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HomeMy Public PortalAbout5313-5315 VILLAGE CIRCLE DR_Building__ 1 )"M .-J— APPLICATION-FOR BUILDING PERMIT caR't461j FOR*APPLICANT TO FILL IN,*3e.3,Y0410 �' / / 7.-: BUILDING. . �, 11 COUNTY OF LOS ANGELES ADORES DEPARTMENT OF COUNTY ENGINEER CITY LE � ( ZIP q d BUILDING AND SAFETY DIVISION NO.OF BLDGS. J. BUILDING J y SIZE OF LOT 7 x 36 NOW ON LOT ADDRES$,� � //a •� p"C�>Pi TRACT• BLOCK ,�A'1LOT NO C LOCA LIT L OWNER /y 2 /zl/9C. (� rQp�v NO. CROSS ST. ASSESSOR ADDRESS MAP BOOK PAGE PARCEL CITY ���5�©��/� ZIP DISTRICT GROUP CONSJ/j FIRE O;ESSED BY ARCHITECT ORz:p C� TEL �� ENGINEER G� NO STATISTICAL CLASSIFICATION SEWER MAP ADDRESS--e;17-)F' Or iNlX JSr r CLASS NO. O yDWELL.LIN ITS' z" BK PG CONTRACTORVOIL 8AL.OWN NOL —7jf0: USE ZONE MAP NO. (J G ADDRESS ZLDGv/nJ NO.'2.37-T[[�� 7 �� SPECI L lCONDITIONS CITY F j`yp(_g, GlTY CLASS ROAD DEPARTMENT APPROVAL REQUIRED YES❑ NO❑ CONSTRUCTION LENDER NAME AND BRANCH BLDG.SETBACK FROM It < FRONT PROP.LINE OF (STREET) c ADDRESS CITY HIGHWAY + YARD TOTAL SETBACK FROM TYPE OF EXISTING L SQ, FT. NO. OF NO. OF CHECK FRONT PROP, LINE HIGHWAY WIDTH c SIZEZ G STORIES X FAMILIES Z ONE + L DESCRIPTION OF WORK NEW ❑ BLDG,SETBACK FROM ADD (STREET) ` SIDE PROP.LINE OF D ALTER ❑ HIGHWAY + YARD _ TOTAL SETBACK FROM TYPE OF EXISTING — REPAIR[] SIDE PROP. LINE HIGHWAY WIDTH USE EXISOT NG BLDG. DEMOL 1:1 + ' APPLICANT r TEL CORNER CUTOFF YES ❑ NO ❑ (PRINT) 6�Z �•O�ijfsr/V N0. - Ap IN OPEN SPACE YES ❑ NO BY (SIGNATURE) ❑ !!!!!! ^ IN COASTAL ZONE YES ❑ NO ❑ VALUATION Ud� CATEGORICAL EXEMPTION YES❑ NO ❑ I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION ENVIRONMENTAL ANO STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY IMPACT EXEMPTION DECLARATION SIGNED (DATE) WITH ALL ORDINANCES AND LAWS REGULATING BUILDING CON- _ STRUCTION. 1 CERTIFY THAT IN DOING THE WORK AUTHORIZErNA IMPACT REPORT PROCESSED (DATE) HEREBY I WILL NOT EMPLOY ANY PERSON IN VIOLATION OF TH LABOR CODE OF THE STATE OF CALIFORNIA IN RELATING TJ WORKMEN'S COMPENSATION INSURANCE. / SIGNATURE OF PERMITTEE k 1 ADDRESS CITYNOL• 'BYMAKE_ CHECKS PAYABLE TO: l FEE HARVEY T. BRANDT. COUNTY ENGINEER ] X —4 -3 �o: 3 ,,5�'1 ' PLAN CHECK VALIDATION CK. M.O. CASH PERMIT VAtM TION CK. .0. CASH 185�OCT 2 3 0 � 15 3.0 ® ' 9 0 6�FEB cU 2 3 6 U,5_ 3 490 76A638A CE080 7/7 1 1 8 PACT 14 1 0 3 5 5.8 8 ®bd ' WORKERS'COMPENSATION DECLARATION APPLICATION FOR BUILDING PERMIT !,hereby affirm that I have a certificate of consent to self insure, or a certificate of Workers' Compensation Insurance, or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. 625246 Company State Fund ❑ Certified co is hereby furnished. FOR APPLICANT TO FILL IN BUILDING PY Y ADDRESS 5313-5315 Village Circle 91 Certified copy is filed withefFesounty building Ir pec-/�A BUILDING tion department. /1/J ADDRESS — Te e City, Ca 91780 9-18-92 4ro Roofi l�`F}�fCITY Temple City zIP 91780LOCALITY Date ApplicantNO.OF BLDGS. NEAREST CERTIFICATE OF EXEMPTM WORKERS' '`SIZE OF LOT NOW ON LOT 2 CROSS ST. COMPENSATION INSURANCE ASSESSOR (This section need not be completed if the permit is for one TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL hundred dollars ($100)or less.) mL OWNER Village Owners HOW No. 818=967-7 TSE ZONE MAP I certify that in the performance of the work for which this NO. permit is issued, I shall not employ any person in any manner ADDRESS 1275 Center CONDITIONS a so as to become subject to the Wkers'Compe ti Laws. CITY COVlria ZIP 91724 OU Date ��_ A Applicant ARCHITECT OR TEL. fy NOTICE TO APPLICANT: If, after makingthis erti ica a of ENGINEER NO. DISTRICT �GROUP TYPE FIRE PROCESSED BY CONST. ZONE Exemption, you should become subject to the Workers' p 1 U Compensation provisions of the Labor Code, you must forth- ADDRESS •�0 3 with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION APT. CONDO. N deemed revoked. CONTRACTOR NO. Z LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS 1152 N. Kraemer No. 344837 (commencing with Section 7000)of Division 3 of the Business LIC. I SEWER MAP and Professions Code,and my license is in full force and effect. CITY Ana ei 2806 CLASS CBK PG VALIDATION License Number 344837 Lic. Class C39 ;SIZES 280 STORIES FAMILLIIES ONE ALUATION Contractor Bronco Roofing Date 9-18-92 DESCRIPTION OF WORK Tear Off existing NE ❑I am exemp9jrgw. 5-31-99 roof an re roof it CalAD ► ALT B.BP.C. for this reason RE Date: USE OF EXISTING BLDG. DESignature APPLICANT TEL• NAL OWNER-BUILDER DECLARATION (PRINT) NO. —I hereby affirm that I am exempt from the Contractor's License 714ATE Law for the following reason (Section 7031.5, Business and ADDRESS NAL Professions Code): PRESENT „ ❑ I, as owner of theproperty, or m employees with BUILDING Hr YADDRESS wages as their sole compensation,will do the work and ^-- ��I' 's the structure is not intended or offered for sale(Section LOCALITY �'`�� 4 7044, Business and Professions Code.) MOVING TEL. , _ jTi!` ❑ I,as owner of the property,am exclusively contracting CONTRACTOR NO. �� with licensed contractors to construct the project (Sec- !�!IA 20-4 e �3 ADDRESS r. tion 7044, Business and Professions Code.) CHECK•E r„�} _•�t t ' REQUIRED TOTAL SETBACK FROM EXIST. t�— ••� •jl•0+=1 CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH r'si'i• .. I hereby affirm that there is a construction lending agency for FRONT ,!-:�il4..a= �,)•, the performance of the work for which this permit is issued P.L. (Sec. 3097, Civ. C.). SIDE P.L. I t�+-00111 9/13/92 Lender's Name LDMA Ref. # Lender's Address , P.C. Fee$ Permit Fee ,: � •� o I certify that I have read this application and state that the Issuance Fee G /� LDMA P/C# 11011. above information is correct. I agree to comply with all County Investigation Fee 'nances and State law relating to building construction, Total Fee LDMA Perm. # a /anhereby authorize re eseaiatIves of this County to enter m Z e abo e-rhentio d pro t for inspection purposes.9-18-92 SEE REVERSE FOR EXPLANATORY LANGUAGE �,�na4ture of Applicant Agent Date