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HomeMy Public PortalAbout5527 MCCULLOCH AVE_Building__ APPLICATION FOR 13- LDING PERMIT ' COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS X27Gal.Lf3 AV. BUILDING ADDRESS I hereby affirm that I have a certificate of consent to self insure, G�f or a certificate of Workers'Compensation Insurance,or a certified 56a7 L LLpcii Ay. copythereof(Sea 3800,Lab.C.) CITY ZIP l �M Q L.ir C1 T V /y,1� LOCALITY ;���.�7 _� Policy No. Company SIZE OF LOT /,��ry q 1(' p NO.OF BLDGS.NOW ON LOT `r-A u G ❑ Certified copy is hereby furnished. & O x id- VIA E NEAREST CROSS ST. ❑ Certified copy is filed with the county building inspection TRACT BLOCK LOT NO. DA(WO; 1-i 0 d5;F,-AA , department. USE ZONE MAP NO. Date Applicant ASSESSO MAP BOOK PAGE PARCEL �T SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' OWNERTE NO. C-1/0- .0/ COMPENSATION INSURANCE M� fW M 004; A 119 —6— 5iD WITHIN 1000 FT.OF SCHOOL? YES NO completed if the permit is for one hundred ADDRESS (This section need not be com G P TS�f /'i 1 f A DISTRICT GROUP TYPE CONST, FIRE ZONE PRSED BY dollars($100)or less.) v 41 1. f-� I certify that in the performance of the work for which is permit CITY' G ZIP 9�- f. S-61 � 'f-. i3 issued, I Shall not employ any pe i4tothe a3 t0 ARCHITECT OR ENGINEER TEL NO. become s bje to the Workers'C ` /II,���snSTATISTICAL CLAS 3J FICATION APT CONDO �Y Date Applicant f%' ADDRESS CLASS NO. DWELL UNITS — AIOTIC APPLICANT. r mte of REQUIRED' TOTAL SETBACK FROM EXIST Exemption, you should beco e s jrkers C TROCTOR TEL NO. SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labol Code, you must for FRONT comply with such provisions or this permit shall be deemed revoked. ADDRESS �LLIIC.NO. P L LICENSED CONTRACTORS DECLARATIONIDE CITY LIC.Cl-A 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..FST SIZE NO.OF STORIES NO.OF FAMILIES NEW BK PG U Professions Code,and m lic n is in full force and tie t/ Z I� � i License Num er A Lic.Class DESCRIPTION OF WORT( 0 of r ADD VALUATION , 0 Contractor ate ALTER ❑ o- GO ISC'� • REPAIR ❑ GO ❑ I am exempt under Sec. BAP.C.for this re n 1Lj_IPA DEMOL ❑ LDMA P/C# USE OF EXISTING BLDG. • • URM ❑ ' Signature APPLICANT(PRINT) TE O. LDMA Perm# _ " ❑ I,as owner per y, r my employees with wages as • z Ht�i•`: o their solL�compe sation, will o the work and the structure is ADDRESS 0 -y not intended or offered for sale (Section 7044, Business and ff� � FINAL o a -1 Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL .J OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE ❑ 1, as Owner of the property, am exclusively contracting With AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL a licensed contractors to construct the project (Section 7044, YES 11 NO AC-ICT,a ❑ Business and Professions Code.) /` 3 , ,L• 7. WILL THE INTENDED USE'OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING .:r,�13� 'I'�ZL'a OCCUPANT REQUIRE A PERMIT FOR CON ION OR MODIFICATION FROM THE SOUTH 1-x,1 Wf 47 __ CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FOR CJO%F^r�r R`_ GUIDELINES ##yam b I T Ei 1" w the eperformance of the work for which this permits issued ereby affirm that there is a construction lending agency o vas❑ .No❑ _ ` #t AL = "' N 3097,CIV.C. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING � A✓J 8: ei L, I CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, II dd\\ff kI ,�VA1/ CHECK TITLE 2,CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING HAZARDOUS L Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD. CHANGE o Lender's Address o OWNER OR AGENT o I certify that I have read this application and state under penalty C of perjury that the above information is correct.I agree to comply P.C.FEE PERMIT FEE f;,..•,.I_,. -,r-,�•i,., CM with all c ty ordinances and tate laws relating to building 3'a. a 3 ��LI=� wlLIU y f: y.:: s (�by tho representatives of this C my ISSUANCE FEEJ1 6 V s i AM 8,_y constru and heV a / to e e bo - d property for ins pe n pur es. CO � INVESTIGATION FEE TOTgL FEE !� SEE REVERSE FOR EXPLANATORY LANGUAGE i APPLICATION FOR BUILDING PERMIT COUNTY OF LOS ANGELES BUILDING AND ''SAFETY /- WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDINGDREss I hereby affirm that I have a certificate of consent to self insure, BUILDING�DDRES or a certificate of Workers'Compensation Insurance,or a certified CITY & ZIP copy thereof(Sec.3800,Lab.C.) g LOCALITY Policy NO. Company SIZE OF LOTF f NO.OF BLDG&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. ASSESSOgPlA =2 PAG PARCEL SPECIAL CONDITIONS Date Applicant jf ��.� 0 CERTIFICATE OF EXEMPTION FROM WORKERS' N COMPENSATION INSURANCE WITHIN 1000 FT OF SCHOOL? YES NO • A (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.) 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. r;4/ 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 LICENSED CONTRACTORS DECLARATION SIDE � 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.FT.SIZE NO.OF STORIES NO.OF FAMILIES } Professions Code,and my license is in full force and effect. NEW ❑ BK PG , IZ DESCRIPTION F WORK ADD ALUATION © N Q License Number LID.Class / U Contractor Date G© / ALTER ❑ 1 am exempt under Sec. 2 >;I. REPAIR E] BAP.C.for this reason �„�- �vj��/ �� DEMOL ❑ LpMp PIC W Date: USE OF EXISTI BLDG. URM 11 IL Signature APPLICAN ( NT) TEL NO. LDMA Perm z Pt a owner of the property, or my employees with wages as z N•:+_-I .T* their sole compensation, will do the work and the structure is ADDRESS _ •�i! FINAL DATE ~ �"i`A "•�i not intended or offered for sale (Section 7044, Business and G .�• •_ i-v.4t-- Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL •�` �� J y T iR 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, YES Business and Professions Code.) WILL 11 No ❑ ��ii!! WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING CHECK 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. iy,,iPlMi I hereby affirm that there is a construction lending agency for YES❑ NO❑ n N the performance Of the work for which this permit IS issued(Sec. IHAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING N3097,CIV.C.) _CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, i� ("1'!• 1 1:-{•, .!;:+•' TITLE 2,CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING HAZARDOUS [I'. L •-�. t .-•.. ; Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD. � a+ o Lender's Address Ej`J`' I 1til` " OWNER OR AGENT —' 0 1 certify that I have read this application and state under penalty 0 of perjury that the above information is correct.I agree to comply P.C.FEE PERMIT FEE $ with all 'county ordinances and State laws relating to building A ' co construction, and hereby authorize representatives of this County ISSUANCE FEEf a7ter u the ab e-ment'mned property for inspection purp es. m � INVESTIGATION FEETOTAL FEE o of Appk=a Agml SEE REVERSE FOR EXPLANATORY LANGUAGE WORKERS'COMPENSATION DECLARATION insure-br a'certificate tof Workers'iificate of Compensaf on Insurancelf e, APPLICATION FOR BUILDING P E RM I T or a certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company BUILDING r ❑ Certified copy is hereby furnished. FOR APPLICANT TO FI L IN ADDRESS C V lo C ❑ Certified copy is filed with the county building inspec- BUILDING '7 tion department. ADDRESS l� V- LOCALITY es-4 ale. CI NEAREST DateApplicant CITY ZIP l�O CROSS ST. live. 1a ir- CERTIFICATE OF EXEMPTION FROM WORKERS' -No-OF R1 DGS- -ASSESSOR COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK 2S73 PAGE J20s PARCEL OQS� hThis section need not be completed if the permit is for one / USE ZONEMAP undred dollars ($100)or less.) P TRACT 31/3 BLOCK LOT NO. �Q NO. .� 3 X77 �/ TEL. �/ SPECIAL ? 1-certify that'in.the performance of the work for which this OWNER a-r�;/LS O I a NO. X73 CONDITIONS permit is issued, I shall not employ any persoh in any manner Sj _6,� p DISTRICT .GROUP TYPE FIRE ESSED BY O CONST. ZONE U so as to bec :/e;,biect to the Wgrkers'Compens tion aws. ADDRESS GOG ^� r cc Date G Applicant v �� CITY ITECi OR ZIP TEL. STATISTICAL CLASSIFICATION APT. CONDO. O. NOTICE TO APPLICANT: If, after making this Certificate of ARCH ENGINEER NO. CLASS NO. DWELL.UNITS tel Exemption, you should become subject to the Workers' tL Compensation provisions of the Labor Code, you must forth- ADDRESS SEWER MAP U) with comply with such provisions or this permit shall be TEL z deemed revoked. CONTRACTOR ~ NO. BK. PG 0� VALIDATION LICENSED CONTRACTORS DECLARATION LIC. I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS A NO. VALUATION (commencing with Section 7000)of Division 3 of the Business and LIC, Professions Code, and my license is in full force and effect. CITY17' CLASS $ pop. FT. NO.OF NO.OF CHECK License Number Lic.Class SIZE ���+ STORIES FAMILIES ONE Contractor Date DESCRIPTION OF WORK NEW ❑ $ ADD I am exempt under Sec. ALTER ❑ FINAL B.BP.C. for this reasonREPAIR /❑ DATE , ` IR USE OF FIN v Die' EXISTING BLDG. DEMOL ❑ By Signature � ,) APPLICANT . TEL,:'a W DER DECLARATION PRINT N NO. R- I hereby affirm that I am exempt from the Contractor's License ADDRESS `/ 14c C U I O G , Law for the following reason (Section 7031.5, Business and Professions Code): PR ENT e�>( 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. ❑ 1, as owner of the property, am exclusively contracting CONTRACTOR NO. with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). .5 6 9,3 A REQUIRED TOTAL SETBACK FROM EXIST., CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP.LINE WIDTH I hereby affirm that there is a construction lending agency for FRONT , # 0 0 0.6 0.1 the performance of the work for which this permit is issued P.L. tSec. 3097, civ. C.). SIDE 16&6 3 Q Lender's Name 11 NC0,11V S�r�(1f t � P L 0 0 o 6 a 6.3 U Lender's Address!%no w P L Nv"A ST . PIU I�VCb'y P.C.Fee$ Permit Fee �/3 j 17=8 6 p I certify that I have read this application and state that they 2e?d Issuance Fee above information is correct. I a e to comply with all County Investigation Fee ordinances n State laws re ting to building construction, Total Fee P and hereby au onze repre ntatives of this County to enter o the abo -mentione property for inspection purpose SEE REVERSE FOR EXPLANATORY LANGUAGE Si re of licant ®s or A nt i Date t• 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 1308010087 PHONE: (626) 285-0488 EXT: ILEGAL ID: I NO. OF CONST I BUILDING ADDRESS: I ITR: 13613 LT: 106 SQ. FT STORIES TYPE J 5527 MCCULLOCH AV I (STRUCTURE: V-B I TEMP CA 917802940 I (ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET: DAINES J 18573-008-005 I I THOMAS PAGE: 597 GRID: C3 LOCALITY: TEMPLE CITY CAI 1 TENANT: EXIST BLDG USE: RESID USE ZONE: R-1 ISSUED ON: PROCESSED BY: (EXIST OCC GRP: 108/01/13 SR 1 I [OWNER: TEL. NO: JBLDGS. NOW ON LOT: VALUATION: IFI TE FI BY: CODE: [ IMOLINA MARTHA (626) 862-5051- 1 1,500 I 15527 MCCULLOCH AV 1 1ky,4 qI ITEMP 917802940 1 FEES PAID IDE!3CRrPTION OF WORK I I I ICHANGE CEILING DRYWALL AND 4OUNTER TOPS I I IFEE DESCRIPTION: QUANTITY: DOM: AMOUNT-1 I APPLICANT: TEL. NO: I I I [SAME AS OWNER - IAA BLDG PERMIT ISSUANCE 27.80 1 I 1 JAB STATE GREEN BLDG FEE 1500.00 VAL 1.00 ISPECIAL CONDITIONS: I J JAC STRONG MOTION RESID 1500.00 VAL 0.50 1 I I JB2 PERMIT W/ENERGY 1500.00 VAL 90.40 I IFR INV WORK W/O PERMIT 344.00 DOL 344.00 J I ICONTRACTOR: TEL. NO: I TOTAL FEES 463.70 JAPPROVALS DATE INSPECTOR SIGNATURE 1 1SAME AS OWNER - LIC. NO I LOCATION AND SETBACKS I I I I I ISOILS ENGINEER APPROVAL I JARCHITECT OR ENGINEER: TEL. NO: I IFOUNUATION/TRENCH FORMS I J I 1 LIC. NO: [ 1SLAR/UNDER FLOOR [ J I I 1RAISED FLOOR FRAMING I I IMAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP:J JUNDERFLOOR INSULATION I I I 1 3 001 IFLOOR SHEATHING I I I I I I [NO. OF FAMILIES: DWELLING UNITS: APT/COND: STAT CLASS: I I I I I NO 21 1 IROOF SHEATHING I J I [ SCHOOL WITHIN HAZARDOUS J ISHEAR PANELS 1 I I JAIR QUALITY: 1000 FEET MATERIALS I 1 I 1 NO NO NO I 1FRAME INSPECTION I 1 IFIRE SPRINKLER HANGERS I I I I I 11NSULATION/WEATHER STRIPI I I I I IINTERIOR LA DRYWALL 1 I [ JEXTERIOR LATH I J I I IRATED FLOOR/CEIL ASSEM. [ J IRATED WALL ASSEMBLIES I 1RATED SHAFTS/OPENINGS 1 1 1 I 1T-BAR CEILINGS 1 1 1 1 i 1LOT DRAINAGE 1 1 1 1 1REPORT ID: DPR261 ROUTE TO: BS0508 I I I I