HomeMy Public PortalAbout6351 TEMPLE CITY BLVD_Building__ ?s 76A630A
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APPLICATIaVi 861O�UILDI ERMIT
COUNTY OF LOS ANGELES _ BUILDING AND SAFETY
"C," FOR APPLICANT TlO/FALL INfl\fB
BUILUING
DDRESS
ADIDRIE55(.(���j( rl.� lelCALITY
EAREST
CITY ZIPROSSST
qq NO OFBLDGSSESSOR
SIZE OF LOT �-O NOW ON LOTAP BOOK PAGE PARCEL
ITRACT I Z BLOCK L C-7 IF DISTRICT GROUP aJY�^
EL /
OWNE 1 9� NO 0/0 el
�^ ATISTICAL CLA$AFI TION SEWER MAP
ADDRESS 7" S CLASS NO WELL UNITS BK PG
CITY ZIP1ENGINEER ORG C, d TNOALUATIONADDRE // G DG SETBA K F.//TELONT PROP LINE ISTREETI
CONTRACTOR g ANOT SETBACKFROM F E STING
LICIGHWAY + YARD TPROPUNE HWAVWIDTH
ADDRESS NOUCCITY CLACONSTRUCTION LENDER I , ^ _ DG SETBACK FROM
NAMEAND BRANCH N/Ki SIDE PROP LINE OFISTREETI
HIGHWAY + YARD TOTAL SETS ACK TYPEOF EXISTING
ADDRESS CITY SIDE PROP LINE HIGHWAY WIDTH O
u
SO F OAESCHECK +
SIZE STORESA ''EFMILIONE dON
USE ZONE MAP O
DESCRIPTION OF WORK jj�JJHZ2 A A 100 NEW _ NO G
SPECIAL �VOyI
ADD CONDITIONS
ALTER FINAL .4 _9 BY BY ' f Z
REPAIR DATE ,/,.a ff•��(�
EXISTTIING BLDG "�//V� OEMOL /J" /�C7
C Z
APPLICANT L� 1, TEL/� a3 o r 275 0 A
(PRINT) , N, Ft��YLICC NO'Z 2 Q
BY(SIGNATURE) _/' / l # • • • • 2 3
' " `\ > ` 2 = • 1440
HEREBY ACKNOWLEDGE i Ai HAVE 70 O THISMPP APR iLL AND STALE
THAT
THE ABOVE 6 CORRECT AND AGREE 171 COMPLY WITH ALL ORDINANCES
ANO LAWS RFGUED LNG BUILDING CONSTRUCTION 1 CERTIFY THAT IN DOING THE ��� 0 0 0 1 [f CIC V
WORK AUTHORIZED HEREBY WILL LI MIA IN ANY PERSON IN VIOLATION OF
PTHE LABEIR E1bAiIONCNSURANCEE STALE OF CALIFORNIA IN RELATING 70 WORKMEN 5COM _ 1023-8_ 0U 0
SIGNATURE OF
PERMITTEE
ADDRESS !i"". Z _'275 1 A
TEL E
J/1/\ <YIs!/K-1 4 e a e o • 1
`
CITY NO
// J, 'D
P C Fee / /i (O Cl Perm It Fee Perm ; 2 • 6 6 4,5 0
/ Issuance Fee A0 ° 464 5 x 5
r
Total Fee (970 1 /0 —;?—:5
WORKERS COMPENSATION DECLARATION
hereby affirm that I have a certificate of consent to self APPLICATION FOR BUILDING PERMIT '
insure or a certificate of Workers Compenstlon Insurance or
\a certified copy thereof (Sezc � 1. FW C ) Co. oE, NLL ,
_ H�.[ECR COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No CI (0(1 " Company
Certified copy is hereby furnished FOR APPLICANT TO FILL IN ADNESS
ESS
- Certified copy is filed with the county building inspec BUILDING //�
tion department ADDRESS
^ \(,�zJ ( ^C CI BIS LOCALITY
(Z� l6 7 omplE C L� ZIP CRROO55SST
Date Applicant CITY
CERTIFICATE OF EXEMPTION ROM WORKERS NO OF BLDGS ASSESSOR
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK PAGE pgjiCPL
(This section need not be completed If the permit is for one TRACT BLOCK LOT NO USE ZONE NO MA e2oo3
hundred dollars(2100)or less ) y
.�+ it SPECIAL 1
I certify that in the performance of the work for which this OWNER sR H t NCOQ\CK NO` CONDITIONS 0
permit is Issued I shall not employ any person in any manner �j z� -' // DISTRICT GROUP TYPE FIRE SSED BY V
se,as to become subject to the Workers'Compensation Laws ADDRESS 'L c)0 5 5 A) �tDIG P-L D f l�(� �r b� ` �' CONS ZONE ! Ilk
0
CITY5.4113 6A82LE _ , zIP t7'lllLo 0
Date Applicant 11 ARCTEC<OR \ f STATISTICAL CLASSIFICATION APT CONDO W
NOTICE TO APPLICANT If after making this Certificate of ENGINEER NC CLASS NO
Exemption you should become subject to the Workers 40 DWELL UNITS_ d
N
Compensation provisions of the Lobar Code you must forth gDDRE SEWER MAP z
with comply with such provisions or this perms shall be -
deemed revokedCONiRq.CTOR NO
BK vG VALIDATION
TEL
LICENSED CONTRACTORS DECLARATION _ //
I herebv affirm that I am licensed under provisions of Chapter 9 ADDRES51 NC!" Ill VALUATION
Ommencing with Section 7000)of Division 3 of the Business and LIC 1
Professions Code and my license is in full force and eff t CITY F CLASS s to DOO
(f R O OF NO OF CHECK
'
License Number �� 10� Llc Cie IZE D� STORIES FAMILIES ONE
`�q�
ContractorlJ iClk NVLCAkC� _- NEW
Dote IZ. (`f�p DESCRIPTION OF WORK ❑
s ADD
I am exempt from the licensing requirements as I am a L�f=iV �flLl.
licensed architect or a registered professional engineer ALTER ❑ FINAL
acting in my professional capacity (Section 7051, i REPAIR
Busmeas and Professions Code) USE OF ❑ FINAL
EXISTING BLDG DFMOL ❑
Lic or Reg No Dote APPLICANT TEL
OWNER BUILDER DECLARATION (PRINT)l _ NO
I hereby affirm that I am exempt from the Contractor Is License
Law for the following reason (Section 7031 5 Business and ADDRESS
Professions Code) PRESENT
❑ BUILDING
I, as owner of the property or my employees with ADDRESS
wages as their sole compensation,will do the work and J f A 34 ,10 A
the structure is not intended or offered for sole(Section LOCALITY i
7044 Business and Professions Code) _ ING TEl
# .'ee
❑ I as owner of the property om exclusively coay OMRGosctsACTOR NO
with licensed contractors to construct the project (Sec ADDRESS 2 e 10600
tion 7044 Business and Professions Cade)
CONSTRUCTION LENDING AGENCY
REQUIRED YARD HWY TOIAL SETBACK FROM EXIST i• 1 0 6 0 0 xu
hereby affirm that there is a construction lending agency for SET BACK PROP LINE WIDTHFRONT - 1217-80
the performance of the work for which this permit is issued PL
(Sec 3097 Gv C I SIDE
PL
Lender s Nome
Lender s Address PC Fee S Perms Fee
I certify that I hove read this application and state that the Issuance Fee
above information is correct I agree to comply with all County Investigation Fee
ordinances and State laws relating to budding construction Total Fee
b and hereby authorize representatives of this County to enter
upthea above mentioned
property for inspection purposes�s f
n Pv Y / s-"r•� / sy^ I&- SEE REVERSE 1'0111 EXPLANATORY LANGUAGE
Signature of Applicant or Agent Dote �s