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APPLICATION
cAPPLICATION FOR BUILDING PERMIT LI
COUNTY OF LOS ANGELES AODRE'b9 02 Trelavn Ave.
DEPAATNENT OF COUNTY ENGINEER
BUIMING AND SAFETY DIVISION LOCALITY Temple Cit
JOHN A LAMBIE COUNTY ENGINEER NEAREST
WILLIAM JH SEN SUP TOP BUILDING CROSS ST
FOR APPLICANT TO FILL IN DISTRICT O - OUP TypE P CESSED BY J
S Q CONST 'r L�
BUILDING STATISTICALCLASSWICATION SEW ER MAP
ADDRESS O2 Trelarme Av • CLASS NO�DWELL UNITS Q 47 EIK PD
LOT NO 9
L BLOCK MAP f1 STATE
NUMBERZO HWY YES( NO
TRACT 12706
USEZONE SPECIAL
NO OF BLDGS �I CONDITIONS
9"E OF OT NOW ON LOT
--0 e C arage 8C
BUILDING EXIST
R, TEL SETBACK YARD HWY STREET NAME WIDTH
OWNER R NO FRONT
ela" va. T le Ci P L
S `�� s, SIDE
ARCHITECT OR TEL P L
ENGINEERISTAIMAl"j) FTzMNO INSPECTION RECORO
d
ADDRESS �/ O
c
Poole Inc. N - 221 u
A RE rea Ong vd• � O ate 0
DESCRIPTION OF WORK A
W
NEW X ADD ALTER REPAIR DEMOLISH Z
SO FT NO OF NO OF O
SIZE STORIES FAMILIES
USE OF
STRUCTURE PriH � wim
Std
SIGNATURE 0-
APPLICANT
VALUATION 3200*00
APPROVALS D TE INSPECT R9SIGNATURE
UNDATl/ FJFORMSION MATERIALS
,Q 3 ' /
FEE 7y FEE E /V
FRAME FIRESTOPS
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION BRACING BOLTS
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY FURNACE LOCATION
WITH ALL COUNTY ORDINANCES ANO LTA TE LAWS RE ULATING GAS VENT DUCTS
BUILDING CONSTRUCTION CE11111Y THAT IN THE P RMANCE
OF THE WORK FOR WHICH T PERMIT I6 I66U6 ALL NOT LATH INT
EMPLOY ANY PERSON IN AN MANNER SO AS O CO 6U BUECT
TO THE WORKME OMP ATION LA S LI RNIA
LATH EXT
SIGNATUR F A-- I MBER COR-
pE RECT AND POSTED
AD e stone • FINAL
CLYDE N DIRLAM PRINCIPAL ST CT RAL ENGINEER
PLAN CHECK VALIDATION r D uex PERMIT VALIDATION c MO CASH
Ll f
.07 4 7 2 G Iti'Y 2 3 2 3 D 3 75
V07473 15 GL
TEMPLE CITY f�
I
APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES ABUILDING
DDRESS O
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION LOCALIT
JOHN A LAMBIE COUNTY ENGINEER NEAREST
WILLIAM A JENSEN SUR T OF allILDING CROSS ST
DISTRICT NO GROU TYPE P ^IB
FOR APPLICANT TO FILL IN coNsr
BUILDING nn �J STATISTICAL CLASSIFICATION SEWER MAP
ADDRESS y[/ [, q
CLASS NO DWELL UNITS
LOT NO BLOCK WATER rypT REQUIRED RECEIVED
99 CERTIFICATE
TRACT L Q MAP HIGHWAY
NO OF BLDGS NO ICIRCLp STATE MAJOR SECON LOCAL
SIZE OF LO NOW ON LOT USE ZONE SPECIAL
USE OF � ' CONDITIONS
EXISTING BLDG
OWN TO 6�S BUILDING EXIST
SETBACK YARD HWY STREET NAME WIDTH
ADDRESS FRONT Zo
ARCHITECT OR TEL P L
ENGINEER NO SIDE }
ADDRESS P L y
O
TEL V
CONTRALTO N
Ed
ADDRESS G S O
DES ON OF WORK WrV
a
NEW AD ALTER REPAIR DEMOLISH Z
Sq FT 91� NO OF '/ NO OF
SIZE STORIES v FAMILIES A
USESTRUC
Ar.
SIGNATURE OF
APPLICANT
VALUATIONS 0 d
APPROVALS PATE. INSPECTgR YSIGNATURE
FEE FEE S OFORMSI MATERIALSON
iz-
rRAME FIRE STOPS
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION BRACING BOLTS )
ANO STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY FURNACE LOCATION
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING GAS VENT DUCTS
OUILOING CONSTRUCTION I CERTIFY THAT IN DOING THE WORK
AUTHORIZED HERESY I WILL NOT EMPLOY IY PE N IN VIOLA LATH INT Ir✓1
TION OF THE LABOR CODC OF TX STAT F CA OflNIA RELAT
ING TO WORKMEN 5 COMO IN NCE LATH EXT
SIGNATUREOF HOUSE NUMBER COR
PERMITTEE IRECT AND POSTED
ADD =EE
I FINAL V IRA—
JOHN
CHECK VALIDATION CK I NO [ASH JOHN F LPERMVNCI STRUCTURAL E GINEER
_ PERALIDATIOIO N GK .0 D,BH
L" 3943Z SEP18 1 D 11.50-
. � -
WORKERS' COMPENSATION DECLARATION11
A e
y a certificate
that I have r certificate Come of consent to ,elf APPLICATION FOR BUILDING PERMIT
insure, or a certifiante of Workers' Compensation Insurance,
or a certified copy thereof (Sec 3800 Lob C ) COUNTY OF LOS'641EIIf - BUILDING AND SAFETY
Policy No I Company BUILDING
❑ Certified copy is hereby furnished FOR APPLICANT TO FILL IN ADDRESS
❑ Certified copy is filed with the coun)y building IrinpeC- BUILDING 1
hon department ADDRESS
Date Applicant CITY ZIPG LOCALITY
NO OF NEAREST
CERTIFICATE OF EKEMPTION FROM WORKERS" SIZE OF LOT NOW ON LOT CROSS ST
COMPENSATION INSURANCE
(This section need not be completed ofthe permit is for one TRACT BLOCK I LOT NO Mp,p BpOx 6-; f' pAOE o a PAROL �a
hundred dollars ($100) or less ) OWNER i NLp USE ZONE MAP
iA— �
I certify that in the performance of the work for which this INO
permit is issued, 1 shall not employ any person in any manner ADDRESS 402N4, As&e SPECIALIONS d
so as to become sublect to the Workers Compensation Laws p� O
CITY 7 ZIP C (rr
Date AR
Applicant CHITECT TELK
NOTICE TO APPLICANT If, after making this Certificate of ENGINEER NO DISTRICT GROUP CONST
TYPE I PROCESSED BY rQ
Exemption, you should become subject to the Workers' /� _ /
Compensation provisions of the labor Code, you must forth- ADDRESS V�� Y
with GCll!-est-
comply with such provisions or this permit shall be �( TEL - 'n
deemed revoked CONTRACTOR G 41 /�'� NO STATISTICAL CLASSIFICATION APT CONDO Z
LICENSED CONTRACTORS DECLARATIONUC CLASS NO DWELL UNITS_
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS ¢off- Tr.� Q t j Mx NO now
SEWER MAP
(commencing with Section 7000)of Division 3 of the Business LIC
and Professions Code,and my license is in full force and effect CITY L's' U
CSS BK PG VALIDATION
SOFT t. } OF NO OF CHECK
License Number Uc ClassSIZE > .1 STORIES FAMILIES ONE
VALUATION
Contractor Dal DESCRIPTION OF WORKS Q FEW ❑ 11
❑ am exempt under Sec
Q� ` � ' ADD 0 polo
s, O77
nrs�,rv�!p � ALTER ❑
B 8P C for this reason BNL IX��'n r"b W c.Gao4X FAIR ❑ f
Me USE OF
EKIsTING BLDG MJW7,1 ❑
Signature APPLICANT - TEL —y ,
(PRINT) t a- H �, t2 FIO .Ql -&VW FINAL,
4 -=7-_!
OWNER-BUILDER DECLARATION �
I hereby affirm that I am exempt from the Contractoes License a 1�Y� NwhR rT_
Low for the following reason (Section 7031 5, Business and IX FINAL^_
Professions Code) - By r a
El I, as owner of the properly, or my employees with BUILDING
ADDRESS
wages as their sale compensation,will do the work and
the structure is not intended or offered far sale(Section LOCALITY 0
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-
tion 7044, Bumness and Professions Code ) ADDRESS ^:,'l7 pu"rD
CONSTRUCTION LENDING AGENCY Bq YARD HVyv PROP LIN F WIDTH I /"
I hereby affirm that there is a construction lending agency for FRONT . r' c ITcii,-
the performance of the work for which this permit is issued P L - riI I a' c� 1
(Sec 3097, Civ C ) SIDE +'
P L
Lenders Name
PC Fee$ /iJ Perms Fee /r V Ref N
Lenders Address L/
I certify that I have read this application and state that the Issuan �T 75- LDMA P/C N
above information is correct I agree to comply with all County Investigation Fee 7/
ordinances and State lawn relating to building construction, Taal Fee ,0 6. 3 6 1 LDAKA Perm N
< and hereby authorize representatives of this County to enter �_jy _ :-� ',i{LI I,1
TY4 upon the bore-mentioned prq(xrry for in"clion pu
� � s n
a
-242 i-{' fj Y _ fQ ItEVEM FOR EXPLANATo"LANGUAGE
Signature of A)Splicallt or Agent Dbte