HomeMy Public PortalAbout5018 PAL MAL AVE_Building__ i
. - `. .. APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES ' BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING AD R S
I hereby affirm that I have a certificate of consent to self insure, BUILDING ADDR / �-
or a certificate of Workers'Compensation Insurance,or a certified `5D L
copy thereof(Sec.3800,Lab.C.) Y I+I�L ,� � ',f ZIP /• :TO LOCALITY
Policy No. Company IZ F LOT �/ NO.OF BLDGS.NOW ON LOT s elm-
❑ Certified copy is hereby furnished. 110 �( NEAREST CROS ST
TRACT ��� BLOCK LOT NO Cmq — _ a
❑ Certified copy is filed with the county building inspection USE ZONE MAP NO/,_/ //�7�
department. !_/
Date Applicant ASSESSOFi�tAP BODK PAG PL� /
VC.Gd DU !� g SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' WNER n ,./� TEL NO.
COMPENSATION INSURANCE rnR13 + 1� Ai • WITHIN 1000 FT OF SCHOOL? YES NO
(This section need not be completed if the permit is for one hundred r✓1 AD ESSD /1
dollars($100)or less.) D l 8 f�oar MAC.,(/ Alva DISTRICT GROUP TYPE CONST. FIRE ZONE CPROCESSED BY
I certify that in the performance of the work for which this permit ��� C J 7 ZIPq/ 7 f
is issued, I shall not employ any person in any manner so as to �L` L,�fes✓
become subject to the Workers'Compensation Laws. ARCHITECT OR ENGINEER TEL NO.
STATISTICAL CLASSIFICATION 1 APT CONDO
Date Applicant ADDRESS CLASS NO. 1:7 DWELL UNITS
NOTICE TO APPLIC4NT.• If, after making this Certificate Of REQUIRED TOTAL SETBACK FROM EXIST
Exemption, you should become subject t0 the Workers' CONTRACTOR TEL NO. SET BACK YARD HWY PROP LINE WIDTH
Compensation provisions of the Labor Code, you must forthwithFRONT
comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC.NO. PL
LICENSED CONTRACTORS DECLARATION SIDE
CRY 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.S NO.OF STORIES NO.OF FAMILIES NEW ❑ BK 6� PG '�' LL
C
Professions Code,and my license is in full force and effect. Ob I I Cz
DESCRIPTION OF WORK VALUATION
License Number Lic.Class �D ON � �� � ADD c
Contractor Date ALTER ❑ $ 000
❑ I am exempt under Sec. *4 P,JR69 15- 7121REPAIR ❑ z
BAP.C.for this reason DEMOL ❑ LDMA P/C#
Date: USS OF EXISTING DG URM ❑
Signature APPLICANT(PRINT) TEL NO. / LDMA Perm
I,as owner of theproperty, or m employees with wa es as OKM a LICKLI: — 3 2 Z
y 9 AD RES O
their sole compensation, will do the work and the structure is g
not intended or offered for sale (Section 7044, Business and 1 �'1) (° FINAL DATE -
Professions Code.) 6 G
WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL 7'~ 13-Q-1 J '
❑ I, as owner of the property, am exclusively contracting with OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE Q
AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE?
licensed contractors to construct the project (Section 7044, YES❑ NO❑ FINAL BY f� > `-1-, --,T
Business and Professions Code.) �w--
.
WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING +
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH I-'•
" CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FOR
GUIDELINES
I hereby affirm that there is a construction lending agency for YES❑ NO❑
N the performance of the work for which this permit is issued(Sec. ,?_�}y; o 15
m I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING
„N 3097,CIV.C.) 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
Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCACMD
CI Lender's Address
OWNER OR AGENT
oI certify that I 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
o f a ;:�•:r ;.1.
a with all county ordinances and State laws relating to building V, 6o
-cc construction, and hereby authorize representatives of this County ISSUANCE FEE
to to 9t upon the above-mp ' d prope, a Inspection purposes. fes, ZCO //��e&n&— it - �SI INVESTIGATION FEE TOTAL FEE
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 1403110073
PHONE: (626) 285-0488 EXT:
ILEGAL ID: I NO. OF CONST BUILDING ADDRESS: 1
ITR: 12205 LT: 20 I SQ. FT STORIES TYPE 5018 PAL MAL AV I
I ISTRUCTURE: 1800 V-B TEMP CA 917803431 1
(ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET: 1
18585-030-024 I I THOMAS PAGE: 597 GRID: C4 LOCALITY: TEMPLE CITY CAI
(TENANT: (EXIST BLDG USE: RESID USE ZONE: R-1 TISSUED ON: PROCESSED BY: I
EXIST OCC GRP: 03/11/14 SR
I I
(OWNER: TEL. NO: IBLDGS. NOW ON LOT: VALUATION: IFINAL DATE FINAL BY: CODE:
1KLODE, DAVID (626) 551-1628- 1 6,800 1
15018 PAL MAL AV 1 I�7�� I
ITEMP 917803431 1 FEES PAID ID19SCRIPTION OF WORK 1
I I ITEAR OFF AND REROOF HOUSE + PATIO, PLYWOOD WITH COMPOSITION 1
IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT:( 1
(APPLICANT: TEL. NO: I
ROY (818) 335-3305- JAA BLDG PERMIT ISSUANCE 27.80 1
4924 BALBOA #606 JAB STATE GREEN BLDG FEE 6800.00 VAL 1.00 ISPFCIAL CONDITIONS:
JENCINO CA 91316 IAC STRONG MOTION RESID 6800.00 VAL 0.70
ID2 PERMIT W/O EN-HC 6800.00 VAL 166.20
1 TOTAL FEES 195.70 1 I
ICONTRACTOR: TEL. NO: 1 (APPROVALS DATE INSPECTOR SIGNATURE 1
ILA ROOFING CONSTRUCTION AND ROOFING (818) 335-3305- I 1 I
4924 BALBOA BLVD #606 LIC. NO I ILOCATION AND SETBACKS I I
JENCINO CA 91316 983599 1 1 I I
I (SOILS ENGINEER APPROVAL I 1 I
1ARCHITECT OR ENGINEER: TEL. NO: I IFOUNDATION/TRENCH FORMS I I I
LIC. NO: I ISLAB/UNDER FLOOR I I I
(RAISED FLOOR FRAMING 1 I I
MAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP:( (UNDERFLOOR INSULATION I I
1 3 001 I 1 I
I I (FLOOR SHEATHING I I
INO. OF FAMILIES: DWELLING UNITS: APT/COND: STAT CLASS: I I_ I I
1 NO 21 1 IROOF SHEATHING 1 I
I I I
1 SCHOOL WITHIN HAZARDOUS ,I 1SHF,AR PANELS
(AIR QUALITY: 1000 FEET MATERIALS 1 I I I
NO NO NO I iFRisME INSPECTION I I 1
I I (FIRE SPRINKLER HANGERS
I I I I I I
I IINSULATION/WEATHER STRIP I I
IINTERIOR LATH/DRYWALL I I
I I
I (EXTERIOR LATH I I
I I I
I I IRATED FLOOR/CELL ASSEM. I I I
I IRATED WALL ASSEMBLIES I I I
I (RATED SHAFTS/OPENINGS
I IT-BAR CEILINGS I I I
ILOT DRAINAGE I 1 I
(REPORT in: DPR261 ROUTE TO: BS0508