HomeMy Public PortalAbout9336 BROADWAY_Building_5/12/2014_b
COUNTY OF IAS'ANGELES'
DEPARTMENT OF PUBLIC WORKS
BUILDING AND SAFETY / LAND DEVELOPMENT
LEGAL ID:
ON FILE
ASSESSOR INFORMATION NUMBER:
8588-030-042
TENANT
OWNER:
MOUNT VERNON HOLDINGS, LLC
2831 ROSE PKNY 8290
HENDERSON NV 89052
APPLICANT:
PERAZA, ERIK
3317 MENTONE AVE
LOS ANGELES CA 90034
CONTRACTOR:
DIVERSFIELD BUILDING CONTRACTORS
2416 FIFTH STREET
LA VERNE CA 91750
ARCHITECT OR ENGINEER:
TEL. NO:
(909) 702 -6858 -
TEL. NO:
(310) 923 -5393 -
TEL. NO:
(909) 261 -0148 -
LIC. NO
760941
TEL. NO:
LIC. NO:
MAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP:
3 00
NO. OF FAMILIES: DWELLING UNITS: APT/CONDI STAT CLASS:
NO 21
SCHOOL WITHIN HAZARDOUS
AIR QUALITY: 1000 FEET MATERIALS
NO NO NO
TEMPLE CITY # 0508
9701 LAS TUNAS
TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
NO. OF CONST
SQ. FT STORIES TYPE
STRUCTURE: V -B
EXIST BLDG USE: REBID
EXIST OCC GRP:
�SLDGS. NOW ON LOT:
USE ZONE: R-1
VALUATION:
25,000
FEES PAID
FEE DESCRIPTION: QUANTITY: UOM
B1
PLANCHECK W/ENERGY
25000.00
VAL
AA
BLDG PERMIT ISSUANCE
AB
STATE GREEN BLDG FEE
25000.00
VAL
AC
STRONG MOTION REBID
25000.00
VAL
B2
PERMIT W/ENERGY
25000.00
VAL
FR
INV WORK W/O PERMIT
688.00
DOL
TOTAL FEES
REPORT ID: DPR261 ROUTE TO: B50508
AMOUNT
438.10
27.80
1.00
2.50
515.50
688.00
1,672.90
BUILDING PERMIT
ALTERATION/REPAIR
BE 0508 1403190079
BUILDING ADDRESS:
9336 BROADWAY
TEMP CA 917802403
NEAREST CROSS STREET:
THOMAS PAGE: 596 GRID: J4 LOCALITY: TEMPLE CITY
ISSUED ON: PROCESSED BY:
05/12/14 SR
FI AL DATE FINAL Bj.A CODE:
l; I�N�� WORK
KITCHEN AND 3 BATHROOMS REHAB
SPECIAL CONDITIONS:
9PPROVALS
LOCATION AND SETBACKS
FOUNDATION/TRENCH FORMS
BLAB/UNDER FLOOR
3AISED FLOOR FRAMING
INDERFLOOR INSULATION
FLOOR SHEATHING
200F SHEATHING
SHEAR PANELS
FRAME INSPECTION
?IRE SPRINKLER HANGERS
INSULATION/WEATHER STRIP
INTERIOR LATH/DRYWALL
,XTERIOR LATH
RATED WALL ASSEMBLIES
RATED SHAFTS/OPENINGS
T -BAR CEILINGS
LOT DRAINAGE
J
DATE INSPECTOR SIGNATURE
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from
the Contractors' State License Law for the reason(s) indicated
below by the checkmark(s) I have placed next to the applicable
item(s) (Section 7031.5, Business and Professions Code): Any
city or county that requires a permit to construct, alter, improve,
demolish, or repair any structure, prior to its issuance, also
requires the applicant for the permit to file a signed statement
that he or she is licensed pursuant to the provisions of the
Contractors' State License Law (Chapter 9 (commencing with
Section 7000) of Division 3 of the Business and Professions
Code) or that he or she is exempt from licensure and the basis
for the alleged exemption. Any violation of Section 7031.5 by
any applicant for a permit subjects the applicant to a civil
penalty of not more than five hundred dollars ($500).):
U I, as owner of the property, or my employees with wages as
their sole compensation, will do (✓) all of or (_) portions of the
work, and the structure is not intended or offered for sale
(Section 7044, Business and Professions Code: The
Contractors' State License Law does not apply to an owner of
property who, through employees' or personal effort, builds or
improves the property, provided that the improvements are not
intended or offered for sale. If, however, the building or
improvement is sold within one year of completion, the Owner -
Builder will have the burden of proving that it was not built or
improved for the purpose of sale.).
(_) I, as owner of the property, am exclusively contracting with
licensed Contractors to construct the project (Section 7044,
Business and Professions Code: The Contractors' State License
Law does not apply to an owner of property who builds or
improves thereon, and who contracts for the projects with a
licensed Contr6for pursuant .to the Contractors' State License
Law).
(_) I am exemdt from licensure under the Contractors' State
License Law for the following reason:
By my signature below I acknowledge that, except for my
personal residence in which I must have resided for at least
one year prior) to completior1 of the improvements covered by
this permit, I cannot legally sell a structure that I have built as an
owner -builder If it has not been constructed in its entirety by
licensed contractors. I understand that a copy of the applicable
law, Section 7044 of'the Business and Professions Code, is
available upon request when this application is submitted or at
the following Web site: httD://www.leainfo.ca.cov/calaw.html.
Date:
Signature of Property Owner or Authorized Agent
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm under penalty of perjury that I am licensed under
provisions of Chapter 9 (commencing with Section 7000) of
Division 3 of the Business and Professions Code, and my
license is in full force and effect.
--//qticense Class License No. /(.t7�%��
Date*_/_1
_ / Contractor Signature
WORKERS' COMPENSAT O EC ON
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION
COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN
EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO
ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION
TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED
FORIN SECTION 3706 OF THE LABOR CODE, INTEREST, AND
ATTORNEY'S FEES.
I hereby affirm under penalty of perjury one of the following
declarations:
I have and will maintain a certificate of consent to self -
insure for workers' compensation, issued by the Director of
Industrial Relations as provided for by Section 3700 of the
Labor Code, for the performance of the work for which this permit
is issued.
Policy No.
I have and will maintain workers' compensation
insurance, as required by Section 3700 of the Labor Code, for
the performance of the work for which this permit is issued. My
workers' compensation insurance carrier and policy number are:
Carrier Policy Number Expiration Date
Name of Agent Phone Number
I certify that, in the performance of the work for which this
permit is issued, I shall not employ any person in any manner
so as to become subject to the workers' compensation laws of
California, and agree that, if I should become subject to the
workers' compensat! visions of Section 3700 of the Labor
Code shall forth com ly with those provisions
a r of t Dati�
LOBBYIST ORDINANCE CERTIFICATION
Complete this section for permits in
Unincorporated Los Angeles County only
This is to certify that I, as permit applicant, am familiar with the
requirements of Los Angeles County Code Chapter 2.160 at seq.,
(relating to the Los Angeles County Lobbyist Ordinance) and that
all persons acting on behalf of myself complied and will continue
to comply therewith through the application process.
Applicant (Print Name) Applicant Signature
Company Name Date
JOB ADDRESS
LOCALITY
HAZARDOUS MATERIAL DECLARATION
Will the applicant or future building occupant handle a hazardous
material or a mixture containing a hazardous material equal to or
greater than the amount specified on the hazardous materials
information guide?
Yes ❑ No ❑
Will the intended use of the building by the applicant or future
building occupant require a permit for construction or
modification from the South Coast Air Quality Management
District (SCAQMD)? See permitting checklist for guidelines.
Yes ❑ No ❑ /
I have read the hazardous materials information guide and the
SCAQMD permitting checklist, I understand my requirements
under the Los Angeles County Code Title 2, Chapter X220'
Sections 220.100 through 220.140 concerning hazardous
material reporting and for obtaining a permit from the SCAOMD.
ASBESTOS NOTIFICATION
❑ Notification letter sent to AQMD and/or EPA
❑ I declare that notification of asbestos removal is not
applicable to addressed project.
DECLARATION REGARDING CONSTRUCTION LENDING
AGENCY
I hereby affirm under penalty of perjury that there is a
Construction lending agency forthe performance of the work for
which this permit is issued (Section 3097, Civil Code).
Lender's Name
Lenders Address
By my signature below, I certify to each of the following:
I am the property owner or authorized to act on the
property owner's behalf.
I have read this application and the information I have
provided is correct.
I agree to comply with all applicable city and county
ordinances and state laws relating to building
construction.
I authorize representatives of this county to enter the
above -identified pe for inspection purposes.
Signature�gfr�re�rty O err or Authorized Agent
t
COUNTY OF LOS ANGELES
TEMPLE CITY N 0508
BUILDING PERMIT
DEPARTMENT OF
PUBLIC WORKS
9701 LAS TUNAS
ALTERATION/REPAIR
BUILDING AND SAFETY
/ LAND DEVELOPMENT
TEMPLE CITY CA 91780
BE 0508 1403190080
PHONE: (626) 285-0488 EXT:
DUPLICATE
LEGAL ID:
NO. OF CONST
1 BUILDING ADDRESS:
ON FILE
1 SQ. FT STORIES TYPE
1 9336 BROADWAY
STRUCTURE: V -B
TEMP CA 917802403
ASSESSOR INFORMATION NUMBER:
NEAREST CROSS STREET:
8588-030-042
THOMAS PAGE: 596 GRID: J4 LOCALITY: TEMPLE CITY Ci
TENANT:
(EXIST BLDG USE: REBID USE ZONE: R-1
(ISSUED ON: PROCESSED BY:
(EXIST OCC GRP:
105/12/14 SR
OWNER:
TEL. NO:
I
JBLDGS. NOW ON LOT: VALUATION:
i
FIa DATE FIN3�L BY: CODE:
MOUNT VERNON HOLDINGS, LLC
(909) 702-6858-
1 6,000
1_LJ
2831 ROSE PKWY #290
1
1
HENDERSON NV 89052
J FEES PAID
DESORIPTION O WORK
(REMODEL RUMPUS ROOM
IEEE DESCRIPTION: QUANTITY: DOM: AMOUNT:)
APPLICANT:
TEL. NO:
I
I
O-LAUGHLIN, BRIAN
(909) 702-6853-
IAA BLDG PERMIT ISSUANCE 27.80
1
P 0 BOX 487
JAB STATE GREEN BLDG FEE 6000.00 VAL 1,00
1SPECIAL CONDITIONS:
LA VERNE CA 91750
JAC STRONG MOTION REBID 6000.00 VAL 0.60
J
1B2 PERMIT W/ENERGY 6000.00 VAL 164.30
1
TOTAL FEES 193.70
CONTRACTOR:
TEL. NO:
JAPPROVALS DATE INSPECTOR SIGNATURE
DIVERSIFIED BUILDING CONTRACTORS
(909) 261-0148-
1
2416 FIFTH STREET
LIC. NO
1
1LOCATION AND SETBACKS 1 1
LA VERNE CA 91750
760941
(SOILS ENGINEER APPROVAL
ARCHITECT OR ENGINEER:
TEL. NO:
1
FOUNDATION/TRENCH FORMS 1
LIC. NO:
SLAB/UNDER FLOOR
IRAISED FLOOR FRAMING
MAP NO: SEWER MAP HOOK: PAGE:
FIRE ZONE: CMP:J
I
JUNDERFLOOR INSULATION
3 001
FLOOR SHEATHING
NO. OF FAMILIES: DWELLING UNITS:
APT/COND: STAT CLASS:
1
NO 21
IROOF SHEATHING
SCHOOL WITHIN HAZARDOUS
1
SHEAR PANELS
AIR QUALITY: 1000 FEET
MATERIALS
1 1
NO NO
NO
(FRAME INSPECTION
FIRE SPRINKLER HANGERS
INSULATION/WEATHER STRI
INTERIOR LATH/DRYWALL
EXTERIOR LATH
RATED FLOOR/CEIL ASSEM.
RATED SHAFTS/OPENINGS
T -BAR CEILINGS
IAT DRAINAGE
ID: DPR261 ROUTE TO: HS0508
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from
the Contractors' State License Law for the reason(s) indicated
below by the checkmark(s) I have placed next to the applicable
item(s) (Section 7031.5, Business and Professions Code): Any
city or county that requires a permit to construct, alter, improve,
demolish, or repair any structure, prior to its issuance, also
requires the applicant for the permit to file a signed statement
that he or she is licensed pursuant to the provisions of the
Contractors' State License Law (Chapter 9 (commencing with
Section 7000) of Division 3 of the Business and Professions
Code) or that he or she is exempt from licensure and the basis
for the alleged exemption. Any violation of Section 7031.5 by
any applicant for a permit subjects the applicant to a civil
penalty of not more than five hundred dollars ($500).):
U I, as owner of the property, or my employees with wages as
their sole compensation, will do (,/) all of or (_) portions of the
work, and the structure is not intended or offered for sale
(Section 7044, Business and Professions Code: The
Contractors' State License Law does not apply to an owner of
property who, through employees' or personal effort, builds or
improves the property, provided that the improvements are not
intended or offered for sale. If, however, the building or
improvement is sold within one year of completion, the Owner -
Builder will have the burden of proving that it was not built or
improved for the purpose of sale.).
U I, as owner of the property, am exclusively contracting with
licensed Contractors to construct the project (Section 7044,
Business and Professions Code: The Contractors' State License
Law does not apply to an owner of property who builds or
improves thereon, and who contracts for the projects with a
licensed Contractor pursuant to the Contractors' State License
Law).
(_) I am exempt from licensure under the Contractors' State
License Law for the following reason:
By my signature below I acknowledge that, except for my
personal residence in which I must have resided for at least
one year prior) to completion�I of the improvements covered by
this permit, I c nnot legally sell a structure that I have built as an
owner -builder if it has not been constructed in its entirety by
licensed contractors. I understand that a copy of the applicable
law, Section 7044 of the Business and Professions Code, is
available upon request when this application is submitted or at
the following Web site: hftD://www.leainfo.ca.aov/calaw.htmi.
Date:
Signature of Property Owner or Authorized Agent
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm under penalty of perjury that I am licensed under
provisions of Chapter 9 (commencing with Section 7000) of
Division 3 of the Business and Professions Code, and my
license is in full force and effect.
License Class License No.
Date Contractor Signature
WORKERS' COMPENSATION DECLARATION
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION
COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN
EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO
ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION
TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED
FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND
ATTORNEY'S FEES.
I hereby affirm under penalty of perjury one of the following
declarations:
I have and will maintain a certificate of consent to self -
insure for workers' compensation, issued by the Director of
Industrial Relations as provided for by Section 3700 of the
Labor Code, for the performance of the work for which this permit
is issued.
Policy No.
I have and will maintain workers' compensation
insurance, as required by Section 3700 of the Labor Code, for
the performance of the work for which this permit is issued. My
workers' compensation insurance carrier and policy number are:
Carrier Policy Number Expiration Date
Name of Agent Phone Number
_ I certify that, in the performance of the work for which this
permit is issued, I shall not employ any person in any manner
so as to become subject to the workers' compensation laws of
California, and agree that, if I should become subject to the
workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions
Signature of Applicant Date
LOBBYIST ORDINANCE CERTIFICATION
Complete this section for permits in
Unincorporated Los Angeles County only
This is to certify that I, as permit applicant, am familiar with the
requirements of Los Angeles County Code Chapter 2.160 et seq.,
(relating to the Los Angeles County Lobbyist Ordinance) and that
all persons acting on behalf of myself complied and will continue
to comply therewith through the application process.
Applicant (Print Name) Applicant Signature
Company Name Date
JOB ADDRESS
LOCALITY
HAZARDOUS MATERIAL DECLARATION
Will the applicant or future building occupant handle a hazardous
material or a mixture containing a hazardous material equal to or
greater than the amount specified on the hazardous materials
information guide?
Yes ❑ No ❑
Will the intended use of the building by the applicant or future
building occupant require a permit for construction or
modification from the South Coast Air Quality Management
District (SCAQMD)? See permitting checklist for guidelines.
Yes ❑ N.o ❑
I have read the hazardous materials information guide and the
SCAQMD permitting checklist, I understand my requirements
under the Los Angeles County Code Title 2, Chapter X20'
Sections 220.100 through 220.140 concerning hazardous
material reporting and for obtaining a permit from the SCAQMD.
ASBESTOS NOTIFICATION
❑ Notification letter sent to AQMD and/or EPA
❑ I declare that notification of asbestos removal is not
applicable to addressed project.
DECLARATION REGARDING CONSTRUCTION LENDING
AGENCY
I hereby affirm under penalty of perjury that there is a
Construction lending agency for the performance of the work for
which this permit is issued (Section 3097, Civil Code).
Lender's Name
Lender's Address
By my signature below, I certify to -each of the following:
I am the property owner or authorized to act on the
property owner's behalf.
I have read this application and the information I have
provided is correct.
I agree to comply with all applicable city and county
ordinances and state laws relating to building
construction.
I authorize representatives of this county to enter the
above -identified property for inspection purposes.
Signature of Property Owner or Authorized Agent
Date
%l_OUNTY 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 91700
BL 0508 1405210067
PHONE: (626) 285-0488 EXT:
LEGAL ID:
NO.
OF CONST
BUILDING ADDRESS:
ON FILE
I SQ. FT STORIES TYPE
9336 BROADWAY
(STRUCTURE:
V-B
TEMP CA 917802403
ASSESSOR INFORMATION NUMBER:
I NEAREST CROSS STREET:
8588-030-042
I
I THOMAS PAGE: 596 GRID: J4 LOCALITY: TEMPLE CITY
TENANT:
(EXIST BLDG USE: REBID
USE ZONE: R-1
(ISSUED ON: PROCESSED BY:
]EXIST OCC GRP:
105/21/14 SR
OWNER:
TEL. N0:
I
18LDG5. NOW ON IAT:
VALUATION:
ON:
I
F DATE FI CODE:
;Ekg
MOUNT VERNON HOLDINGS, LLC
(909) 702-6858-
��
2831 ROSE PKWY #290
I�Jid I V'
HENDERSON NV 89052
FEES PAID
-
IDASCRIPTION OF WORK
ICO NVERT EXISTING CLOSET TO BATHROOM
IFEE DESCRIPTION:
QUANTITY: DOM:
AMOUNT:(
APPLICANT:
TEL. NO:
I
I
O'LAUGHLIN, BRIAN
(90.9) 702-6853-
IAA BLDG PERMIT ISSUANCE
27.80
I
PO BOX 487
IAB STATE GREEN BLDG FEE
1500.00 VAL
1.00
ISPECIAL CONDITIONS:
LA VERNE CA 91750
IAC STRONG MOTION REBID
1500.00 VAL
0.50
1
IB1 PLANCHECK W/ENERGY
1500.00 VAL
90.30
IB2 PERMIT W/ENERGY
1500.00 VAL
90.40
(nr�'4ic (bmjpvf4
CONTRACTOR:
TEL. NO:
1
TOTAL FEES
210.00
IAPPWALS - INSPECTOR
DIVERSIFIED BUILDING CONTRACTORS
(909) 261-0148-
I
gdNATURE
v
2416 FIFTH STREET
LIC. NO
_
(LOCATION AND SETBACKS
LA VERNE CA 91750
760941
ISOILS ENGINEER APPROVAL
ARCHITECT OR ENGINEER:
TEL. NO:
1
IFOUNDATION/TRENCH FORMS I I
LIC. NO:
1SLAB/UNDER FLOOR I
RAISED FLOOR FRAMING 1
MAP NO: SEWER MAP BOOK: PAGE:
FIRE ZONE: CMP:(.
1
(UNDERFLOOR INSULATION 1 1
3 OOI
IFLOOR SHEATHING
NO. OF FAMILIES: DWELLING UNITS: APT/COND: STAT CLASS:
I
I
NO 21
1
IROOF SHEATHING I
SCHOOL WITHIN
HAZARDOUS
(SHEAR PANELS
AIR QUALITY: 1000 FEET
MATERIALS
NO NO
NO
i
(FRAME INSPECTION
FIRE SPRINKLER HANGERS
(INSULATION/WEATHER STRIP,
1
11NTEAIOR LATH/DRYWALL
I
iEXTERIOR LATH L
I
(RATED FLOOR/CEIL ASSEM.
]RATED WALL ASSEMBLIES
I
I
1RATED SHAFTS/OPENINGS
1
T-BAR CEILINGS
LOT DRAINAGE
(REPORT ID: DPR261
I
ROUTE TO: BS0508
i I I
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from
the Contractors' State License Law for the reason(s) indicated
below by the checkmark(s) i have placed next to the applicable
item(s) (Section 7031.5, Business and Professions Code): Any
city or county that requires a permit to construct, alter, Improve,
demolish, or repair any structure, prior to its issuance, also
requires the applicant for the permit to file a signed statement
that he or she is licensed pursuant to the provisions of the
Contractors' State License Law (Chapter 9 (commencing with
Section 7000) of Division 3 of the Business and Professions
Code) or that he or she is exempt from licensure and the basis
for the alleged exemption. Any violation of Section 7031.5 by
any applicant for a permit subjects the applicant to a civil
penalty of not more than five hundred dollars ($500).):
U I, as owner of the property, or my employees with wages as
their sole compensation, will do (✓) all of or (_) portions of the
work, and the structure is not intended or offered for sale
(Section 7044, Business and Professions Code: The
Contractors' State License Law does not apply to an owner of
property who, through employees' or personal effort, builds or
improves the property, provided that the improvements are not
intended or offered for sale. If, however, the building or
improvement is sold within one year of completion, the Owner -
Builder will have the burden of proving that it was not built or
improved for the purpose of sale.).
U I, as owner of the property, am exclusively contracting with
licensed Contractors to construct the project (Section 7044,
Business and Professions Code: The Contractors' State License
Law does not apply to an owner of property who builds or
improves thereon, and who contracts for the projects with a
licensed ContraFtor pursuant.to the Contractors' State License
Law).
( 1 I am exemdt from licensure under the Contractors' State
License Law for the following reason:
By my signature below I acknowledge that, except for my
personal residence in whict I must have resided for at least
one year priorlto completion. of the improvements covered by
this permit, I cannot legally sell a structure that I have built as an
owner -builder If it has not been constructed in its entirety by
licensed contractors. i understand that a copy of the applicable
law, Section 7044 of'the Business and Professions Code, is
available upon request when this application is submitted or at
the following Web site: httD://www.leainfo.ca:aov/calaw.html.
Date:
Signature of Property Owner or Authorized Agent
LICENSED CONTRACTOR'S DECLARATION I JOB ADDRESS
I hereby affirm under penalty of perjury that 1 am licensed under I LOCALITY
provisions of Chapter 9 (commencing with Section 7000) of
Division 3 of the Business and Professions Code, and my
license is in full force and effect. HAZARDOUS MATERIAL DECLARATION
License Classes License No. %(oAQI Will the applicant or future building occupant handle a hazardous
material or a mixture containing a hazardous material equal to or
Date 2f r Contractor Signature than the amount specified on the hazardous materials
information guide?
WORKERS'COMPENS D ION Yes ❑ No ❑
WAAM. NG: FAILURE TO SECU WORKERS' COMPENSATION Will the intended use of the building by the applicant or future
COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN building occupant require a permit for construction or
EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO modification from the South Coast Air Quality Management
ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION District (SCAQMD)? See permitting checklist for guidelines.
TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED
FORIN SECTION 3706 OF THE LABOR CODE, INTEREST, AND
ATTORNEY'S FEES.
I hereby affirm under penalty of perjury one of the following
declarations:
I have and will maintain a certificate of consent to self -
insure for workers' compensation, issued by the Director of
Industrial Relations as provided for by Section 3700 of the
Labor Code, for the performance of the work for which this permit
is issued.
Policy No.
I have and will maintain workers' compensation
insurance, as required by Section 3700 of the Labor Code, for
the performance of the work for which this permit is issued. My
workers' compensation insurance carrier and policy number are:
Carrier Policy Number Expiration Date
Name of Agent Phone Number
I certify that, in the performance of the work for which this
it is issued, I shall not employ any person in any manner
so as to become subject to e -w ers' compensation laws of
California, and agree if I shou d become subject to the
workers' compensation pr isions of Section 3700 of the Labor
Code hall forth ccmply it those provisions
_7
ZSigture p/ Date '
LOBBYIST ORDINANCE CERTIFICATION
Complete this section for permits in
Unincorporated Los Angeles County only
This is to certify that I, as permit applicant, am familiar with the
requirements of Los Angeles County Code Chapter 2.160 at seq.,
(relating to the Los Angeles County Lobbyist Ordinance) and that
all persons acting on behalf of myself complied and will continue
to comply therewith through the application process.
Applicant (Print Name) Applicant Signature
Company Name Date
Yes ❑ N o ❑ r
I have read the hazardous materials information guide and the
SCAQMD permitting checklist, I understand my requirements
under the Los Angeles County Code Title 2, Chapter 220'
Sections 220.100 through 220.140 concerning hazardous
material reporting and for obtaining a permit from the SCAQMD.
ASBESTOS NOTIFICATION
❑ Notification letter sent to AQMD and/or EPA
❑ I declare that notification of asbestos removal is not
applicable to addressed project.
DECLARATION REGARDING CONSTRUCTION LENDING
AGENCY
I hereby affirm under penalty of perjury that there is a
Construction lending agency for the performance of the work for
which this permit is issued (Section 3097, Civil Code).
Lender's Name
Lender's Address
By my signature below, I certify to'each of the following:
I am the property owner or authorized to act on the
property owners behalf.
I have read this application and the information I have
provided is correct.
I agree to comply with all applicable city and county
ordinances and state laws relating to building
construction.
I authorize represen tives of this county to enter the
pro
idefner
tgfoperty fo'inspectionAeerposes.
Sgnatu
COUNTY OF LOS ANGELES
DEPARTMENT OF PUBLIC WORKS
BUILDING AND SAFETY / LAND DEVELOPMENT
LEGAL ID:
ON FILE
ASSESSOR INFORMATION NUMBER -
8588 -030-042
RUNT VERNON HOLDINGS, LLC
831 ROSE PKWY #290
ENOERSON NV 89052
TZ, JUAN
6 FIFTH STREET
VERNE CA 91750
ERSIFIED BUILDING CONTRACTORS
6 FIFTH STREET
VERNE CA 91750
ARCHITECT OR ENGINEER:
TEL. NO:
(909) 702 -6858 -
TEL. NO:
(909) 201 -0148 -
TEL. NO:
(909) 261 -0148 -
LIC. NO
760941
TEL. NO:
LIC. NO:
TEMPLE CITY # 0508
9701 LAS TUNAS
TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
NO. OF CONST
SQ. FT STORIES TYPE
STRUCTURE: V -B
HXIST BLDG USE: RESID USE ZONE: R-1
EXIST OCC GRP:
BLDGS. NOW ON LOT: VALUATION:
1 15,000
MAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP:1
3 001
NO. OF FAMILIES: DWELLING UNITS: APT/COND: STAT CLASS: 1
NO 21
SCHOOL WITHIN HAZARDOUS
AIR QUALITY: 1000 FEET MATERIALS
NO NO NO
FEES PAID
FEE DESCRIPTION: QUANTITY: DOM: AMOUNT
AA BLDG PERMIT ISSUANCE
27.80
AB STATE GREEN BLDG FEE
15000.00
VAL
1.00
AC STRONG MOTION RESID
15000.00
VAL
1.50
B1 PLANCHECK W/ENERGY
15000.00
VAL
281.10
B2 PERMIT W/ENERGY
15000.00
VAL
330.70
TOTAL FEES
642.10
ID: DPR261 ROUTE TO: BS0508
BUILDING PERMIT
ALTERATION/REPAIR
BL 0508 1408250086
DUPLICATE
BUILDING ADDRESS:
9336 BROADWAY
TEMP CA 917802403
NEAREST CROSS STREET:
THOMAS PAGE: 596 GRID: S4 LOCALITY: TEMPLE CITY
ISSUED ON: PROCESSED BY:
08/25/14 SR
F DAT�E.}`r FINAJ. Fes': CODE:
G-IPT IONWORKX\
-/➢_nIL\`r/'
REMODEL MASTER BEDROOM AND UNDRY ROOM
CONDITIONS:
APPROVALS DATE
LOCATION AND SETBACKS li
SOILS ENGINEER APPROVAL
FOUNDATION/TRENCH FORMS
SLAB/UNDER FLOOR
RAISED FLOOR FRAMING
UNDERFLOOR INSULATION
FLOOR SHEATHING
ROOF SHEATHING
SHEAR PANELS
FRAME INSPECTION
FIRE SPRINKLER HANGERS
INSULATION/WEATHER STRIP
INTERIOR LATH/DRYWALL
EXTERIOR LATH
RATED FLOOR/CEIL ASSEM. 1
RATED WALL ASSEMBLIES
RATED SHAFTS/OPENINGS
T -BAR CEILINGS
LOT DRAINAGE
I I
INSPECTOR SIGNATURE
OWNER -BUILDER DECLARATION LICENSED CONTRACTOR'S DECLARATION I JOB ADDRESS
I hereby affirm under penalty of perjury that I am exempt from
the Contractors' State License Law for the reason(s) indicated
below by the checkmark(s) I have placed next to the applicable
item(s) (Section 7031.5, Business and Professions Code): Any
city or county that requires a permit to construct, alter, improve,
demolish, or repair any structure, prior to its issuance, also
requires the applicant for the permit to file a signed statement
that he or she is licensed pursuant to the provisions of the
Contractors' State License Law (Chapter 9 (commencing with
Section 7000) of Division 3 of the Business and Professions
Code) or that he or she is exempt from licensure and the basis
for the alleged exemption. Any violation of Section 7031.5 by
any applicant for a permit subjects the applicant to a civil
penalty of not more than five hundred dollars ($500).):
U I, as owner of the property, or my employees with wages as
their sole compensation, will do (,/) all of or (_) portions of the
work, and the structure is not intendedor offered for sale
(Section 7044, Business and Professions Code: The
Contractors' State License Law does not apply to an owner of
property who, through employees' or personal effort, builds or
improves the property, provided that the improvements are not
intended or offered for sale. If, however, the building or
improvement is sold within one year of completion, the Owner -
Builder will have the burden of proving that it was not built or
improved for the purpose of sale.).
U I, as owner of the property, am exclusively contracting with
licensed Contractors to construct the project (Section 7044,
Business and Professions Code: The Contractors' State License
Law does not apply to an owner of property who builds or
improves thereon, and who contracts forthe projects with a
licensed Contractor pursuant.to the Contractors' State License
Law). '
U I am exempt from licensure under the Contractors' State
License Law for the following reason:
By my signature below I acknowledge that, except for my
personal residence in whicf I must have resided for at least
one year priorlto completioq of the improvements covered by
this permit, I cannot legally sell a structure that I have built as an
owner -builder if it has not been constructed in its entirety by
licensed contractors. I understand that a copy of the applicable
law, Section 7044 of'the Business and Professions Code, is
available upon request when this application is submitted or at
the following Web site: httD://www.leeinfo.ca.cov/calaw.html.
Date:
Signature of Property Owner or Authorized Agent
I hereby affirm under penalty of perjury that I am licensed under
provisions of Chapter 9 (commencing with Section 7000) of
Division 3 of the Business and Professions Code, and my
license is in full force and effect.
fLicense Class License No. ✓ /
`Date�L /J
Contractor Signature
i
WORKERS'COMPENSAFTION DECLARATION
WARtJING: FAILURE TO SECURE WORKERS' COMPENSATION
COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN
EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO
ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION
TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED
FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND
ATTORNEY'S FEES.
I hereby affirm under penalty of perjury one of the following
declarations:
I have and will maintain a certificate of consent to self -
insure for workers' compensation, issued by the Director of
Industrial Relations as provided for by Section 3700 of the
Labor Code, for the performance of the work for which this permit
is issued.
Policy No.
I have and will maintain workers' compensation
insurance, as required by Section 3700 of the Labor Code, for
the performance of the work for which this permit is issued. My
workers' compensation insurance carrier and policy number are:
Carrier Policy Number Expiration Date
Name of Agent Phone Number
I certify that, in the performance of the work for which this
permit is issued, I shall not employ any person in any manner
so as to become subject to the workers' compensation laws of
California, and agree that, if I should become subject to the
workers' compensation provisions of Section 3700 of the Labor
Code, I s II forthwith with those provisions
gre Applicant Date
LOBBYIST ORDINANCE CERTIFICATION
Complete this section for permits in
Unincorporated Los Angeles County only
This is to certify that I, as permit applicant, am familiar with the
requirements of Los Angeles County Code Chapter 2.160 at seq.,
(relating to the Los Angeles County Lobbyist Ordinance) and that
all persons acting on behalf of myself complied and will continue
to comply therewith through the application process.
Applicant (Print Name) Applicant Signature
Company Name Date
LOCALITY
HAZARDOUS MATERIAL DECLARATION
Will the applicant or future building occupant handle a hazardous
material or a mixture containing a hazardous material equal to or
greater than the amount specified on the hazardous materials
information guide?
Yes ❑ No ❑
Will the intended use of the building by the applicant or future
building occupant require a permit for construction or
modification from the South Coast Air Quality Management
District (SCAQMD)? See permitting checklist for guidelines.
Yes ❑ N o ❑
I have read the hazardous materials information guide and the
SCAQMD permitting checklist, I understand my requirements
under the Los Angeles County Code Title 2, Chapter 220'
Sections 220.100 through 220.140 concerning hazardous
material reporting and for obtaining a permit from the SCAQMD.
ASBESTOS NOTIFICATION
❑ Notification letter sent to AQMD and/or EPA
❑ 1 declare that notification of asbestos removal is not
applicable to addressed project.
DECLARATION REGARDING CONSTRUCTION LENDING
AGENCY
I hereby affirm under penalty of perjury that there is a
Construction lending agency for the performance of the work for
which this permit is issued (Section 3097, Civil Code).
Lender's Name
Lender's Address
By my signature below, I certify to.each of the following:
I am the property owner or authorized to act on the
property owner's behalf.
I have read this application and the information I have
provided is correct.
I agree to comply with all applicable city and county
ordinances and state laws relating to building
construction.
I authorize representatives of this county to enter the
above -identified property for inspection purposes.
Si ature f r r Authorized Agent
- pyx
COUNTY OF LOS AftELES
DEPARTMENT OF PUBLIC WORKS
BUILDING AND SAFETY / LAND DEVELOPMENT
LEGAL ID:
I ON FILE
ASSESSOR INFORMATION NUMBER:
18588-030-042
1
TENANT:
OWNER :
CHIN, YU
9336 BROADWAY
TEMP 917802403
APPLICANT:
(SAME AS OWNER
I
CONTRACTOR:
SAME AS OWNER
JARCHITECT OR ENGINEER:
TEL. NO:
TEMPLE CITY
9701 LAS TUNAS
TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
NO. OF CONST
SQ. FT STORIES TYPE
STRUCTURE: V -B
EXIST BLDG USE: RESID
EXIST OCC GRP:
BLDGS. NOW ON LOT:
FEE DESCRIPTION:
TEL. NO:
- JAA BLDG PERMIT ISSUANCE
JAB STATE GREEN BLDG FEE
JAC STRONG MOTION RESID
ID1 PLANCHECK W/O EN -HC
ID2 PERMIT W/O EN -HC
TEL. NO: JFR INV WORK W/O PERMIT
LIC. NO
TEL. NO:
LIC. NO:
MAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP:
3 00
NO. OF FAMILIES: DWELLING UNITS: APT/COND: STAT CLASS:
NO 21
SCHOOL WITHIN HAZARDOUS
AIR QUALITY: 1000 FEET MATERIALS
NO NO NO
PERMIT EXPIRES 180 DAYS IF
1) WORK DOES NOT COMMENCE, OR
2) WORK IS SUSPENDED OR ABANDONED, OR
3) FAILS TO OBTAIN CODE REQUIRED INSPECTION
REPORT ID: DPR261
# 0508 BUILDING PERMIT
ALTERATION/REPAIR
_ BL 0508 1507130057
BUILDING ADDRESS:
USE ZONE: R-1
VALUATION:
2,100
FEES PAID
QUANTITY: UOM: AMOUNT:
1
27.80
2100.00 VAL 1.00
2100.00 VAL 0.50
2100.00 VAL 84.20
2100.00 VAL 99.00
344.00 DOL 344.00
TOTAL FEES 556.50 I
ROUTE TO: BS0508
9336 BROADWAY
TEMP CA 917802403
NEAREST CROSS STREET: ALESSANDRO
THOMAS PAGE: 596 GRID: J4 LOCALITY: TEMPLE CITY CAI
ISSUED ON: PROCESSED BY:
07/13/15 SR
FINAL DAT ( FINAL 8/�� CODE:
D�IIfI�
DESCRIPTYON dF WORK
REPLACE WINDOW AND DRYWALL AT THE SIDE OF THE HOUSE I
SPECIAL CONDITIONS:
>PROVALS DATE
)CATION AND SETBACKS
)ILS ENGINEER APPROVAL
)UNDATION/TRENCH FORMS
,AB/UNDER FLOOR
USED FLOOR FRAMING
IDERFLOOR INSULATION
AOR SHEATHING
0F SHEATHING
TEAR PANELS
AME INSPECTION
RE SPRINKLER HANGERS
SULATION/WEATHER STRIP
TERIOR LATH/DRYWALL
TERIOR LATH
TED FLOOR/CEIL ASSEM.
TED WALL ASSEMBLIES
TED SHAFTS/OPENINGS
BAR CEILINGS
T DRAINAGE I I
INSPECTOR SIGNATURE
0
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from
the Contractors' State License Law for the reason(s) indicated
below by the checkmark(s) I have placed next to the applicable
item(s) (Section 7031.5, Business and Professions Code): Any
City or county that requires a permit to construct, alter, improve,
demolish, or repair any structure, prior to its issuance, also
requires the applicant for the permit to file a signed statement
that he or she is licensed pursuant to the provisions of the
Contractors' State License Law (Chapter 9 (commencing with
Section 7000) of Division 3 of the Business and Professions
Code) or that he or she is exempt from licensure and the basis
for the alleged exemption. Any violation of Section 7031.5 by
any applicant for a permit subjects the applicant to a civil
penalty of not more than five hundred dollars ($500).):
U I, as owner of the property, or my employees with wages as
their sole compensation, will do (✓) all of or (_) portions of the
work, and the structure is not intended or offered for sale
(Section 7044, Business and Professions Code: The
Contractors' State License Law does not apply to an owner of
property who, through employees' or personal effort, builds or
improves the property, provided that the improvements are not
intended or offered for sale. If, however, the building or
improvement is sold within one year of completion, the Owner -
Builder will have the burden of proving that it was not built or
improved for the purpose of sale.).
U I, as owner of the property, am exclusively contracting with
licensed Contractors to construct the project (Section 7044,
Business and Professions Code: The Contractors' State License
Law does not apply to an owner of property who builds or
improves thereon, and who contracts for the projects with a
licensed Contrbctor pursuant.to the Contractors' State License
Law).
(_) I am exemdt from licensure under the Contractors' State
License Law for the following reason:
By my signature below I acknowledge that, except for my
personal residence in which I must have resided for at least
one year priorito completion of the improvements covered by
this permit, I c'nnot legally sell a structure that I have built as an
owner -builder If it has not been constructed in its entirety by
licensed contractors. I understand that a copy of the applicable
law, Section 7044 of the Business and Professions Code, is
available upon request when this application is submitted or at
the following Web site: hfD://www.leainfo.ca.aov/calaw.htmi.
--t-ate:
Signature of Prope Owner or Authorized Agent
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm under penalty of perjury that I am licensed under
provisions of Chapter 9 (commencing with Section 7000) of
Division 3 of the Business and Professions Code, and my
license is in full force and effect.
License Class License No.
Date Contractor Signature
WORKERS' COMPENSATION DECLARATION
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION
COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN
EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO
ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION
TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED
FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND
ATTORNEY'S FEES.
I hereby affirm under penalty of perjury one of the following
declarations:
I have and will maintain a certificate of consent to self -
insure for workers' compensation, issued by the Director of
Industrial Relations as provided for by Section 3700 of the
Labor Code, for the performance of the work for which this permit
is issued.
Policy No.
—I have and will maintain workers' compensation
insurance, as required by Section 3700 of the Labor Code, for
the performance of the work for which this permit is issued. My
workers' compensation insurance carrier and policy number are:
Carrier Policy Number Expiration Date
Name of Agent Phone Number
I certify that, in the performance of the work for which this
permit is issued, I shall not employ any person in any manner
so as to become subject to the workers' compensation laws of
Califomia, and agree that, if I should become subject to the
workers' compensation provisions of Section 3700 of the Labor
Code, I shall fo w h comply with those provis_io_n.,s/J 7
'Signature of pylic t Dat /
LOBBYIST ORDINANCE CERTIFICATION
Complete this section for.permits in
Unincorporated Los Angeles County only
This is to certify that I, as permit applicant, am familiar with the
requirements of Los Angeles County Code Chapter 2.160 at seq.,
(relating to the Los Angeles County Lobbyist Ordinance) and that
all persons acting on behalf of myself complied and will continue
to comply therewith through the application process.
Applicant (Print Name) Applicant Signature
Company Name Date
JOB ADDRESS '
LOCALITY
HAZARDOUS MATERIAL DECLARATION
Will the applicant or future building occupant handle a hazardous
material or a mixture containing a hazardous material equal to or
greater than the amount specified on the hazardous materials
information guide?
Yes ❑ No ❑
Will the intended use of the building by the applicant or future
building occupant require a permit for construction or
modification from the South Coast Air Quality Management
District (SCAQMD)? See permitting checklist for guidelines.
Yes ❑ N o ❑
I have read the hazardous materials information guide and the
SCAQMD permitting checklist, I understand my requirements
under the Los Angeles County Code Title 2, Chapter 220'
Sections 220.100 through 220.140 concerning hazardous
material reporting and for obtaining a permit from the SCAQMD.
ASBESTOS NOTIFICATION
❑ Notification letter sent to AQMD and/or EPA
❑ I declare that notification of asbestos removal is not
applicable to addressed project.
DECLARATION REGARDING CONSTRUCTION LENDING
AGENCY
I hereby affirm under penalty of perjury that there is a
Construction lending agency for the performance of the work for
which this permit is issued (Section 3097, Civil Code).
Lender's Name
Lender's Address
By my signature below, I certify to each of the following:
I am the property owner or authorized to act on the
property.owner's behalf.
I have read this application and the information I have
provided is correct.
I agree to comply with all applicable city and county
ordinances and state laws relating to building
construction.
I authorize representatives of this county to enter the
above -identified property for inspection purposes.
Signature o�POwner or Authorized Agent
,�Aate '