HomeMy Public PortalAbout6009 TEMPLE CITY BLVD_Building__ PSA638A CE 9803 3-69 APPLICATION FOR BUILDING PERMIT �I
COUNTY OF LOS ANGELES BUILDING
DEPARTMENT OF COUNTY ENGINEER ADDRESS
BUILDING AND SAFETY DIVISION LOCALITY
JOHN A. LAMBIE, COUNTY ENGINEER ;
COLEMAN W. JENKINS, SUPT OF BUILDING CROSS NEAREST
FOR APPLICANT TO FILL IN
DISTRICT NU. UR O TYPE NIT! PR ,E - ,
(PR-IN-T OR TYPE ONLY)
BUILDING STATISTICAL CLLAASS`IFICATION SEWER MAP
ADDRESS 6009 Tem le a Blvd. CLASS NO. • DWELL.UNITS G
LOT NO. BLOCK USE ZONE/// MAP I J1 D
TRACT �� �jV
SPECIAL
NO. OF BLDGS. CONDITIONS
SIZE OF LOT NOW ON LOT
USE OF
EXISTING BLDG. BLDG. SETBACK FROM
TEL. FRONT PROP. LINE OF (STREET)
OWNER SigMUnd Cazwell NO. TYPE OF EXISTING SETBACK HIGHWAY + YARD = TOTAL
HIGHWAY WIDTH FROM C.L.
ADDRESS 9518 Olive Street-' ' .
CITY Tem le City, California +
ARCHITECT OR TEL. BLDG.SETCK FRO
SIDE PROP. LINE OFM (STREET)
ENGINEER N0.
TYPE OF EXISTING SETBACK H�'Gk{WAY + YARD = TOTAL
ADDRESS HIGHWAY WIDTH , FROM C.L.
TEL. + _
CONTRACTOR Rl idN0.
ADDRESS NO. 4 CORNER CUTOFF YES ❑ NO ❑
CITY Lo CLASS 5917 SEE REVERSE SIDE FOR SPECIAL APPROVALS
CONSTRUCTION LENDER
NAME AND BRANCH
ADDRESS i
SQ. FT. N0. OF NO. OF n
SIZE STORIES FAMILIES NEW W
USE OF ADD
STRUCTURE ALTER ❑
i
REPAIR ❑
SIGNATURE OF DEMOL ❑
APPLICANT
VALUATION$ APPROVALS DATE INSPECTOR'S SIGNATURE
F E$ FEE$ 12.00 FO NDATIFORMS, MA.ERIIA SN
IHEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION FRAME: FIRE STOPS,
BRACING BOLTS
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY- FURNACE: LOCATION,
WITH ALL ORDINANCES AND LAWS REGULATING BUILDING CONSTRUC- GAS VENT DUCTS
TION. I CERTIFY THAT IN DOING THE WORK AUTHORIZED HEREBY I
WILL NOT EMPLOY A Y PERSON IN VIOLATION OF THE LABOR CODE LATH, INT.
OF THE STATE OF IFORIIIA�IN REL-ATING TO WORKMEN'S COM-
PENSATION INSUR C $,g jV]Y�'= LATH, EXT.
SIGNATURE OF /,/i/v�/� HOUSE NUMBER CORRECT
PERMITTEE AND POSTED
ADDRESS 337 Se.Woods- Loss eleslCa ;f FINAL
JOHN F. LEWIS, PRINCIPAL ST T RAL ENGINEER
PLAN CHECK VALIDATION CK. M.O. CASH' - PERMIT VALIDATION CK. M.O. CASH
Lrit,o 2 NOV 4 1 D 1 2.0 N
WORKERS'COMPENSATION DECLARATION
hereby affirm that I have a certificate of consent to self APPLICATION F O �JILDINGI 'PERMIT.insure,or a certificate of Workers'Compenstion Insurance,ora certified copy thereof(Sec. 3800, La ,C.) COUNTY OF LOS ANGELBUILDING AND SAFETY ^�
Policy No. Company
BUILDING
❑ 'Certified•capy is hereby furnished.�ffj' --rte FOR APPLICANTIO FILL IN ADDRESS ®e •/
Certified copy is filed'with the county'SJTIi3T09a ec- BUILDING /� / /�
tion epartment. ADDRESS LOCALITY
Applicant - •I CITY /G �i � ZIP CROSS T.
Date
. ASSESSOR `
ER IFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NO.OF BLDGSNOW ON'LOT � MAP BOOK PAGE RCEL
COMPENSATION INSURANCE '
(This section need not be completed if the permit is.for one 1. USE ZONE MAP
TRACT BLOCK LOT NO. '
hundred dollars'($100)or.less.) / TEL. SPECIAL
CL
OWNER �i tG NO. CONDITIONS
. ('certify that in•the,performance of the work for which this O
m
permit is,issued, I shall not employ any person in any anner I S�v �/�TK T� DISTRICT GROUP TYPE FIRE" P E BY
ADDRESS CONST. <
p
so as-to become subject to the Workers'Compensation Laws. I ®O'
CITY ///C � ZIP 7 H
Date Applicant j STATISTICAL C W15ATION T: ONDO. (J
NOTICE TO'APPLICANT: If, after making this Certificate of ARCHITECT OR TEL. O(/ �y
Exemption, you should become subject to the Workers' ENGINEER NO. , CLASS NO. DWELL. UNITS _ N
I Compensation provisions of the Labor Code, you must forth- ADDRESS SEWER MAP
•with comply with such provisions or this pefmif shall be
',deemed revoked. CONTRAGrORAff(/rit�!`OJ✓�DO� T 0 �3 BK. PG. VALIDATION
LICENSED CONTRACTORS DECLARATION ,I Y�� �� �i ` LIC.
I hereby affirm that I am licensed under.provisions of Chapter 9' ADDRESS! jT e ; NO. / VALUATION
(commencing with Section 7000)of Division,3 of the Business and /fit LIC.
Professions Code, and my license is in full force and effect. CITY CLASS $ (J
< So.. NO.OF NO.OF CHECK
License Number Lic.Class SEE STORIES FAMILIES ONE
$t
• Contractor Date I DESCR I PTJGN OF WORK NEW ❑
ADD ' ❑
❑
licensed
exempt from the licensing requirements as[-am a ,
licensed architect or a fegistered professional engineerALTER [:] FINAL
fatting in my professional capacity (Section 7051, REPAIR E] DATE
Business and Professions Code). USE OF r
FINAL
' - EXISTING BLDG.' PfjL DEMOL. ❑ By.
Lic.or Reg..No. 'Date APPLICANT ,I, q TEL J '
OWNER-BUILDER DECLARATION. PRINT) I
.lel/�Ow�OG�/ 0.�3 'iD� I
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and ADDRESS <
Professions,Code): PRESENT
❑ I, as owner of the propefty, or my employees with ADDRESS
wages-as their sole compensation,will do the work and "
`the structure is not intended or offered for sale(Section i LOCALITY
7044, Business and Professions Code). MOVING TEL.
I, as owner of the property, am exclusively contracting
CONTRACTOR NO. �2 9 7 6 A '
/ with licensed contractors to construct the project (Sec- ADDRESS # 0 0 0 0 0
tion 7044, Business and Professions Code).
i REQUIRED TOTAL SETBACK FROM EXIST.
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH I Z o a 4 a O O
'I hereby affirm that there is a construction lending'agency for• FRONT
the performance-of the work for which this permit is issued P.L. 0 0 o 4 3,O O 5
(Sec. 3097,,Civ.C.). - SIDE
Lender's Name P.L. 1-.06-8,0
i P.C.Fee$ Permit Fee l�
ILender's Address
J certifythat I have read this application and state that the "`:'
PP Issuance Fee ,
above informatioh is correct. I agree to cornply with all Couti)y Irivesti4at)ori.F'ee.
ordinances and State laws relating to building construction,
an eby authorize representatives of this County to enter:: '; tTotal Fee / I
o �p he abo - e Toned pro rty for inspect' rpo
- SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date ®s