HomeMy Public PortalAbout5220 Daleview Ave_Building_2/20/1950_DEPARAWNT OF BUILDING AND SAFETY J
COUNTY OF LOS ANGELES
WM. J. FOX, CHIEF ENGINEER
ad .M, .'.i u IJM iLW 1 w rluwu idrru m.,AW
FOR ApFLICANT TO FILL IN
_1..' ( I-.
fB2x1ON FOR PERMT
5�rUIILDING
BUILDING // /f� y.
ADDRESS „s +./�(� y /P('(I/�j/f:. �A� d/t
v
LOCALITY
NEAREST r
CROSS ST. / '/-CCF••
OWNER i�unGoLn� ,LJ. k{(?P Qer t
MAIL-/f�� • V
ADDRESS SS• Zn IVO' I✓/31..i' '?1�✓R7'V P. •7
CITY1—
ARCHITECTOR 1 TEL.
ENGINEER NO.
ADDRESS
TEL.
CONTRACTOR ;'�4l}�Ai•p. NO.
ADDRESSI�V,,(i_^
LEGAL I
DESCRIPTION LOT NO. r BLOCK
TRACT
NO. OF BLDGS.
SIZE OF LOT p (} Y �'Gl I NOW ON LOT
USE OF ) / NO.OF
EXISTING BLDG. l�lu.�,_e_.. I FAM I41ES
+ DESCRIPTION OF WORE
R NEW I I ALTERATION I I ADDITION I
7 REPAIR I I DEMOLITION I I I
SQ. FT. r" NO. OF
SIZE J / 2..- ROOMS //STORIES
EXT. WALLOOF
41r /.• I COVERING(a(,1(�'I. gt,e4(
COVERING l�Rf ;WbNT(G.
USE OF STRUCTURE I F
Y
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS AP-
PLICATION AND STATE THAT THE INFORMATION GIVEN IS
CORRECT.
I AGREE TO COMMPpC7 WITH THE CORRECTIONS LISTED
HEREON AND WITHAL4 COUNTY ORDINANCES AND STATE
LAWS REGULATINQ' /gU:ILDING CONSTRUCTION.
SIGNATURE OF �/ ti
i".�"'
PERMITTF- (^ j �JL 1./fly ��
ADDREEs Sa.2o AA V"L[.z#4-CF41 ^' �'II •
AUTHORIZED AG+
>EAGIGA. DOSS IOW
IJ
FOR OFFICE USE ONLY
1
DISTRICT NO. PLAI( �� � . Np� I �PERMIT ` `� •
RECEIVED BY I DATE OF APPL. I TE SSUED
BUILDINGAODRESS
LOCALITY
T- C.
NEAREST
E/C.
CROSS ST.
/L' ���
NO. OF
I I TYPEi�
I GRO=UP
ZFIRE
ONE
PLANS Z
BLDG.
SETBACK LINE Zt��
ORD. NO.
APPROVED
BY
DATE
USEAPPROVED
ZONE
BY
DATE
HOUSE NUMBERING
MAP NUMBER •�'� -FIELD CHECK BV
NO. ASSIGNED BY- LT/ DATE_
CORRECTIONF
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APPROVALS
INSPECTOR'S SIGNATURE DATE
r
'FOUNDATION: LOCATION
FORMS, MATERIALS
FRAME: FIRE STOPS,
BRACING, BOLTS
FURNACE:LOCATION,
GAS V ENTDU CTS
ILATH, INT. _ �
LATH, EXT. A& c:;*v
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u
CfPLASTER, INT.
FEyA_A
O/PLAST, ..o //l
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VALUATION FEE��-', /•. I FINAL
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COUR=Y OF LdS ANGELES
DEPARTMENT OF PUBLIC WORKS
BUILDING AND SAFETY / LAND DEVELOPMENT
LEGAL ID:
IF: 14020 IT: 5
ASSESSOR INFORMATION NUMBER:
8574-007-005
OWNER: TEL. NO:
AIMANZAN RUBEN R;GLORIA F (626) 443-7978-
5220 DALEVIEW AV
TEMP 917803523
4PPLICANT:
TEL. NO:
TAME AS OWNER
-
CONTRACTOR:
TEL. NO:
SAME AS OWNER
-
LIC. NO
ARCHITECT OR ENGINEER:
TEL. NO:
LI, DAVID
(626) 288-1216-
1000 SAN GABRIEL BLVD
LIC. NO:
4101
EXT:
ROSEMEAD CA 91770
MAP NO: SEWER MAP BOOK: PAGE:
FIRE ZONE: CMP:
CONST
3 00
NO. OF FAMILIES: DWELLING UNITS:
AFT/COND: STAT CLASS:
0
NO 21
SCHOOL WITHIN HAZARDOUS
AIR QUALITY: 1000 FEET
MATERIALS
NO NO
NO
FEE DESCRIPTION
B1 PLANCHECK W/ENERGY
AA BLDG PERMIT ISSUANCE
AS STATE GREEN BLDG FEE
AC STRONG MOTION RESID
B2 PERMIT W/ENERGY
08 CERTIF OF OCCUPANCY
* ADDITIONAL DATA ON FILE
REPORT ID: DPR261
FEES PAID
QUANTITY: UOM:
82870.00 VAL
105580.00 VAL
105580.00 VAL
105580.00 VAL
TOTAL FEES
B
ROUTE TO: BS0508
WORK
ADDITION�NT OF EXIS�HOUSE NEW LIVING ROOM, DINING
AMOUNT:IROOM, 556 SQ.FT. EXTENTION OF EXISTING FAMILY ROOM 169 SQ.F
IAND PORCH 23 SQ.FT.
1,054.40
27.80 ISPECIAL CONDITIONS:
5.00
10.60
1,461.20
101.40 JAPPROVALS DATE INSPECTOR SIGNATURE
2,660.40 1
LOCATION AND SETBACKS
SOILS ENGINEER APPROVAL (,
FOUNDATION/TRENCH FORMS
SLAB/UNDER FLOOR
RAISED FLOOR FRAMING
UNDERFLOOR INSULATION
IST LEVEL FLOOR SHEATH
2ND LEVEL FLOOR SHEATH
ROOF SHEATHING
FIRE DEPT, FRAME INSPECTp
BLDG DEPT. FRAME INSPEQP'
SHEAR PANELS
INSOLATION/WEATHER "I
INTERIOR LATH/DRYWALL
)
EXTERIOR LATH
LOT DRAINAGE
SMOKE DETECTION DEVICES
FIRE DEPARTMENT APPROVAL
I �
TEMPLE CITY
4 0508
BUILDING PERMIT
9701 LAS TUNAS
RESIDENTIAL ADD
TEMPLE CITY CA 91780
BL 0508 1311180031
PHONE: (626) 285-0488
EXT:
NO. OF
CONST
NEW
BUILDING ADDRESS:
SQ. FT STORIES
TYPE
_ _OCCUP
GROUPI 5220 DALEVIEW AV
ISTRUCTUR£:
725 1
V -R
R-3
TEMP CA 917803523
GARAGE:
I NEAREST CROSS STREET:
OTHER:
23 1
V -B
U
I THOMAS PAGE: 597 GRID: D4 LOCALITY: TEMPLE CITY C
EXIST BLDG USE:
USE 20NE:
ISSUED ON: PROCESSED BY:
MIST OCC
GRP:
03/25/14 SR
BLDGS. NOW ON LOT:
VALUATION:
105,580
IF L U TE FI BY: CODE:
FEE DESCRIPTION
B1 PLANCHECK W/ENERGY
AA BLDG PERMIT ISSUANCE
AS STATE GREEN BLDG FEE
AC STRONG MOTION RESID
B2 PERMIT W/ENERGY
08 CERTIF OF OCCUPANCY
* ADDITIONAL DATA ON FILE
REPORT ID: DPR261
FEES PAID
QUANTITY: UOM:
82870.00 VAL
105580.00 VAL
105580.00 VAL
105580.00 VAL
TOTAL FEES
B
ROUTE TO: BS0508
WORK
ADDITION�NT OF EXIS�HOUSE NEW LIVING ROOM, DINING
AMOUNT:IROOM, 556 SQ.FT. EXTENTION OF EXISTING FAMILY ROOM 169 SQ.F
IAND PORCH 23 SQ.FT.
1,054.40
27.80 ISPECIAL CONDITIONS:
5.00
10.60
1,461.20
101.40 JAPPROVALS DATE INSPECTOR SIGNATURE
2,660.40 1
LOCATION AND SETBACKS
SOILS ENGINEER APPROVAL (,
FOUNDATION/TRENCH FORMS
SLAB/UNDER FLOOR
RAISED FLOOR FRAMING
UNDERFLOOR INSULATION
IST LEVEL FLOOR SHEATH
2ND LEVEL FLOOR SHEATH
ROOF SHEATHING
FIRE DEPT, FRAME INSPECTp
BLDG DEPT. FRAME INSPEQP'
SHEAR PANELS
INSOLATION/WEATHER "I
INTERIOR LATH/DRYWALL
)
EXTERIOR LATH
LOT DRAINAGE
SMOKE DETECTION DEVICES
FIRE DEPARTMENT APPROVAL
I �
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 (J) 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 Contrb�or 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 prion to completioq of the improvements covered by
this permit, Icannot 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.htmi.
•-/'Date: z I
SlonatureofPro rty Ow_ np 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.
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:
Carder 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
�pp ZS I
i nature o A scan Da
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 ❑
I have read the hazardous materials information guide and the
SCAQMD permitting checklist, I understand my requiremgnts
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 representatives of this county to enter the
above -identified property for inspection purposes.
tyo�9FF
rized Agent
ate
" C O ( 1 N 2 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 I D :
1 4 0 2 0 L T : 5
S S O R I N F O R M A T I O N N U M B E R :
- 0 0 7 - 0 0 5
O W N E R :
A L M A N Z A N R U B E N R ; G L O R I A F
5 2 2 0 D A L E V I E W A V
T E M P 9 1 7 8 0 3 5 2 3
A P P L I C A N T :
S A M E A S O W N E R
C O N T R A C T O R :
S A M E A S O W N E R
O R E N G I N E E R :
T E L . N O :
( 6 2 6 ) 4 4 3 - 7 9 7 8 -
T E L . N O :
T E L . N 0 :
L I C . N O
T E L . N O :
L I C . N O :
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
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
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 N 0 5 0 8 B U I L D I N G P E R M I T
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 B L 0 5 0 8 1 4 0 3 2 5 0 0 9 8
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 N E W B U I L D I N G A D D R E S S :
S Q . F T S T O R I E S T Y P E O C C U P G R O U P 5 2 2 0 D A L E V I E W A V
S T R U C T U R E : 5 9 2 1 V - 8 R - 3 T E M P C A 9 1 7 8 0 3 5 2 3
G A R A G E : N E A R E S T C R O S S S T R E E T :
O T H E R : I T H O M A S P A G E : 5 9 7 G R I D : D 4 L O C A L I T Y : T E M P L E C I T Y C A
E X I S T B L D G U S E : R E S I D J I S S U E D O N : P R O C E S S E D B Y :
E X I S T O C C G R P : R - 3 1 0 3 / 2 5 / 1 4 S R
1 1
S L U G S . N O W O N L O T : V A L U A T I O N : F I N A L D T E F I N A L B Y : C O D E :
5 0 0 1
( I / / j ( ��
F E E S P A I D D 1 F i I P T I O N �� W O R K
L T O F I N A L I Z E D E X P I R E D P E R M I # B L 4 9 3 5 8 , E L 4 1 4 0 1 A N D P L 0 5 2 1 1
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 : A M O U N T : I T O A D D 2 B E D R O O O M S
A A B L D G P E R M I T I S S U A N C E 2 7 . 8 0 (
A S S T A T E G R E E N B L D G F E E 5 0 0 . 0 0 V A L 1 . 0 0 ( S P E C I A L C O N D I T I O N S :
E 2 A D D I N S P E C T H R L Y R T E 1 . 0 0 0 0 0 H O U 1 4 4 . 9 0 1
T O T A L F E E S 1 7 3 . 7 0
R E P O R T I D : D P R 2 6 1 R O U T E 7 0 : B S 0 5 0 8
O N A N D S E T B A C K S
E N G I N E E R A P P R O V A L
. 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 R 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
L O 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 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
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 whicl1 I must have resided for at least
one year prior) to completion of the improvements covered by
this permit, I cq'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: hUD://www.Ieainfo.ca.aov/calaw.html.
Date: Zs��
ature 7,erty Owner or Authorized Agent
1. _ O -Z
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
YVARNING: 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
��Qign�ature of Applicant D e
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 ❑ 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 ❑ 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.
SiQP@Wr ��of Praperty w r or Authorized Agent
Date J?
OJL:PIY OF LOS ANGELES
DEPARTMENT OF PUBLIC WORKS
BUILDING AND SAFETY / LAND DEVELOPMENT
TR: 14020 . LT: 5
ASSESSOR INFORMATION NUMBER
8574-007-005
TENANT:
OWNER:
ALMANZAN RUBEN RIGLORIA F
5220 DALEVIEW AV
TEMP 917803523
APPLICANT:
SAME AS OWNER
CONTRACTOR:
SAME AS OWNER
OR ENGINEER:
TEL. N0:
(626) 443 -7978 -
TEL. NO:
TEL. NO:
LIC. NO
TEL. NO:
LIC. NO:
IAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP:
XX 3 00
10. OF FAMILIES: DWELLING UNITS: APT/COND: STAT CLASS:
NO 21
SCHOOL WITHIN HAZARDOUS
.IR QUALITY: 1000 FEET MATERIALS
NO NO NO
TEMPLE CITY k 0508
9701 LAS TUNAS
TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
NO. OF CONST
SQ. FT STORIES TYPE
3000 V -B
EXIST BLDG USE: RESID
USE ZONE:
R-1
EXIST OCC GRP:
BLDGS. NOW ON LOT:
VALUATION:
10,000
FEES
PAID
FEE DESCRIPTION:
QUANTITY:
UOM:
AMOUNT:
AA BLDG PERMIT ISSUANCE
27.80
All STATE GREEN BLDG FEE
10000.00
VAL
1.00
AC STRONG MOTION REBID
10000.00
VAL
1.00
D2 PERMIT W/O EN -HC
10000.00
VAL
216.60
TOTAL FEES
246.40
REPORT ID: DPR261 ROUTE TO: BS0508
BUILDING PERMIT
ALTERATION/REPAIR
BL 0508 1407220043
BUILDING ADDRESS:
5220 DALEVIEW AV
TEMP CA 917803523
NEAREST CROSS STREET: EL MONTE
THOMAS PAGE: 597 GRID: D4 LOCALITY: TEMPLE CITY, C
ISSUED ON: PROCESSED BY:
07/22/14 SR
WFINAL DATE .1/j, FI BY: CODE:
1 ,N mF WORK
1/0 EXIST ROOF AND INSTALL M NIER TILE CEDARLITE ICBG 2656
TO MATCH NEW ADDITION
SPECIAL CONDITIONS:
ON AND SETBACKS
ENGINEER APPROVAL
.TION/TRENCH FORMS
RAISED FLOOR FRAMING
FLOOR SHEATHING
ROOF SHEATHING
SHEAR PANELS r
FRAME INSPECTION
^IRE SPRINKLER HANGERS
INSULATION/WEATHER STRIPI
INTERIOR LATH/DRYWALL
RATED FLOOR/CEIL ASSEM.
SHAFTS/OPENINGS
CEILINGS
DATE 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 (J) 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 hot 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).
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 priori 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: htto://www.leoinfo.ca.aov/calaw.html.
%Date: 742 1 T
` Sigaa)ture OfPJope O er or Authorized Agent
/ 1 1p�� jp�J
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 -7h -one 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
; .//t dl 7 ,7
Signature of Applicant / I 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
matedal 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 ❑ N o ❑ !
I have read the hazardous materials information guide and the
SCAQMD permitting checklist, I understand my requirem@nts
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 representatives of this county to enter the
above -identified property for inspection purposes.
Sjgaptyre ofErgparty Ow er Authorized Agent
ate