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