Loading...
HomeMy Public PortalAbout5925 TEMPLE CITY BLVD_Building__ APPLICATION FOR BUILDING PERMIT FOR APPLICANT TO FILL IN (Print or type only) BUILDING COUNTY OF LOS ANGELES ADDRESS 5925 Temple City Blvd. DEPARTMENT OF COUNTY ENGINEER CITY itv zIP BUILDING AND SAFETY DIVISION NO.OF SLOGS. BUILDING SIZE OF LOT eL57,( 7S NOW ON LOT ADDRESS f TRACT BLOCK LOT N LOCALIT TEL. NEAREST OWNER -T r, Nnny NO. CROSS ST. ASSESSOR ADDRESS 1524 Galaxie Drive MAP BOOK PAGE PARCEL DISTRICT I GROUP ITYPEI FIRE ESSED BY CITY Fewnort Beach ZIP 2662 ryry//�� � CONST. ZONE ARCHITECT OR TEL. ✓•C �� y ENGINEER NO. STATISTICAL CLASSIFICATION SEWER M P ADDRESS CLASS NO.��DWELL,UNITS /— BK16 PG TEL. �g CONTRACTOR VirginNO - USE ZONE NOP i�/ ADDRESS 600 S. San Gabriel NO,LIC8399 C- � CONDITIONSSPE CIAL CITY San Gabriel C ASS 0-39 ROAD DEPARTMENT APPROVAL REQUIRED YES❑ NO❑ CONSTRUCTION LENDER NAME AND BRANCH BLDG.SETBACK FROM t FRONT PROP.LINE OF (STREET) i ADDRESS CITY HIGHWAY } YARD _ TOTAL SETBACK FROM TYPE OF EXISTING - ! SQ, FT. NO. OF NO. OF CHECK FRONT PROP. LINE HIGHWAY WIDTH � SIZE STORIES FAMILIES ONE DESCRIPTION OF WORK NEW ❑ �, ADD ❑ BLDG.SETBAC OM .3erool using 1 la er 3 — SIDE PROP.LINE O (STREET) rLALTER HIGHWAY } YARD TOTAL SETBA ROM TYPE OF EXISTING A rwith . rock REPAIR❑❑� SIDE PROP. LIN HIGHWAY WIDTH USE EXISOT NG BLDG. DEMOL ❑ + APPLICANT TEL CORNER CUTOFF YES ❑ NO (PRINT) NO. BY (SIGNATURE) IN OPEN SPACE YES ❑ NO ❑ a IN COASTAL ZONE YES ❑ NO [:]VALUATION$2300000 CATEGORICAL EXEMPTION YES❑ NO ❑ I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION ENVIRONMENTAL AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY IMPACT EXEMPTION DECLARATION SIGNED (DATE) WITH ALL ORDINANCES AND LAWS REGULATING BUILDING CON- STRUCTION. IC THAT IN DOING THE WORK AUTHORIZED IMPACT REPORT PROCESSED (DATE) HEREBY I WILL NOT EMPLOY ANY PERSON IN VIOLATION OF THE LABOR CODE OF THE STATE OF CALIFORNIA IN RELATING TO WORKMEN'S COMPENSJUON INSURANCE. SIGNATURE OF Alp -,e PERMITTEE-- ADDRESS— FINAL ERMITTEEADDRESSFINAL BY CITY NOL• DATE�.�//,� MAKE CHECKS PAYABLE TO: FEE $ FEE $ 33-00 HARVEY T. BRANDT. COUNTY ENGINEER PLAN CHECK VALIDATION CK M O. CASH a PERMIT VALIDATION CK M O CASH 6 6 1i�JAN -51 l 0 3 3.v v oz�, 76A638A CER803 7/73 "i . •-t WORKERS'COMPENSATION DECLARATION insure, o a cer .th;a I haver certificate of consent to self APPLICATION ®L I CAT I O F""' p, I1 LY PERMIT insure, ora certificate of Workers'Compensation Insurance, ®® k� CL49�U or a certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company BUILDING Certified copy is hereby furnished. FOR APPLICANT T/O�FILL IN ADDRESS S- a—$ T• 0, �Lv ❑ Certified copy is filed with the county building inspec- FADDR _S - r- Lr�C.0 QQLd� tion department. / P P LOCALITYjyPca Ci �y NEAREST Date Applicant T e• ZIP �O CROSS ST. s �l CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. ASSESSOR COMPENSATION INSURANCE NOW ON LOT MAP BOOK PAGE PARCEL (This section need not be completed if the permit is for one USE ZONE MAP QBLOCK LOT NO. NO.hundred dollars($100)or less.) . / __J TEL. SPECIACONDILI certify that in the performance of the work for which this I i' A N4 NO. - CONDITIONS QDISTRICT GROUP TYPEFIRE PROCESSED BY O permit is issued,I shall not employ any person in any manner �: J:) P 4 CONST. ZONE U so as to�7;�Zl ect to the Workers'C mpensation Law C 19 CITY 7%(2ZIP 1780 �� _� O Date Applicant STATISTICAL CLASSIFICATION APT. Jq0ND0. NOTICE APPLICANT: If, after maki g this er ificate of ARCHITECT OR TEL. Exemption, you should become subject to the Workers' ENGINEER NO. CIASS NO0.. DWELL. UNITS IL Compensation provisions of the Labor Code, you must forth- ADDRESS SEWER MAP with comply with such provisions or this permit shall be =4 TEL. deemed revoked. CONTRACTOR � NO. BK. PG, VALIDATION LICENSED CONTRACTORS DECLARATION LIC. I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. LVAL.UATION (commencing with Section 7000)of Division 3 of the Business and LIC. c��p Professions Code, and my license is in full force and effect. CITY CLASS d CT/S SQ.FT. NO.OF NO.OF CHECK License Number Lic.Class SIZE STORIES FAMILIES ONE $ Contractor Date v DESCRIPTION OF WORK NEW E] ❑ ADD C]I am exempt under Sec. Y� A fo tom- JIN ALTER ❑ FINAL - A 2 75 O A B.BP.C. for this reason 'XNs-bupA.J REPAIR ❑ DATE,774 FIN . Date: USE OF DEMOL E] By 00002 3 . EXISTING BLDG. Signature APPLICANT TEL. �� o o 4 1,4 5 OWNER-BUILDER DECLARATION PRINT NO. I hereby affirm that I am exempt from the Contractor's License D o o o 4 1.4 5= Law for the following reason (Section 7031.5, Business and ADDRESS rofessions Code): r PRESENT Q a 2 O e 8 5 NG I, as owner of the property, or my employees with ADDRIESSSS 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. ❑ I,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). 2 8 2 9 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 0 0 1 the performance of the work for which this permit is issued P.L. D I o o59.25 tSec. 3097, Civ. C.). SIDE 'o P.L. o 0 o5925v P Lender's Name 7�• 0 9 O 3-8 5 a LInvestigation e Permit Fee Lender's Address /y rI certify that I have read this application and state that the Issuance Fee SSC! n le_ above information is correct. I agree to comply with all County e VV' ordinances and State laws relating to building construction, Total Fee and hereby authorize representatives of this County to enter ' n the b ve-me tion pro arty for inspection p rposes. �1 SEE REVERSE FOR EXPLANATORY LANGUAGE Si nature of Applicant or Agent D to as