HomeMy Public PortalAbout6059 Golden West Ave_Building_10/16/2014_COUNTY OF .LOS
ANGELBS�
TEMPLE CITY
k 0508
BUILDING PERMIT
DEPARTMENT OF
PUBLIC WORKS
9701 LAS TUNAS
ALTERATION/REPAIR
3UILDING AND SAFE'T'Y
/ LAND DEVELOPMENT
TEMPLE CITY CA 91780
BL 0508 1410150047
•
PHONE: (626) 285-0488 EXT:
LEGAL ID:
NO.
OF CONST
BUILDING ADDRESS:
ITR: 6561 LT: 90
ON: .003
SQ. FT STORIES TYPE
1 6059 GOLDEN WEST AV
STRUCTURE:
V-B
I TEMP CA 917801755
1ASSESSOR INFORMATION NUMBER:
I
I NEAREST CROSS STREET: GARIBALDI
15385-019-001
1
THOMAS PAGE: 597 GRID: A2 LOCALITY: TEMPLE CITY CA
(TENANT:
IEXIST BLDG USE: REBID
USE ZONE: R-1
ISSUED ON: PROCESSED BY:
IEXIST OCC GRP:
110/16/14 SR
I
OWNER:
TEL. NO:
I
IBLDGS. NOW ON IAT:
VALUATION:
i
F;NAL DATE / F Nom. BY: CODE:
LE
(626) 215-2722-
9,500
// ,J��7/L jl-,"
16059
6059 GOLDEN WEST AV
1
�J,\(P\R1J
ITEMP 917801755
I
FEES PAID
S RIPTI N OF WORK
;(j��/
I
I
IBATHROOM, KITCHEN TO BE RE DELED AND EXISTING CLOSET TO BE
I
IFEE DESCRIPTION:
QUANTITY: DOM:
AMOUNT:ICONVERTED
INTO A LAUNDRY ROOM
1APPLICANT:
TEL. NO:
I
I
(SAME AS OWNER
-
IAA BLDG PERMIT ISSUANCE
27.80
1
IAB STATE GREEN BLDG FEE
9500.00 VAL
1.00
ISPECIAL CONDITIONS:
IAC STRONG MOTION RESID
IBI PLANCHECK W/ENERGY
IB2 PERMIT W/ENERGY
9500.00 VAL
9500.00 VAL
9500.00 VAL
1.00
202.50
238.30
1
j/��// /�
�) )A 1 (1 [� V
1 CONTRACTOR:
TEL. NO:
IFR INV WORK W/O PERMIT
344.00 DOL
344.00
A iJ111iii0lll»>AAAiil DATE SPE OR SSS IGNATURE
1�
(SAME AS OWNER
-
I
TOTAL FEES
814.60
1
LIC. NO
LOCATION AND SETBACKS
1
ISOZLS ENGINEER APPROVAL 1
1ARCHZTECT OR ENGINEER:
TEL. NO:
1
1FOUNDATION/TRENCH FORMS i 1
LIC. NO:
SLAB UNDER FLOOR
RAISED FLOOR FRAMING
N0: SEWER MAP BOOR: PAGE:
I
FIRE ZONE: CMP0
I
INSULATION
1MAP
0
1UNDERFLOOR
1
FLOOR SHEATHING
IND. OF FAMILIES: DWELLING UNITS:
APT/GOND: STAT CLASS:
I
NO 21
IROOF SHEATHING I
I SCHOOL WITHIN
HAZARDOUS
SHEAR PANELS 1
1AIR QUALITY: 1000 FEET
MATERIALS
NO NO
NO
1FRAME INSPECTION
R
SPRINKLER G�S
I
I
IFIRE
INSULATION/WEATHER STRIPI I
I
JINTERIOR LATH/DRYWALL 11
EXTERIOR LATH
RATED FIAOR/CEIL ASSEM. 1
I
IRATED WALL ASSEMBLIES
I
I
I
IRATED SHAFTS/OPENINGS 1
I
I
I
T-BAR CEILINGS
DRAINAGE
j-
1REPORT ID: DPR261
ROUTE TO: BS0508
_I
ILOT
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 Contractor pursuant .to the Contractors' State License
Law).
(_). I am exem�t 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; 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: http://www.Ieainfo.ca.00v/calaw.html.
Date:
Signature ofP arty Ow 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
4 tic 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
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 ❑ N o ❑
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 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.
Signatur arty Owner or Aut ed Agent
Date % �� A_
C O U N T Y O F , L O S A N G E L E S
D E P A R T M E N T O F P U B L I C W O R K S
. B U I L D I N G A N D S A F E T Y / L A N D D E V E L O P M E N T
L E G A L I D :
I T R : 6 5 6 1 L T : 9 0 U N : . 0 0 3
I
A S S E S S O R I N F O R M A T I O N N U M B E R :
1 5 3 8 5 - 0 1 9 - 0 0 1
T E N A N T
U Y E N L E
6 0 5 9 G O L D E N W E S T A V
T E M P 9 1 7 8 0 1 7 5 5
A S O W N E R
A S O W N E R
O R E N G I N E E R :
T E L . N 0 :
( 6 2 6 ) 2 1 5 - 2 7 2 2 -
T E M P L E C I T Y
9 7 0 1 L A S T U N A S
T E M P L E C I T Y C A 9 1 7 8 0
P H O N E : ( 6 2 6 ) 2 8 5 - 0 4 8 8 E X T :
N O . O F C O N S T
S Q . F T S T O R I E S T Y P E
S T R U C T U R E : 0 2 V - B
G A R A G E :
O T H E R :
E X I S T B L D G U S E : R E B I D
E X I S T O C C G R P : R - 3
B L D G S . N O W O N L O T :
F E E S P A I D
F E E D E S C R I P T I O N : Q U A N T I T Y : U O M :
T E L . N O : I
- J A A B L D G P E R M I T I S S U A N C E
J E 2 A D D I N S P E C T H R L Y A T E 1 . 0 0 0 0 0 H O U
I T O T A L F E E S
T E L . N O :
L I C . N O
T E L . N O :
L I C . N O :
M A P N O : S E W E R M A P B O O K : P A G E : F I R E Z O N E : C M P :
3 0 0
N O . O F F A M I L I E S : D W E L L I N G U N I T S : A P T / C O N D : S T A T C L A S S -
1 N O 9 9
S C H O O L W I T H I N H A Z A R D O U S
A I R Q U A L I T Y : 1 0 0 0 F E E T M A T E R I A L S
N O N O N O
R E P O R T I D : D P R 2 6 1
k 0 5 0 8
B U I L D I N G P E R M I T
B L 0 5 0 8 1 4 1 0 1 6 0 1 0 3
N E W I B U I L D I N G A D D R E S S :
O C C U R G R O U P 6 0 5 9 G O L D E N W E S T A V
R - 3 I T E M P C A 9 1 7 8 0 1 7 5 5
N E A R E S T C R O S S S T R E E T : G A R I B A L D I
T H O M A S P A G E : 5 9 7 G R I D : A 2 L O C A L I T Y : T E M P L E C I T Y C l
I S S U E D O N : P R O C E S S E D B Y -
1 1 0 / 1 6 / 1 4
Y :
1 1 i / 0 I ^ / 1 1 L 6 / 1 1 4 4 ^ X \ / g ' L �� S R
O N : I F 1 0 0 0 D � I P T I O N O F W O R K F I I j A L , $ Y : C O D E :
I T O F I N A L I Z E D E X P I R E D P E E R M I T F O R 2 - S T O R Y A D D I T I O N D A T E D
A M O U N T : I 7 - 2 7 - 8 1
2 7 . 8 0
1 4 4 . 9 0 I S P r C I A L C O N D I T I O N S :
1 7 2 . 7 0 1
R O U T E T O : B S 0 5 0 9
D A T E I N S P E C T O R S I G N A T U R E
L O C A T I O N A N D S E T B A C K S
S O I L S E N G I N E E R A P P R O V A L
F O U N D A T I O N / T R E N C H F O R M S
S L A B / U N D E R F L O O R
R A I S E D F L O O R F R A M I N G
I N D E R F L O O A I N S U L A T I O N
F L O O R S H E A T H I N G
G O O F S H E A T H I N G
S H E A R P A N E L S
? B A N E I N S P E C T I O N
T I R E S P R I N K L E R H A N G E R S
E N S U L A T I O N / W E A T H E R S T R I P I I
I I
L N T E R I O R L A T H / D R Y W A L L
, X T E R I O R L A T H
Z A T E D F L O O R / C E I L A S S E M .
Z A T E D W A L L A S S E h f f i L I E S
Z A T E D S H A F T S / O P E N I N G S j
C - B A R C E I L I N G S
S O T D R A I N A G E
OWNER -BUILDER DECLARATION LICENSED CONTRACTOR'S DECLARATION I JOB ADDRESS 11 ,
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 priorlto completion of the improvements covered by
this permit, I cqnnot 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: htto://www.lecinfo.ca.aov/calaw.html.
—/Date: {
Signature of PropeXZw_n_e_r_or_AD zed 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.
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 carder 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
Signto of A nt 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 ❑ 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 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.
Signaf j re of Pro any O r or Authodzed gent
t�l�l
" C O U N T Y O F , I A S A N G E L E S
D E P A R T M E N T O F P U B L I C W O R K S
. B U I L D I N G A N D S A F E T Y / L A N D D E V E L O P M E N T
L E G A L I D :
J T R : 6 5 6 1 L T : 9 0 U N : . 0 0 3
1
A S S E S S O R I N F O R M A T I O N N U M B E R :
1 5 3 8 5 - 0 1 9 - 0 0 1
O W N E R :
T E L . N O :
L E , U Y E N
( 6 2 6 ) 5 3 6 - 8 7 1 1 -
6 0 5 9 G O L D E N W E S T A V
T E M P 9 1 7 6 0 1 7 5 5
A P P L I C A N T :
T E L . N O :
G U T I E R R E Z , R I C A R D O
( 3 2 3 ) 9 8 2 - 9 5 0 5 -
5 0 1 8 E A G L E R O C K B L V D
I A S A N G E L E S C A 9 0 0 4 1
C O N T R A C T O R :
T E L . N O :
A N R R O O F I N G
( 3 2 3 ) 9 8 2 - 9 5 0 5 -
5 0 1 8 E A G L E R O C K B L V D
L I C . N O
L O S A N G E L E S C A 9 0 0 4 1
8 7 4 9 6 4
A R C H I T E C T O R E N G I N E E R :
T E L . 1 4 0 :
L I C . N O :
M A P N 0 : S E W E R M A P B O O K : P A G E :
F I R E Z O N E : C M P :
3 0 0 1
N 0 . O F F A M I L I E S : D W E L L I N G U N I T S :
A P T / G O N D : S T A T C L A S S :
N O 2 1
S C H O O L W I T H I N H A Z A R D O U S
A I R Q U A L I T Y : 1 0 0 0 F E E T
M A T E R I A L S
N O N O
N O
T E M P L E C I T Y # 0 5 0 8
9 7 0 1 L A S T U N A S
T E M P L E C I T Y C A 9 1 7 8 0
P H O N E : ( 6 2 6 ) 2 8 5 - 0 4 8 8 E X T :
N O . O F C O N S T
S Q . F T S T O R I E S T Y P E
' U R E : 3 9 0 0 V - B
B L D G U S E : R E B I D U S E Z O N E : R - 1
O C C G R P :
N O W O N I A T : V A L U A T I O N :
1 5 , 0 0 0
D E S C R I P T I O N
B L D G P E R M I T I S S U A N C E
S T A T E G R E E N B L D G F E E
S T R O N G M O T I O N R E S I D
P E R M I T W / O E N - H C
I D : D P R 2 6 1
F E E S P A I D
Q U A N T I T Y : D O M :
1 5 0 0 0 . 0 0 V A L
1 5 0 0 0 . 0 0 V A L
1 5 0 0 0 . 0 0 V A L
T O T A L F E E S
R O U T E T O : B S 0 5 0 8
A M O U N T :
2 7 . 8 0
1 . 0 0
1 . 5 0
3 0 0 . 6 0
3 3 0 . 9 0
B U I L D I N G P E R M I T
A L T E R A T I O N / R E P A I R
B L 0 5 0 8 1 4 1 0 2 7 0 0 6 1
B U I L D I N G A D D R E S S :
6 0 5 9 G O L D E N W E S T A V
T E M P C A 9 1 7 8 0 1 7 5 5
N E A R E S T C R O S S S T R E E T : G A R I B A L D I
T H O M A S P A G E : 5 9 7 G R I D : A 2 L O C A L I T Y : T E M P L E C I T Y
I S S U E D O N : P R O C E S S E D B Y :
1 0 / 2 7 / 1 4 S R
J F I I ��N N A A L L ' D D A / T E E F I N A L B Y : C O D E :
A S 5 C 2 R T = O O W O R K
L I F T E X I S T I N G 2 P I E C E S M I S S I O N T I L E R E M O V E U N D E R L A Y M E N T .
I N S T A L L 2 L A Y E R S O F 4 0 L B B A S E S H E E T A N D R E - S E T T I L E
S P E C I A L C O N D I T I O N S :
L O C A T I O N A N D S E T B A C K S
S O I L S E N G I N E E R A P P R O V A L
F O U N D A T I O N / T R E N C H F O R M S
S L A B / U N D E R F L O O R
R A I S E D F L O O R F R A M I N G
U N D E R F L O O R I N S U L A T I O N
F L O O R S H E A T H I N G
R O O F S H E A T H I N G
S H E A R P A N E L S
F R A M E I N S P E C T I O N
F I R E S P R I N K L E R H A N G E R S
I N S U L A T I O N / W E A T H E R S T R I P
I N T E R I O R L A T H / D R Y W A L L
E X T E R I O R L A T H
R A T E D F L O O R / C E I L A S S E M .
R A T E D W A L L A S S E M B L I E S
R A T E D S H A F T S / O P E N I N G S
T - B A R C E I L I N G S
I A T D R A I N A G E
D A T E I N S P E C T O R S I G N A T U R E
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 (J) all of or L) 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). '
L) 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 1 must have resided for at least
one year prior) to 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: htto://www.leainfo.ca.aov/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. �/ (� /
License Class C13014License No. � L - l &_q
"Dateta�Z1 contractorSignature l` -A,, _,
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
wpd rs' c pe eetion' sura ce carrier and policy number ar
Carrier Po IcyPo Icy N� Ex ti, 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
worker ' compensati provisions of Section 3700 of the Labor
Code, hall", hwit c ply with those provisions
�I
ignature of Appli nt Date ' f
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
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 representative(rAv
is county to enter the
above-ide tifierfiroperty fp tion purposes.
Signature o e Owner dAgent
eLe�Jam'LI
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 1411200049
•
PHONE: (626) 285-0488
EXT:
LEGAL ID:
NO.
OF CONST
BUILDING ADDRESS:
TR: 6561 LT: 90
UN: .003
SQ. FT STORIES TYPE
6059 GOLDEN WEST AV
STRUCTURE:
V -B
TEMP CA 917801755
ASSESSOR INFORMATION NUMBER:
_
NEAREST CROSS STREET: GARIBALDI
5385-019-001
THOMAS PAGE: 597 GRID: A2 LOCALITY: TEMPLE CITY CA
TENANT:
IEXIST BLDG USE: REBID
USE ZONE: R-1
JISSUED ON: PROCESSED BY:
IEXIST OCC GRP:
111/20/14 SR
OWNER:
TEL. NO:
IBLDGS. NOW ON LOT:
VALUATION:
IFINAL DATE FINAL B CODE:
UYEN LE
(626) 215-2722-
I
8,000
L
6059 GOLDEN WEST AV
t22
TEMP 917601755
FEES PAID
DEECRIPTIO(v`
M OF WORK
(REPLACE 19 WINDOWS, 4 SLIDING PATIO DOORS, CLOSET CABINET
DESCRIPTION:
QUANTITY: UOM:
AMOUNT:IAND
ENTRY DOOR
APPLICANT:
TEL. NO:
IEEE
SAME AS OWNER
-
IDI PLANCHECK W/O EN -HC
8000.00 VAL
155.60
I
IAA BLDG PERMIT ISSUANCE
27.80
ISPECIAL CONDITIONS:
IAB STATE GREEN BLDG FEE
8000.00 VAL
1.00
IAC STRONG MOTION REBID
8000.00 VAI,
0.80
PERMIT W/O EN -HC
8000.00 VAL
183.00.
CONTRACTOR:
_ID2
TEL. NO:
TOTAL FEES
368.20
(APPROVALS DATE INSPECTOR SIGNATURE
SAME AS OWNER
-
LIC. NO
(LOCATION AND SETBACKS '
I I
ISOILS ENGINEER APPROVAL
ARCHITECT OR ENGINEER:
TEL. NO:
(FOUNDATION/TRENCH FORMS
LIC. NO:
ISLAB UNDER FLOOR
IRAISED FLOOR FRAMING
MAP NO: SEWER MAP BOOK: PAGE:
FIRE ZONE: CMPII
(UNDERFLOOR INSULATION
3 OOI
IFLOOR SHEATHING
NO. OF FAMILIES: DWELLING UNITS:
APT/COND: STAT CLASS:
I
I I
NO 21
1
IRCOF SHEATHING
SCHOOL WITHIN
HAZARDOUS
ISHEAR PANELS
AIR QUALITY: 1000 FEET
MATERIALS
1
NO NO
NO
(FRAME INSPECTION
IFIRE SPRINKLER HANGERS I
(INSULATION WEATHER STRIPI
(INTERIOR LATH/DRYWALL
IEXTERIOR LATH
RATED FLOOR/CEIL ASSEM. j
IRATED WALL ASSEMBLIES
RATED SHAFTS/OPENINGS I�
T -BAR CEILINGS I
(LOT DRAINAGE I
IREPORT 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 Contrti for pursuant.to the Contractors' State License
Law).
(_) I am exemplt 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 priori to completiory 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: htto://www.leainfo.ca.cov/calaw.html.
Date: 1 (— —114
Signature_QLProperty.Qwner 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 carder 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 all forthwith comply with those provisions
V9 atR ureo plica9t_— 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
JOB ADDRESS I
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 conceming 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 toeach 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 P Owner or Authorize Agent
� -1Date Q i! y
COUNTY OF LOS ANGELES
DEPARTMENT OF PUBLIC WORKS
BUILDING AND SAFE9,Y / LAND DEVELOPMENT
LEGAL ID:
TR: 6561 LT: 90 ON: .003
ASSESSOR INFORMATION NUMBER:
5385-019-001
TENANT
OWNER:
TEL. NO:
LE, UYEN
(626) 536-8711-
6059 GOLDEN WEST AV
TEMP 917801755
APPLICANT:
TEL. NO:
ARIMA, JUNE
(626) 249-1909-
411 E HUNTINGTON DR
ARCADIA, CA 91006
CONTRACTOR:
TEL. NO:
SEDONA WEST ROOFING, INC.
(626) 294-1909-
411 E HUNTINGTON DR
LIC. NO
ARCADIA, CA 91006
891842
ARCHITECT OR ENGINEER: TEL. NO:
LIC. NO
NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP:
3 00
OF FAMILIES: DWELLING UNITS: APT/COND: STAT CLASS:
NO 21
SCHOOL WITHIN HAZARDOUS
QUALITY: 1000 FEET MATERIALS
NO NO NO
TEMPLE CITY q 0508
9701 LAS TUNAS
TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
NO. OF CONST
SQ. FT STORIES TYPE
STRUCTURE: 2000 V -B
EXIST BLDG USE: REBID USE ZONE: R-1
EXIST OCC GRP:
BLDGS. NOW ON LOT: VALUATION:
10,500
FEES PAID
FEE DESCRIPTION: QUANTITY: DOM: AMOUNT:
AA BLDG PERMIT ISSUANCE 27.80
AB STATE GREEN BLDG FEE 10500.00 VAL 1.00
AC STRONG MOTION REBID 10500.00 VAL 1.10
D2 PERMIT W/O EN -HC 10500.00 VAL 233.40
TOTAL FEES 263.30
ID: DPR261 ROUTE 10: BS0508
BUILDING PERMIT
ALTERATION/REPAIR
BL 0508 1412220065
BUILDING ADDRESS:
6059 GOLDEN WEST AV
TEMP CA 917801755
NEAREST CROSS STREET:
THOMAS PAGE: 597 GRID: A2 LOCALITY: TEMPLE CITY, C
ISSUED ON: PROCESSED BY:
12/22/14 SR
FINAL DATE� / FINAL BY: CODE:
DESCRIPTION of WORK
TEAR OFF 20 S.F. INSTALL MOMERLITE SAXONY - NO PLYWOOD
CONDITIONS:
APPROVALS DATE
LOCATION AND SETBACKS
SOILS ENGINEER APPROVAL
FOUNDATION/TRENCH FORMS
SLAB/UNDER FLOOR
RAISED FLOOR FRAMING
INSPECTOR SIGNATURE
UNDERFLOOR INSULATION —
FLOOR SHEATHING '�/,�ff{�
w `
ROOF SHEATHING
j
SHEAR PANELS ; i
FRAME INSPECTION
FIRE SPRINKLER HANGERS
INSULATION/WEATHER STRIP
INTERIOR LATH/DRYWALL
EXTERIOR LATH
RATED FLOOR/CEIL ASSEM.
RATED WALL ASSEMBLIES
RATED SHAFTS/OPENINGS
T -BAR CEILINGS
LOT DRAINAGE
OWNER -BUILDER DECLARATION LICENSED CONTRACTOR'S DECLARATION' 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 1, as owner of the property, or my employees with wages as
their sole compensation, will do (V) 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 exemf t 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; 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: httD://www.leginfo.ca.aov/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. P1P_Y/1__
License Class C-3� License No.
Date /Z" ZZ''14
Cbntractor Si9 natu
WORKERS' COMPEN ATIO 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
i�isurance, as required by Section 3700 of the Labor Code, for
the performance of the work for which this permit is issued. My
wonens' omp atio insuranc garner and policy number are:
Carrier olicy umber 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 fo With comply with those provisions
/Z -ZZ ~161
ign ure 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
LOCALITY
HAZARDOUS MATERIAL DECLARATON
Will the applic@nt or future building occupant han6c a Hazardous
material or a mixture containing a hazardous maierial ,:qual to or
greater than the amount specified on the hazardous materials
information guide?
Yes ❑ - N o ❑
Will the intended use of the building by the apr.,ican` or future
building occupant require a permit for o,r,siruction or
modification from the South Coast Air Quality M'Inagement
District (SCAQMD)? See permitting checklist for guidelines.
Yes ❑ N o ❑
I have read the hazardous materials information qu: a and the
SCAQMD permitting checklist, I understand m-,., 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 ',;z;: SCAQMD.
ASBESTOS NOTIFICATION
❑ Notification letter sent to AQMD and/or EPt,
❑ I declare that notification of asbestos remov .' ;ot
applicable to addressed project.
DECLARATION REGARDING CONSTRUCTIOL LENDING
AGENCY
I hereby affirm under penalty of perjury ti-.-,': '�;-ere 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 tiie following:
I am the property owner or authorized t:. ^ci 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 cib., and county
ordinances and state laws relating ,_o building
construction.
I authorize representatives of this county _o enter the
above-identified,pro-p_;for inspection purposes.
Jte ofPr pe � ner or Authorized Agent��'ZZ /C�
COT;NTY OF LOS ANGELES
DEPARTMENT OF PUBLIC WORKS
BUILDING AND SAFETY / LAND DEVELOPMENT
LEGAL ID:
TR: 6561 LT: 90 UN: .003
ASSESSOR INFORMATION NUMBER:
5385-019-001
TENANT
ER: TEL. NO:
UYEN/KHANG (626) 536-8711-
9 GOLDEN WEST AV
P 917801755
LICANT: TEL. NO:
AS OWNER
AS OWNER
OR ENGINEER:
TEL. N0:
LIC. NO
TEL. NO:
LIC. NO:
NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP:
3 00
OF FAMILIES: DWELLING UNITS: APT/COND: STAT CLASS:
0 NO 21
SCHOOL WITHIN HAZARDOUS
QUALITY: 1000 FEET MATERIALS
NO NO NO
FEE DESCRIPTION
D1 PLANCHECK W/O EN -HC
AA BLDG PERMIT ISSUANCE
AB STATE GREEN BLDG FEE
AC STRONG MOTION RESID
D2 PERMIT W/O EN -HC
ID: DPR261
FEES PAID
QUANTITY: DOM
4800.00 VAL
4800.00 VAL
4800.00 VAL
4800.00 VAL
TOTAL FEES
ROUTE TO: SS0508
DEMPTION OF WORK V
I(1) ADD NEW COVER PATIO ON 1ST. FLOOR 220 SF. (2) EX 2 WOOD
AMOUNT:IDECK ON 2ND: FLOOR TO BE REPAIRED
112.70 T
27.80 T
1.00 T
0.50 T
132.60 T
274.60
SPECIAL CONDITIONS:
APPROVALS DATE INSPECTOR SIGNATURE
LOCATION AND SETBACKS
SOILS ENGINEER APPROVAL
FOUNDATION/TRENCH FORMS, i
BLAB/UNDER FLOOR ( 'll�• 'pel
3AISED FLOOR FRAMING
INDERFLOOR INSULATION T
LST LEVEL FLOOR SHEATH
2ND LEVEL FLOOR SHEATH
SOOF SHEATHING
FIRE DEPT. FRAME INSPEI�
3LDG DEPT. FRAME INSPECTP�'/fik
SHEAR PANELS I' / ��
INTERIOR LATH/DRYWALL
EXTERIOR LATH
LOT DRAINAGE
TEMPLE CITY
k 0508
BUILDING PERMIT
9701 LAS TUNAS
RESIDENTIAL ADD
TEMPLE CITY CA 91780
BL 0508 1501260036
PHONE: (626) 285-0488 EXT:
NO. OF
CONST NEW
BUILDING ADDRESS:
SQ. FT STORIES
TYPE OCCUP
GROUP 6059 GOLDEN WEST AV
(STRUCTURE:
220 1
V -B U
I TEMP CA 917801755
GARAGE:
I NEAREST CROSS STREET: GARIBALDI
OTHER:
THOMAS PAGE: 597 GRID: A2 LOCALITY: TEMPLE CITY C
IEXIST BLDG
USE:
USE ZONE:
TISSUED ON: PROCESSED BY:
EXIST OCC
GRP:
102/18/15 SR
BLDGS. NOW
ON LOT:
VALUATION:
IFINAL DATE FINAL BY: CODE:
4,800
1
FEE DESCRIPTION
D1 PLANCHECK W/O EN -HC
AA BLDG PERMIT ISSUANCE
AB STATE GREEN BLDG FEE
AC STRONG MOTION RESID
D2 PERMIT W/O EN -HC
ID: DPR261
FEES PAID
QUANTITY: DOM
4800.00 VAL
4800.00 VAL
4800.00 VAL
4800.00 VAL
TOTAL FEES
ROUTE TO: SS0508
DEMPTION OF WORK V
I(1) ADD NEW COVER PATIO ON 1ST. FLOOR 220 SF. (2) EX 2 WOOD
AMOUNT:IDECK ON 2ND: FLOOR TO BE REPAIRED
112.70 T
27.80 T
1.00 T
0.50 T
132.60 T
274.60
SPECIAL CONDITIONS:
APPROVALS DATE INSPECTOR SIGNATURE
LOCATION AND SETBACKS
SOILS ENGINEER APPROVAL
FOUNDATION/TRENCH FORMS, i
BLAB/UNDER FLOOR ( 'll�• 'pel
3AISED FLOOR FRAMING
INDERFLOOR INSULATION T
LST LEVEL FLOOR SHEATH
2ND LEVEL FLOOR SHEATH
SOOF SHEATHING
FIRE DEPT. FRAME INSPEI�
3LDG DEPT. FRAME INSPECTP�'/fik
SHEAR PANELS I' / ��
INTERIOR LATH/DRYWALL
EXTERIOR LATH
LOT DRAINAGE
OWNER -BUILDER DECLARATION LICENSED CONTRACTOR'S DECLARATION 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 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 exem fit 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, 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: http://www.leginfo.ca.gov/Galaw.html.
Date: ,l 1 u — I <'
Signature ofProrty Own4er Authorized A
v
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
lel-- .. Z'% g
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
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 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, 1 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.
Signatur of P Owner or AuthorizedAgent
Date