SEWER MAP (commencing with Section.7000)of Division 3 of,the Business ��e�D11 � /dCLASS W / " CITY and Professions Code,and my'license is:in full force and effect. _ BK. PG. VALIDATION SQ. FT. NO, OF. NO. OF CHECK License Number�`� 61_11' Lic..Class SIZE STORIES FAMILIES ONE � /�7;�,' VALUATION ContractoC �^ Date ��, DESCRIPTION OF WORK NEW DO. ❑I:am exempt under Sec. ' ' ��GS�7� /9 ADD a ALTER ❑ B.BP.C. for this reason G—�L��NG" CLQ REPAIR ❑ a Date: USE OF EXISTINGBLDG.d//I/GGL� F /L J�.Z ;DEMO, ❑ Signature APPLICANT TEL. ��/�S�j�� FINAL (PRINT).�/S�Q �S �ll��/�S NO. `�� '/N OWNER-BUILDER DECLARATION DATE/� I hereby affirm that I am exempt from the Contractors License D�S �� j 'Law for the following reason.,(Section 7031.5, Business and ADDRESS FINAL' �/� f . Professions Code)`. - PRESENT - gy C _ e' r A t•T a BUILDING C 0 I; as owner of the property,ror my employees with ADDRESS - I � ` �� '`° wages as their sole compensation,will do the work and ' LOCALITY I,END',, ' the structure is notintended or offered for sale(Section � � _.. • 7044, Business and Professions Code MOVING TEL. _ ❑ 1, as owner of the property, am exclusively contracting CONTRACTOR NO.' TOTAL q'E_p 7® ,�, with licensed contractors to construct the project (Sec- ADDRESS } {'` ' ' tion 7044,.Business•and Professiohs Code.) , ` ti• ��°'-r=' • 'REQUIRED YARD HWY TOTAL SETBACK FROM- EXIST. t•31f�r�� al l�l CONSTRUCTION LENDING AGENCY SET•BACK PROP. LINE WIDTH I hereby affirm that there is a construction lending agency for FRONT the performance of the work:for`which'ihis permit is'issued P.L.' (Sec. 3097, Civ: C.). SIDEICICI'i- 0s11139 P.L.. Lender's Name c 7+„'+ m ti CDMA Ref. # - - d: 3 AN,€ 9°a l i - _ P.C. Fee$. Permit Fee Lender's Address 0 Poll- 1 certify that I have read this application and state that the Issuance Feb CDMA P/C# above information is correct. I agree to comply with all County Investigation Fee 6 ordinances and State laws-relating to building.construction,. Total Fee CDMA Perm. it ¢ and hereby authorize represenlotive4 of this County to enter upo e ove- e tion Pi inspection.purposes. ¢ . Ips—� SEE REVERSE FOR EXPLANATORYLANGUAGE . Signature of Applicant r Agent Date t ;"tl5'3 2SM SETS 10-46 ., DEPARTMENT OF BUILDING AND SAFETY 3' APPLICATION FOR PERMIT ;;,:'-COUNTY OF LOS ANGELES �''��'• WM. J. FOX, CHIEF ENGINEER FOR APPLICANT TO FILL IN _ FOR OFFICE USE ONLY j 3 4 a»- DISTRICT NO. PLAN CK NO PERMIT NO. BUILDING /'�/^, ADDRESS{fi j c/✓J LOCALITY �/yy�j�4 ,i RECEIVED BY DATE OFAPPL. DATE ISSUED NEAREST '*T` ,.q /�y (v Y� /� / . CROSS ST. BUILDING / � 9 OWNER; .i ✓ ,,.Q tf��' ' ,VI��.Qdi6� t .4tfAttA ADDRESS MAIL DDRESS !8¢ f - \ ,o" _LOCALITY A1�(" �\/(f EAREST TE C►TY ..-2 %1 49' NOLO "CROSS 5T. e FIRE NO.OF TYPE GROUP ARCHITECT ORa TEL. ZONE I PLANS ENGINEER NO. l BLDG. /_ .+.�,. /��,O_Rp.NO. ADDRESS SETBACK LINE APPROVED CONTRACTOR NO, "` BY - DATE USE APPROVED ADDRESS' ZONE/ �• BY DATE '. LEGAL �. - CORRECTIONS DESCRIPTION I LOT�yNO. BLOCK TRACT- - f 1 NO.OF BLDGS. . i`{• SIZE OF LOT` i t I NOW ON LOT USE,OF Y IFAOM•ILOIE9/ ROOMS _EXISTING BLDG. DESCRIPTION OF WORK NEW V ALTERATION ;ADDITION 0 A REPAIR MOVING DEMOLISH p SQt FT. ! {`,� NO.OF - Z SIZE . �A M ROOMS / STORIES / D WALL! ��, , n ,��..1l I! ROOF r r OVER NG t cx) I COVERING USE OF NEW 0A'mj-'o_-10BUILDING . � ,: e'- w w•sw- � td ' I HEREBY ACKNOWLEDGE THAT I 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 {�-U 4�i• AND STATE LAWS REGULATING BUILDING CONSTRUCTION. FRAME: FIRE STOPS, - ' RACING,BOLTS SIGNATURE OFBt� \ i . OWNER LATH, INT.: -AUTHORIZED AGT � a.S LATH,EXT.: P.C.$, PLASTER. INT. (... _ FEE. A"A `PLASTER, EXT. V VALUATION 1 FINAL- FEE —e -2 25M SETS•1Q-46 DEPARTME14T OF BUILDING AND SAFETY. APPLICATION FOR PERMIT COUNTY OF LOS ANGELES 11 WM. J. FOX, CHIEF ENGINEER BVILDING FOR APPLICANT TO FILL IN FOR OFFICE USE ONLY �3 BUILDING 5DISTRICT PLAN CK. NO. , PERMIT NO..'''�� ADDRESS /y-,--- / A�{�` Jr LOCALITY (l[-,�/f/�/f,/� �,/(, (�/jRE EIVED BY DATE OAF APPL. DATEISSUED NCROSS EAREST V /I/Ir�i.o�.n /— J"V Y'fJL�✓4a..^' /— —�� /_ / 1 BUILD NG _ OWNER) ►.�L9'j �i I �I'r1� �. 'M{�!i/ -ADDRESS MAIL J /_ \" „^ " LOCALITY' ADDRESS / NEAREST CITY AA/A►�l./V�/�t•Tl'��l NOL• " CROSS ST. a FIRE NO. TYPE GROUP. ARCHITECT OR• TEL. ZONE I PLANS ENGINEER NO. ..z: SG. 7 RD. NO. . ADDRESS � SETBACK LINE /sop/ APPROVED CONTRACTOR NO. BY DATE USE APPROVED ADDRESS ZON / BY DATE LEGAL ] �, I DESCRIPTION � I L�dY NO. (� BLOCK CORRECTIONS TRACT �'/.i 1? d //pJ . .. s .. NO.OF BLDGS. k r, e SIZE OF LOT. °�, A(/� NOW ON LOT ({/� r� USE OF r _ NO.OFNO.OF a �' _ EXISTING BLDG. I FAMIUES� ROOM A DESCRIPTION OF WORK NEW ALTERATION ADDITION O � A REPAIR MOVING DEMOLISH SI,,. FT. NO. OF Z SIZE ROOMS ( STORI PS / - D r WALL ROOF COVERING COVERING' ' USE OF NEW.< ( ' BUILDING I HEREBY ACKNOWLEDGE THAT 'I HAVE READ THIS APPROVALS. APPLICATION AND STATE THAT THE ABOVE IS CORRECT FOUNDATION: LOCATION /INSPECTOR DATE AND AGREE TO COMPLY WITH ALL COUNTY'ORDINANCES FORMS, MATERIALS AND STATE LAWS REGULATING BUILDING CONSTRUCTION. !� FRAME: FIRE STOPS, SIGNATURE OF ////�� ! BRACING, BOLTS ' OWNER / /� !� LATH, INT.: AUTHORIZED AG)• •- �) A_ LATH,EXT.: P.C.$ PLASTER. INT. -�"� L ✓ � y� FEE PLASTER, EXT. VALUATION v wFINAL FEE WORKERS' COMPENSATION DECLARATION . .herMjy affirm that.l have a certificate of consent to.self insure, oT:a certificate of Workers' Compensation Insurance, APPLICATION ATION FR a-•r . y ® BUILDING PERMIT or,a certified copy thereof (Sec: 3800, Lab C.) COUNTY OF LOS ANGELES • BUILDING AND SAFETY ��'-- Policy No g L Compan51A El Certified coy is hereb furnished. w�-��13 FOR APPLICANT TO FILL IN BUILDING �y PY Y ADDRESS LJ Certified copy is filed with the county uilding inspec- BUILDING 4� - tiorr.depdriment. ADDRESS Dot e 'o Applican CITY' C' ZIP LOCALITY �~ 1. NO. OF BLDGS. NEAREST CC T�OF EXEMPTION-F M WORKERS_'. SIZE OF LOT NOW ON LOT s COMPENSATION INSURANCE ` ' ASSESSOR CROSS-OR ASSESSOR . (This section need not be completed if the permit is for one. TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL -hundred dollars ($.100)or'less.) TEL. OWNER o. NO. 4JS'OP USE ZONE. MAP I certify, that in the performance of the work-for which this SPE permit is issued,T shall not employ any person in any manner ADDRESS �� D"Q- SPECIAL a CONDITIONS. so as to become subject to the Workers''Compensation"Laws. 0 CITY r / eA ZIP ' Date -Applicant ARCHITECT OR TEL DISTRICT GROUP TYPE FIRE PROCESSED BY NOTICE TO APPLICANT: If, after-makingthis Certificate of ENGINEER NO. CONST. ZONE U Exemption, you should become subject to the -Workers' p U 4 UJ Compensation,provisions of the Labor Code, you:must forth- ADDRESS .�O � �' n. with comply•.with.such provisions-or this permit shall be TEL r STATISTICAL CLASSIFICATION APT. CONDO. N deemed revoked. CONTRACTOR ° NO.�.3 '61 Z LICENSED,CONTRACTORS DECLARATION LIC. CLASS NO. I DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS f v. , mt. NO. 3 LIC. SEWER MAP (commencing with Section 7000)of Division 3 of the Business CLASS and Professions Code,and my license is in full force and effect. CITY OS /9q e.1 a CJS tj -a BK PG VALIDATION �� SQ. FT. NO. OF NO. OF CHECK License Number,�Lic. Class SIZE STORIES FAMILIES ONE VALUATION !�. DESCRIPTION OF WORK c O Us NEW -❑. Contractor Date 1��a3-� H �( C ❑1 am exempt under Sec. - ADD 0 _ ALTER., .. B.&P.C..for this reason ` ' REPAIR ❑, a USE OF Date: EXISTING BL C+ ` DEMOL ❑ Signat APPLICANT TEL. g OWNE -BUILDER DECLARATION (PRINT). ft NO. - DATE FINAL I hereby affirm that I am exempt from:the Contractor's License_ ap )) Law for the following reason;(Section'7031.5, Business and ADDRESS S° &t v hC n'P e'900. FINAL Professions Code): PRESENT ' By BUILDING .. ❑ I, as owner of the property; or my'employees with 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. w � ❑ I, as owner of The. ro erT am exclusive) contractingCONTRACTOR NO. P P. Y, Y µ' with licensed contractors-to construct the project_(Sec- ." ADDRESS - tion.7044, Business cind Professions Code:). ' 'CONSTRUCTION LENDING AGENCY RETQUIRE YARD HWY TOTAPROPALINEFROM WIDTH I hereby affirm that there is a construction lending agency for FRONT the performance of the work for which This permit is issued P.L.. (Sec. 3097, Civ. C.).• SIDE P.L- Lerider's Name. Ref. # . - LDMA , Lender's Address P.C. Fee$ Permit Fee �O t i••'"- o I ce:'tify that I have read this application and state that the Issuance Fee 'T'l LDMA P/C# ®. - above information is correct. I agree to comply with all County Investigation Fee` 8 ordinances and State laws relating•to building construction, Total Fee e ,LDMA Perm. # .and hareby authorize representatives of this County to enter u n t e ab -mentioned property for-inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE .Sig ature of Applicant or Agent gale .. - WORKERS' COMPENSATION DECLARATION ~ h � firm rcertificate C.) self FOR BUILDING PERMITinurep�C6 certificate of Wr or certified copy thereof (Sec: 3800,.Lab. COUNTY OF,LOS ANGELES BUILDING AND SAFETY Policy No.'. Company BUILDING: ❑ Certified copy is hereby furnished. FOR"APPLICANT'Ta FILL IN ADDRESS ''•-Certified copy is-filed with the"county building ins c-" BUILDING _ ADDRESS' ' '.,tion department. - (1 ZIP- 1 LOCALITY Date'_ CApp licant .. : CITY• A "" NO. OF BLDGS. _ CER' TIFICATE OF EXEMPTION FROM WORKERS SIZE OF LOT NOW ON LOT. NEAREST COMPENSATION INSURANCE CROSS SL - ASSESSOR (This section need not be completed if the permit is f r on TRACT' BLOCK LOT NO. MAP BOOK - PAGE. PARCEL hundred dollars ($100),or less.)- ' TEL. USE MAP' OWNER L NO. NO. - 1 certify that in'the performance of the work for which this. "permit is issued, I shall notemploy.any person in any manner ADDRESS a SPECIAL CONDITIONS •so•as to become subject to the Workers.'Compensation laws. 0 CITY �' ZIP D U Date Appl+caaT ARCHITECT OR TEL. DISTRICT> GROUP. TYPE , FIRE PROCESSED,BY. NOTICE TO•APPLICANT: If, after makin this Certificate of ENGINEER NO.' 9- CONST. ZONE �• Exemption, you should become subject to'.the Workers' ® U Compensotion,provisions of the Labor Code, you must forth- = ADDRESS d ' with comply with such provisions or.,this;permit shall be TEL. STATISTICAL CLASSIFICATION APT. CONDO. N deemed revoked. CONTRACTOR "^V ' NO.• . • Z LICENSED CONTRACTORS DECLARATION p LIC.NO CLASS NO. c�-� DWELL. UNITS I hereby affirm that I am licensed-under provisions of Chapter.9 ', ADDRESS D NO V' V • (commencing with Section 7000)of.Division 3.of the Business ' . LIC. SEWER MAP' and Professio_ns Code,arid my license is in full force and effect. - CITY- CLASS - BK. PG. VALIDATION ` SQ.,FT. NO. OF NO. OF CHECK License Number �1-1'C�Lic. Class�S-J SIZE STORIES FAMILIES 'ONE VALUATION m Contractor l A' �� ✓ Date - ~ DESCRIPTION OF.WORK•� NEW ❑ s ro ADD. ., ❑I am exempt under Sec: L. ALTER ❑ BAP.C. for'this reason $ - _ REPAIR•.❑ , Date: . USE-OF - EXISTING BLDG. ( DEMOL•❑ Si nature APPLICANT TEL.q FINAL g OWNER- UIL ER ECLARATION (PRINT) Y ' :ti :NO.W�+ c� bflTE. Thereby affirm that I am exempt from the Contra ton's icense 4 Law for the following reason (Section 7031.5,. ss and ADDRESS' FINAL Professions.Code). PRESENT. _ _By_ . '• BUILDING wtt�T g ❑ I, as owner of'the property, or my:errtp'Ioyees with ADDRESS: ACCT. • - wages as their sole compensation,will do the work-and _ _- LOCALITY ++ ;^ the structure is not intended or offered for sale(Section ® :•s0 '�L o� 7044, Business and Professions Code) MOVING TEL. ITEMS ❑ ,I, as owner of the property,am exclusively contracting CONTRACTOR NO. 1 t 1 Li ti with licensed contractors to'consteuct the project (Sec- 'ADDRESS TOTAL IL33 @ 63 'tion 7044;Business,and Professions Code.) REQUIRED.. TOTAL SETBACK FROM EXIST. L� 8's' ' YARD HWY CHEGT, .•iO�. CONSTRUCTION.LENDING AGENCY' SET BACK PROP. LINE WIDTH I hereby affirm that there is a constructi'o lending agency for FRONT - �1 the performance.of the work for w this pe�rnit'is issued ' P.L. "' - - CHANGE ,i.1. NGE _ (Sec. 3097, Civ. C.). :SIDE , ' P.L. Lender's Name }��ryr' pr(J%O LDMA Ref. # 0000-0001 �� 4 t P C. Fee$ Permit Fee n 3 Lender's Address 525E i` # 8:1)ti I certify th have read thisapplicption and'-state that ssuance Fee 7� LDMA P/C# above information is correct. I a ee to rply with all County Investigation Fee 8 ordinances and St' a laws rela " o-building construction, I Total Fee. U �• LDMA Perm. #. a an ' reby uth i e represen ves of this County to enter up n t e` tinnedpe ty for inspecti nooses: - 1% SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant Agent Date Af p�OC�Q�00o 1 G OG e U LONG pC�RNT COUNTY OF LOS ANGELES BUILDING AND SAFETY • WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRE s BUILDING ADDRESS \uA I hereby jaffirm-that I have a certificate of consent to self insure, �� • � `y �- or a'certificate of Workers' Compensation Insurance,orca a certified CITY 1" %ZIP copy.thereof(Sec.3800,Lab.C.) LOCALITY' POlicy'No. Company SIZE OF LOT NO.OF BLDGS.NOW ON LOT 9certified ertified Copy is hereby furnished. - .:: NEAREST CROSS ST.Copy is filed with t coy ty bui ding insp tion . TRACT BLOCK LOT NO. USE ZONE MAP NO. - `depar en Date Applicant -ASSESSOR MAP BOOK" PAGE' '" PARCEL ��'� ®FJ>7 SPECIAL CONDITIONS ,CERTI KATE OF EXEMPTION FROM OR RS' OWNER TEL o. } COMPENSATION INSURANCE. 2 a i�D WITHIN.1000 FT.OF SCHOOL? YES NO (This section need not be completed if the permit is'for-one hundred ADDRESS k� .DISTRICT GROUP TYPE CONST.: FIRE ZONE PROCESSED BY dollars.($100)•or less.)• SUV CITY ZIP I certify that in the performance of the.work for which this permit Temet;C. oy is issued, I shall not employ any person•in any manner•so as t0 - ARCHITECTOR ENGINEER'" TEL NO. O become subject to the Workers'Compensation Laws. T J t� it STATISTICAL CLASSIFICATION APT, CONDO Date - Applicant : - ADDRESS. - C, CLASS NO. — a�e — DWELL UNITS ' NOTICE TO APPLICANT If, after making this*Certificate of L w REQUIRED TOTAL SETBACK FROM 'EXIST Exemption, you Should become, Subject to. the Workers' CONTRACTOFJ TEL NO. SET BACK "YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith OOE2 I FRONT comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC.NO. PL C�R LICENSED CONTRACTORS DECLARATION ( M l� C SIDE LIC.CLASS- P L 1 hereby affirm that I am licensed underprovisions,of Chapter 9 6 C-ITle SEWER MAP - .(commencing with Section 7000).of Division 3 of the Business and. SQ.FT.SIIE NO.O STORIES NO.OF FAMILIES NEW BK PG_ } Professions Code,and my license is-In full force.and effect. (p d SCR TION OF WORK - ADD ❑ VALUATION D License Number ,Lia Class D� ,,, $ (a µ• - � Contractor ✓ Date ':- ALTER ❑ cc REPAIR ❑ $ OH ❑ I am exempt under Sec. DEMOL B.&P:C.for this reason ❑ CDMA P/C# ; U W Date: USE OFEXISTING BLDG. :" URM � ❑ S r a_ L11 CYA16) i CO Signature • CANT(PRINT) TEL NO. LDMA Perm# *•��» z I, as owner of the property,'ormy, employees with wages as G 74 Li "�SO ti. as their sole compensation, will do the work.and the structure•is. ADDRESS — •II _ - . - _.11;��' not intended or offered for sale (Section 7044, Business and 5 WV g � � DL FINAL DATE .Q Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL ` •—=l J -S ITEM' f M t OR A MIXTURE CONTAINING A,HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE _ - - ❑ I,.as owner of the property,.am exclusively contracting with AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY licensed contractors to construct the project (Section 7044, f f I f HL 23.1 -36 Business and Professions Code.) YES❑ .NO'❑ _ WILL THE INTENDED USE OF.THE BUGLING BY THE,APPLICANT OR FUTURE BUILDING - - " f»HI.'..54 'i"��j_; OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH + , .. CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR - ..•LL,,�qqff,,�� LL_ - » GUIDELINES. L•i1i1I9;.[L e!0 Iereby affirm that there is a construction lending agency for ves El. No 11he performance of the work for which this permit is issued(Sea (HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING a -3097, CIV.C.) CHECKLIST4 UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE. - - T — '•—' TITLE 2,CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING HAZARDOUS - I_I_ITI—S I(!I�i ?i• .. Lender's Name. MATERIALS REPORTING AND FOR OBTAINING APERMIT FROM THE SCAQMD. »__� ' o . Lender's AddressJ3It1L� OWNER OR AGENT j o. I certify that 1 have.read this application and state under penalty of perjury that the above information is correct.I agree to comply P.C.FEE - PERMIT FEE;, �• $ with all county rdinances and—State laws relating to building " m rlwe truc nereby rize representatives of this County ��// , a ISSUANCETEE toe ov en io ed property for inspection urp es. GJe �. '}. INVESTIGATION FEE TOTAL FEE �j /• ' / �anaw.e Aon ca. A em ✓oa�e _ (`� ., , 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 1306110103 PHONE: (6,26) 285-0488 EXT: ILEGAL ID: NO. OF CONST BUILDING ADDRESS: 1 ITR: 12977 LT: 2 1 SQ. FT STORIES TYPE 5737 LOMA AV 1 I _ISTRUCTURE: 2500 V-B TEMP CA 917802453 (ASSESSOR INFORMATION NUMBER: 1 I NEAREST CROSS STREET: 1 15387-022-002 THOMAS PAGE: 596 GRID: H3 LOCALITY: TEMPLE CITY CAI I I ITENANT: IEXIST BLDG USE: RESID USE ZONE: R-1 (ISSUED ON: PROCESSED BY: I JEXIST OCC GRP: 106/11/13 SR I I I I I (OWNER: TEL. NO: IBLDGS. NOW ON LOT: VALUATION: F NA- D TE FI L BY: CODE: IMR. A LEE - 25,000 1 15737 LOMA AV I I ITEMP 917802453 1 FEES PAID EKSCRIPTION OF WORK I ITEAR OFF REROOF 1/2" PLYWO D REPLACE WITH 30 YR COMPOSITION IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT: ISHINGLES AND KITCHEN REMODEL (APPLICANT: TEL. NO: I I I IFAN, JOHN (626) 622-9090- IAA BLDG PERMIT ISSUANCE 27.80 1__ 15740 OAK AVENUE IAB STATE GREEN BLDG FEE 25000.00 VAL 1.00 ISPECIAL CONDITIONS: ITEMPLE CITY CA 91780 JAC STRONG MOTION RESID 25000.00 VAL 2.50 JB2 PERMIT W/ENERGY 25000.00 VAL 515.50 1 TOTAL FEES 546.80 J JCONTRACTOR: TEL. NO: I JAPP3OVALS DATE INSPECTOR SIGNATURE J IJOHN G FAN (626) 622-9090- 15740 OAK AVENUE LIC. NO I ILOCATION AND SETBACKS 1 1 1 ITEMPLE CITY CA 91780 702434 J SOILS ENGINEER APPROVAL I I I I I I JARCHITECT OR ENGINEER: TEL. NO: I IFOUNDATION/TRENCH FORMS I I 1 1 LIC. NO: 1 (SLAB/UNDER FLOOR I I I I I I -IRAISED FLOOR FRAMING 1 1 J I I I I I I IMAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP: 1 JUNDERFLOOR INSULATION I I 1 3 001 1_ 1-1 I I _I IFLOOR SHEATHING I I .. INO. OF FAMILIES:' DWELLING UNITS: APT/COND: STAT CLASS: I I_ I NO 21 1 IROOF SHEATHING I r I 1 SCHOOL WITHIN HAZARDOUS I 1SHEAR PANELS J I J (AIR QUALITY: 1000 FEET MATERIALS IJ 1 NO NO NO 1 IFRAME INSPECTION I I I I I I J I IFIRE SPRINKLER HANGERS I I 1 I I I I I I JINSULATION/WEATHER STRIPI I I I I I I I }..._- JINTERIOR LATH/DRYWALL I I I IEXTERIOR LATH I I IRATED FLOOR/CEIL ASSEM. - I I I i I J I (RATED WALL ASSEMBLIES J J I IRATED SHAFTS/OPENINGS I J I I I I I I IT-BAR CEILINGS 1* ADDITIONAL DATA ON FILE I J I ILOT DRAINAGE I I I i I I I IREPORT ID: DPR261 ROUTE TO: BSO508 J J J I I I