HomeMy Public PortalAbout6030-6030 1/2 TEMPLE CITY BLVD_Building__ aAPLIATIN FOR BUILDING PERMIT
COLMT-T OF LOS ANGELES BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS � y
I hereby affirm that I have a certificate of consent to self insure, BUILDING ADDRESS
or a certificate of Workers'Compensation Insurance,or a certified1
RTvn-
copy thereof(Sec.3800,Lab.C.) CITY — ZIP
LOCALIT
Policy No. 1046104 Company STATE FUND SIZE OF LOT NO OF BLDGS.NOW ON LOT
❑ NEAREST CROWST
Certified copy is hereby furnished.
CXCertified copy is filed with the county building inspection TRACT BLOCK LOT NO.
department. USE ZONE MAP NO.
Date 5-2-96 Applicant ASSESSOR MAP BOOK PAGE PARCEL
SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' %V PHELAN IU29018YES NO
COMPENSATION-INSURANCE WITHIN 1000 FT.OF SCHOOL?
(This section need not be completed if the permit is for one hundred 198MS TEMPLE CITY BLVD. DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY
dollars($100)or less.) p
I certify that in the performance of the work for which this permit TEMPLE CITY Z51780
is issued, I shall not employ any person in any manner so as to �C.
become subject to the Workers'Compensation Laws. ARCHITECT OR ENGINEER TEL NO.
STATISTICAL CLASSIFICATION APT CONDO
Date Applicant ADDRESS CLASS NO. DWELL UNITS
NOTICE 70 APPLICANT If, after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST
Exemption, you should become subject to the Workers' CONTRACTOR19V-?4040
NOSET BACK YARD HWY PROP LINE WIDTH
ND
Compensation provisions of the Labor Code, you must forthwith RAOL ROOFING & CONST. 19V--4040 FRONT
comply with such provisions or this permit shall be deemed revoked. 5 ADDRESS
SE E. VALLEY BLVD. 1 y 3 7 PL >_9
LICENSED CONTRACTORS DECLARATION SIDE O
I hereby affirm that I am licensed underprovisions of Chapter 9 SAN GABRIEL C-39�S P L U
(commencing with Section 7000)of Division 3 of the Business and
SO FT SIZE NO.OF STORIES NO.OF FAMILIES SEWER MAP
Professions Code,and my license is in full force and eff ct. NEW ❑ BK PG O
License Number 451y37 Lic.Class C9 DESCRIPTION OF WORK ADD ❑ VALUATION ® U
Contractor
RANDOL ROOFINq
ate 1-31-98 — 00 E T 2—PLY $ 4,872.00 a
ALTER ❑
U)
❑ I am exempt under Sec. BITTT _ITP FIBERGLAS CAP, — REPAIR M ACCT.r • n
B.BP.C.for this reason DEMOL 11 ToZ
r
LDMA P/C
Date: USE OF EXISTING BLDG. URM 11 # 1}`3'03158.85
Signature LDMA Perm# 1 ITEMS 1
El 1, & CONST. IW-24040 I, as owner of the property, or my employees with wages as � TOTAL �..5� o
85
their sole compensation, will do the work and the structure is ADDRESS
not intended or offered for sale (Section 7044, Business and 529 E. VALLEY BLVD. , SAN GABRIEL, CA FINAL DATE J{ a CHECK .58,85
Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL CHANGE .0
❑ I, as owner Of theproperty, am exclusively contracting With OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE FINAL BY
y g AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? n
licensed contractors to construct the project (Section 7044, C
YES 11 No ElBusiness and Professions Code.) (• ��— � rr � ��
HALL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH
CONSTRUCTION LENDING AGENCY COAST AIR OUAUTY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR AMI 11�, i 1 q Fi{i 1,o f
L
GUIDELINES
I hereby affirm that there is a construction lending agency for YES❑ NO❑
the performance Of the Work for Which this permit IS issued(Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING
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 SCAOMD.
Lender's Address
cc OWNER OR AGENT
3 I certify that I have read this application and state under penalty
a P.C.FEE PERMIT FEE /��
c of perjury that the above information is correct.I agree to comply "d
J
with all county ordinances and State laws relating to building
construction, and hereby a thorize representatives of this County ISSUANCE FEE =7 30
e r p the a tioned property for inspection urp es. /
a INVESTIGATION FEE TOTAL FEE /Stf
�i h w AWd Oct.
SEE REVERSE FOR EXPLANATORY LANGUAGE
18A888A 1398•8
If-SS 4P P L I CATI ON FOR BUILDING PERMIT '
-
DIVISION OF BUILDING AND SAFETY BUILDING
T.
Department of County Engineer r .
County Of 1.08 Angeles -IlLOCALITY
JOHN A.LAMBIE, COUNTY ENGINEER NEAREST
CASSATT D.GRIFFIN,SUPT OF BUILDING CROSS ST.
FOR APPLICANT TO FILL IN D1STR GROUP , TYPE SEWER. MAPPG
'`J CONST.
BUILDADDRESNG S ®� GA g go �lTl� L�jOr, MAP STATE YES VOA
• NUMBER CONDITIONS'
HWY
LOT NO. // SOS BLOCK USE ZONE SPECIAL
TRACT IOJ f0
NO.OF BLDGS.
SIZE OF LOT X NOW ON L•bT BUILDING YARD HWY STREET NAME EXIST.
USE OF
SETBACK WIDTH
• •
EXISTING BLDG. FRONT.
�S- / �) P.L. a P�.e e L
OWNER4ViLuAm W. #-G,4i i ,_yc& 7Df��• mtjir 57 SIDE
P.L.
MAIL A S_8C4� 5-
ADDRESS �7St7 �•C1/� O TRACT DWELL. 1 UNIT '
�(
TEL /jam(0� 5 INDUSTRIAL
CITY J (ALO c7y NO. Fj( - DWELL. 1 UNIT 6 .PUBLIC BLDG.
ARCHITECT OR TEL. 2 DUPLEX cz 2 UNITS
ENGINEER NO. 3 APT. UNITS 7 ADDN..ALT., ETC.
8 MISCEL.
ADDRESS /' I T 4 COMMERCIAL
CONTRACTOR OMIIT, •-L/dG No A/�/ 7� A/ ? INSPECTION RECORD
ADDRESS 44'1 G4;19li�1e{;.0 RtW01 j
DESCRIPTION OF WORK g' y $i_ ':{j'rb'i
ADD ALTER REPAIR DEMOLISH -)1.51
1941pi.N. &1r•7� j d .1h _
SQ.FT s• OF NO.OF 6 PrT Tl 7� UJ.
Q STORIES .%FAMILIES
USE=UCTURE �t
AM ZY4qas E_
SIGNATURE OF
APPLICANT Q,�A APPROVALS
ADDRESS ] 1M 4" . - DATE INSPECTOR'S SIGNATURE
LOCA
LjFiEC. S FOUNDATION
FORMS.MATERIIALSION Z• "�: FIRE STOPS. / �[r'gl✓VALUATION EE $� 'FURNACE: LOCATION. 12
I,HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS A GAS VENT. DUCTS
APPLICATION AND STATE THAT THE ABOVE IS CORRECT `
AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES LATH. INT.
AND STATE LAWS REGULATING. ILDING CONSTRUC-
TION. li /
/ LOTH, EXT.
SIGNATURE OF i�' (� HOUSE,NUMBER COR- /
PERMITTEE r CL'C' RECT AND POSTED V �/
ADDRES FINAL Z-Z _51 I
JOHN A.LAMBIE.COUNTY ENGINEER VALIDATION CLYDE N.DIRLAM. CHIEF.BLDG. INSPECTOR
CK NO CASH '-
% � 9 5 5 Auc23 6 1. 9.00 b �►
LX, 09 6 7 9051 AU028 1 38.04 in