HomeMy Public PortalAbout9917 WOODRUFF AVE_Building__ i
APPLICATION F®R BUILDING PERMIT �
COUNTY OF LOS ANGELES BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS
I hereby affirm that I have a certificate of consent to self Insure, BUILDING ADDRESS _ _
or a certificate of Workers'Compensation Insurance,or a certified g w O O cj (Z V fit_ / p �r1�v
copy thereof(Sec.3800,Lab.C.) CITY ZIP 1 �lV o
703 ?6 ,f I,.4T.0 FVi�� PE
re✓1'►('! c,t r`C 7 $d LOCALITY ALL"
Policy No. Company SIZE OF LOT NO.OF BLDGS.NOW ON LOT
❑ Certified copy is hereby furnished. NEAREST CROSS ST.
❑ Certified copy is filed with the count building Inspection. TRACT BLOCK LOT NO.
department. b"Af Adip��wA.� USE ZONE MAP NO.
Date a Applicant ASSESSOR MAP BOOK PAGE PARCEL
I Z SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' R 5 C/f��,f}a��&& Z SOWNER
_.5'4y S YES No
COMPENSATION INSURANCE ADDRESS WITHIN 1000 FT.OF SCHOOL?
(This section need not be completed If the permit is for one hundred .SAnn G. DISTRICT GROUP TYPE CONST.' FIRE ZON ROC D BY
dollars($hat or less.) CITY zip /`J� f-3
9 3 3��I certify that in the performance of the work for which this permit ,n
Is Issued, I shall not employ any person in any manner so as to ARCHITECT OR ENGINEER TEL.NO.
become subject to the Workers'Compensation Laws. STATISTICAL CLASSIFICATION /CONDO
Date Applicant ADDRESS CLASS NO. DWELL UNITS
NOTICE TO APPLICANT. If, after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST
Exemption, you should become Subject to the Workers' CONTRACTOR _• TEL NO. SET BACK YARD HWY PROP LINE WIDTH
Compensation provisions of the Labor Code,you must forthwith V14�,LE 1"�r/Al 141/7 dyG/
comply with such provisions or this permit shall be deemed revoked. ADD ESS LIC.NO. FRONT
15 �i4im c«ice iFl&00 y P L ,.
LICENSED CONTRACTORS DECLARATION CITY LIC.CLASS SIDE
PL O
I hereby affirm that I am licensed under provisions of Chapter 9 2 PL_ G..3 Cl SEWER MAP 9=
SQ.FT SIZE NO.OF STORES NO.OF FAMILIES
(commencing with Section 7000)of Division 3 of the Business and NEW ❑ BK PG
Professions Code,and my license is in full force and effect. v
800 C-39 DESCRIPTION OF WORK ADD ❑
License Number Q LID.Class E�/}I OOF AT- p4Nr vaLunnON �
Contractor P QLem 5��Data -2—3 1—1 1 [3ALTER $ �f 0 0 CO)OF HOUSE. REPAIR
❑ I am exempt under Sac.
B.&P.C.for this reason DEMOL ❑ LDMA P/C#
Date. USE OF EXISTING BLDG. URM ❑
Signature k aA..4_t.J APPLICANT(PRINT) TEL NO. Z 1
LDMA Perm M
❑ 1,as owner of the property, or my employees with wages as p
their sole compensation,will do the work and the structure is ADDRESS FINAI D Q t] rlir!.T e s
not intended or offered for sale (Section 7044, Business and
Professions Code.) 07 43.75
WILLTHEAPPLICANTORFUTUREBUILDINGOCCUPANTHANDLEAHAZARDOUSMATERIAL7)-!:;) J _
OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN >_
❑ 1, as owner of the property, am exclusively contracting with THE AMOUNTS SPEfJFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FI 4 1 1TL'M''1
licensed contractors to construct the project (Section 7044, ,� �P
YES❑ NO TOTAL 43_� o d' 5
Business and Professions Code.)
WILL THE INTENDED USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING
OCCUPANT REQUIREA PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THESOUTH CHECK 43.75 C
CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST
FOR GUIDELINES. {, y er-
I hereby affirm that there is a construction lending agency for YES 1:1NO,n `.HAA r- 'G`
the performance of the Work for which this permit Is Issued(Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD
3097,Civ.C.). PERMITTING CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELESCOUNTY (1 _ 1'�j j ■
CTIONS 2.20.100THROUGH 2.20.140 CONCERNING
Lender's Name R(apC SD TLE LS REP K Q AND FOR OBTAINING A PERMIT FROM THE SCAOMD. 0000-0100+ 7/12 90
Lender's Address �J "W °'G" V 76 1 AM 110 0111
OWNERORAGOff
°0 1 certify that I have read this application and state that the above P.C.FEE PERMIT FEE
g Information is correct. I agree to comply with all county
bN ordinances and State laws relating to building construction,and j
hereby authorize representatives of this County to enter upon ISSUANCE FEE
the above-mentioned property for Inspection purposes. 0
a INVESTIGATION FEE
ro TOTAL FEE
sqMmanppom,naApom Dorn
e+�
SEE REVERSE FOR EXPLANATORY LANGUAGE
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 BUILDING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ALTERATION/REPAIR
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 BL 0508 0807210001
PHONE: (626) 285-0488 EXT:
ILEGAL ID: I NO. OF CONST BUILDING ADDRESS: [
ITR: 6561 IT: 49 I SQ. FT STORIES TYPE 1 9917 WOODRUFF AV 1
(STRUCTURE: 1000 V-B I TEMP CA 917801730 I
(ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET: AGNES
15385 -028-012 1 1 THOMAS PAGE: 597 GRID: A2 LOCALITY: TEMPLE CITY, Cl
(TENANT: IEXIST BLDG USE: RESID USE ZONE: R-2 JISSUED ON: PROCESSED BY: EXPIRES ON: [
(EXIST OCC GRP: 107/21/08 SR 01/17/09 1
(OWNER: TEL. NO: IBLDGS. NOW ON LOT: VALUATION: IFINAL DATE FINAL BY: CODE: I
ICHAN, MARK (626) 287-0812- 1 4,000
19917 WOODRUFF AV I I
ITEMP 917801730 1 FEES PAID IDEBCRIION OF WORK 1
I I ITEAR OFF AND REROOF REPLACE PLYWOOD WITH 30 YEAR COMPOSITIONI
IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT:ISHINGLES 1
(APPLICANT: TEL. NO: I I I
ISAME AS OWNER - 1AA BLDG PERMIT ISSUANCE 27.75 1 I
1 AC STRONG MOTION RESID 4000.00 VAL 0.50 ISPECIAL CONDITIONS: I
1 1D2 PERMIT W/O EN-HC 4000.00 VAL 115.80 1 I
TOTAL FEES 144.05 1
(CONTRACTOR: TEL. NO: I 1APPROVALS DATE INSPECTOR SIGNATURE 1
ISAME AS OWNER - I I I
I LIC. NO I ILOCATION AND SETBACKS
I I I
I 1 ISOILS ENGINEER APPROVAL I I I
(ARCHITECT OR ENGINEER: TEL. NO: I [FOUNDATION/TRENCH FORMS I I I
1 LIC. NO: I ISLAB/UNDER FLOOR I I I
I 1RAISED FLOOR FRAMING 1
I I I I I
IMAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP:I JUNDERFLOOR INSULATION I I I
115OH269 3 Oil 1 1-1
I I IFLOOR SHEATHING I I I
INO. OF FAMILIES: DWELLING UNITS: APT/COND: STAT CLASS: I I I I I
NO 21 1 [ROOF SHEATHING I I
1 SCHOOL WITHIN HAZARDOUS I ISHEP.R PANELS
(AIR QUALITY: 1000 FEET MATERIALS I I I I I
NO NO NO I IFRAD')E INSPECTION I I I
IREQUIRED TOTAL SETBACK FROM EXIST 1FIRE SPRINKLER HANGERS I
ISET BACK YARD: HWY: PROP LINE: WIDTH: I I I I
IFRONT PL- I INSULATION/WEATHER STRIPI
I SIDE PL- I I I I
I I (INTERIOR LATH/DRYWALL
I I I
IEXTERIOR LATH I I I
I I IRATED FLOOR/CEIL ASSEM. [ [ [
I 1RATED WALL ASSEMBLIES [ [
1 1RATED SHAFTS/OPENINGS I I 1
[ [ IT-BAR CEILINGS I I [
I I
ILOT•DRAINAGE [ 1
IREPORT ID: DPR261 ROUTE TO: BS0508 I [ I I
I I I I I I