HomeMy Public PortalAbout5428 CLOVERLY AVE_Building__ TEMPLE CITY
7UUS,CIS#803 V!G APPLICATION FOR BUILDING- PEFZN4IT -
5
COUNTY OF LOS ANGELES BUILDING
DEPARTMENT OF COUNTY ENGINEER ADDRESS
B=ING AND SAFETY DIVISION LocALITY r
JOHN A LAMBIE, COUNTY ENGINEER NEAREST C
WILLIAM A JENSEN SUP T OF BUILDING CROSS ST
0DIST �T GRO�JP -SPE P SED BY
FOR APPLICANT TO FILL IN L� ��j(_ CONST
!
BUILDING _ �l /� j STATISTICAL CLASSIFICATION SE R MAP
ADDRESS S S {s 1O�ILIa/" rens. fK - �
_ I CLASS NO DWELL' UNITS
LOT NO BLOCK MAP NUMBER TATE YES NO
TRACT Ao, a/) P- !.W ZONE SPECIAL
NO OF _ CONDITIONS
SIZE OF LOT d 2.G dI NOW ON LOTS
USE OF '
EXISTING BLDG BUILDING YARD HWY S EET NAME EXIST
// SETBACK WIDTH
OWNER /D E IIdO O FRONT
C /, P L
ADDRESS S C: / r� SIDE
ARCHITECT OR TEL P L
ENGINEER NO INSPECTION RECORD
ADDRESS
CONTRACTOR S TEL a
NO - 1 / O
ADDRES G `2- -6
DESCRIPTION OF WORK
r F - ,Rin//Y h119Z1 MILL ,CSE
NEW ADD ALTER REPAIR DEMOLISH
S FT NO OF NO OF Long nA 7-Eb jz=e �s/t//h/
I' p�
SIZE STORIES FAMILIES /
USE OF "?-O A4 6/1/V,'--) l/
STRUCTURE
SIGNATURE OF ����� - /�'�� �✓ '
APPLICANT
VALUATION$
APPROVALS DATE INSPECTOR S SIGNATURE
PC �Oa PMT FOUNDATION LOCATION /
FEE $ FEE $ O FORMS MATERIALS
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS AP- FRAME FIRE STOPS
BRACING BOLTS
PLICATION AND STATE THAT THE ABOVE IS CORRECT AND
AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND FURNACE LOCATION
GAS VENT DUCTS
STATE LAWS REGULATING BUILDING CONSTRUCTION
1 CERTIFY THAT IN DOING THE WORK AUTHORIZED I LATH, INT /_X
WILL NOT EMPLOYNY PERSON IN VIOLATION OF THE
WORKMEN S CO SATION LA S OF CALIFORNIA LATH EXT 6I
SIGNATURE OF ^ HOUSE NUMBER COR-
PERMITTE % _FECT AND POSTED
ADDRESS --' 37
(✓^sem '�"�'� FINAL e�Z�-� A
CLYDE N DIRLAM, RINCIPAL URAL ENGINEER
PLAN CHECK VALIDATION CK , M O CASH` PERNIIT VALIDATION CK mo CASH
LL 3 s S w �InR 1 4 2 3 D- X 1 5 L*
®.
( (�, 2 R 1 1 D 5 U .0 L r.
{= L ,
WnRKERt'COMPENSATION DECLARATION
I
h0i5by a rm thatj*have a certificate of consent to-self
`msu,:e,6'r a :tificate of Workers Compensation Insurance APPLICATION F OR -BUILDING , PERMIT
or a certified copy thtreof (Sec 3800, Lab C ) w
Policy No ompany��a C4S�41 S -- COUNTY OF LOS ANGELES, C BUILDING AND SAFETY ,k
Certified copy is hereby furnished, =r'�, 'FOR APPLICANT,TO FILL-IN , ADDUILRESS' '
Certified copy is filed with the county building inspec BUILDING L jL —0 ,G'4%r'1�H✓ /t VC'
„ tion department o r ADDRESS c7``TT TTJJ lam+ n_ / 1` c r LOCALITY t C
M
Date AppliconT' CITY °/�/� �� �C _/ Y ZIP
CROSS NEARESST
CERTIFICATE OF EXEMPTION FROM WORKERS' NO OF BLDGS r ASSESSOR
h SIZE OF LOT bO X I3 S` NOW ON LOT 5 MAP BOOK PAGE
COMPENSATION INSURANCE„ ' � PARCEL ,
(This section need not be completed if the"permit is for one /n��� �,' USE ONE MAP n f
" hundSPECIAL
�redidollars ($100)or less ) rF x TRACT CV.2 BLOCK' e LOT NO NO
I'certify that in the performance of the work for which TEL
this
OWNER O'ZZ.e /moo� NOuO�'r Y� CONDITIONS a rtr d
'1p rmit is-issued, I shall not employ any person in any manner r w DIS�CT GR UP TYPE FIRE PROCESSED BY O
so as To become sub ect to ihe`Workers'Com ensation Laws, ADDRESS �� + �✓� �`;� CONST Z E V
` r�jI P S # , ✓
CITY ^>!j,/I�^ K .t �L`(� ,,`{r' ZIP r � -+�°� � ( P � � �- ' O `
"Date Applicant 4 y " x TEL r w i STATISTICAL CLASSIFI�,gTION APT106NDO F
NOTICE TO APPLICANT` If,-after making this Certificate of ARCHITECT OR, y u t Z/, V
ENGINEER b t r , r 'NO CLASS NO I DWELL UNITS
Exemption you should become subject,to the Worker`s 1 y, d
Compensation provisions of the Labor Code, you must forth- ADDRESS - _ dt '^; SEWER MAP
with comply with such provisions or kethis permit shall be � ) Gt j �J _
r deemed revod , r CONTRACTOR / /a� �,v5r� TEL 3S'Z BKVALIDATION
NO
�
LICENSED CONTRACTORS DECLARATION r
LIC UU
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS t D 's g 3 NO VALUATION "
(commencing,with Sectiori 7000)of Dnnsion13 of the Business and - ,// LIC
Professions Code, and my license is in full force and effect ' CITY i'T �� ��sq CLASS $ �v
SQ FT NO OF NO OF CHECK
License Number Lic Class SIZE ��00 STORIES FAMILIES ONE
' r !/ �OG! �0 DESCRIPTION OF WORK V N br NEW ❑ $ 12 J,3yA
Contractor /�K /� Date•
_ s� o ADD Q #,e'e a o`2 3,
m
I aexempt^'under Sec i "FINAL
, ALTER 0
n
B&P C for this reason REPAIR ❑ DAT " 1 a,e 3 9 2 7-
~Date' USE OFf FI e,° 3 9 2,0 7'5
EXISTING BLDG107-SI l�i DEMOL ❑ B
Signature J T APPLICANT j� y TEL f o6, 1 —87
9 . PRINT l e ✓�v G!+ NO
OWNER-BUILDER DECLARATION pp
2 I hereby affirm that I am exempt from the Contractor s License ADDRESS
Law for the following reason (Section 7031 5, Business and -
;i
Professions Code) � ,_ � :� � IPRESENT,
BUILDING - a
1, as owner of the property,.o• my-'employees with ADDRESS a r
' 'wages as their sole compensation,will do the work and T
" the structure is not intended or offered for sale(Section LOCALITY
7044, Business and Professions Code) MOVING r TEL
CONTRACTOR * NO
,.,I, as owner°of the property, am'exclusively contracting ,
With licensed contractors to=construct the project (Sec- " I -
ADDRESS
tion 7044, Business and Professions Code)
REQUIRED TOTAL SETBACK FROM EXIST
J CONSTRUCTION LENDING,`AGENCY, SET BACK YARD HWY PROP LINE WIDTH
I hereby affirm that-there is a constructionelending agency for FRONT ®+ t
the performance of the work for>,;vhich this'permit is,issued, P Li _ a 7j ] A
(Sec 3097, Civ,C ) SIDE _` • s e e o
v , "'Lender s Name P L ` t
$ 3 PC Fee$ Permit Fee 16 1/�� r a1 i ° ° 4 7 1. 7,5 v
Lender's Address 1 XA, '
I certify that I have"read this application and stote that the 16
SU �i yt° �' a 7;3 `8 7
Issuance Fee 1
above information is correct I agree to comply w'ith all County In estigation Fee ^t j'�,
ordinances-and State laws el tin buildingTotal Fee construction, i a tt� i
v and hereby author e r Ives of this County to enter
supo e- ent perty for inspectioPur oses
w i
o { ° SEE REVERSE FOR EXPLANATORY LANGUAGE - ♦ t ,
Signatur/ofAprlicall6t or Agent Z. ate