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HomeMy Public PortalAbout5434 CLOVERLY AVE_Building__ r �DEPATMENT OF BUILDING AND SAFETYL�i I�®�RR� COUNTY OF LOS ANGELES EMU a WM' J FOX, CHIEF ENGINEER FOR APPLICANT TO FILL IN FOR OFFICE USE ONLY DISTRICT X10 PLANCK NOPERMIT NO BUILDING ADDRESS s - _ 1,0/12Z RE EIVED BY , I DATY.OFAPPL,,� -DATE ISSUED LOCALITY r NEAREST CR088 STf BUILDING /r/ V/ / ADDRESS D (�(rd (+ OWNER •,I, + LOCALITY MAIL ADDRESS Q, NEAREST TEL /� /� CROSS ST CITY '-. NO FIRE NO OF I =' ARCHITECT 07,j TEL ZONE PLANS PLANS ENGINEER !Vga- l O / SETBACK LINE V��/�/ `� ADDRESS APPROVED TEL BY 1 I ' DATE CONTRACTOR NO USE APPROVED ZONE BY DATE ADDRESS ! �' HOUSE NUMBERING DESCRIPTILEGAL ON LOT` V BLOCK MAP NUMBER —FIELD CHECK BY TRACT ! S 6J1/ /C W NO ASSIGNED BTRA� /I,; I C NO ASSIGNED B AT01,//.7— ��� �►"� l / I NO OFBLDGS -- CORRECTIONS SIZE OF LOT 3 Q' ' .Q Qt NOW ON LOT B/ � USE OF NO OF _ EXISTING BLDG, FAMILIES DESCRIPTION OF WORK NEW I /,-I ALTERATION I I ADDITION 0 REPAIR I DEMOLITION SQ FT NO OF /✓/!� p� SIZE Q U ROOMS STORIES / ✓ Z EXT WALL � � � ROOF }�� COVERING Q � 4� I COVERING /</ ifollt � La«clt USE OF 8TR CTUR6 APPROVALS c INSPECTOR'S SIGNATURE DATE I HEREBY ACKNOWLEDGE THAT-1 HAVE READ THIS AP- FOUNDATION LOCATION PLICATION AND STATE THAT THE INFORMATION GIVEN IS FORMS, MATERIALS CORRECT , i 1 AGREE TO COMPLY WITH THE CORRECTIONS LISTED FRAME FIRESTOPS, HEREON AND WITH ALL COUNTY ORDINANCES AND STATE BRACING, BOLTS LAWS REGULATING BUILDING CONSTRUCTION FURNACE LOCATION, �' r f�r✓ SIGNATURE OF (/ � GAS VENT, DUCTS r PERMITTE LATH, INT n A ADDRESS LATH, EXT .. AUTHORIZED AGT PLASTER, INT 7GA638A Dess I0-6o $ P C $ 0 ✓ FEE b PLASTER, EXT VALUATION, FEE $ FINALS APPLIC�►TIOIoI FOR RIJIL®II�VtCarPERMIT w t T1s. � t ` COUNTY OF LOS ANGELES "' BUILDING AND SAFETY.- r ' r WORKER'S COMPENSATION DECLARATION s FOR APPLICANT TO FILL IN BUILDING ADDRESS / ..+ -`` I BUILDI AD RESS _ khereby affirm that I have a'certificate of consent to self m`sure / V / or a certificate of Workers Compensation Insurance or a certified L copy+thereof'(Sec 3800 Lab,C) , Cl7 A " 4 ZIP -' LOCALITY Policy tJo;'USDV1 Company J ` w SIZE OF LOT NO OF BLDGS NOW ON LOT _ t` ❑ Certified copy is hereby furnished' NEAREST CROSS ST` ❑ Certrf_led copy Is filed with the count bulIdmg ms'ect, n ,r< TRACT BLOCK LOT NO ' r de artmen t + USE ZONE 1 MAP NO x I` ASSESSOR MAP BOOK PAGE PARCEL k Datet�--`—6-'�— Applicant C`�!� ` SPECIAL CONDITIONS � `�1 OWNER TEL NO « - �� ,�' CERTIFICATE OF EXEMPTION FROM,WORKERS' / s COMPENSATION INSURANCE � , t�Ill a`? WITHIN 1000 FT OF SCHOOL'? YES No (This section need,not be completed if the "`���!lIJJJ CITY }C!permit is for one hundred A�D , / 410 xi r DISTRICT GROUP TY CONST FIRE ZONE PROCESSED BY , dollars ($100)or less / 9 c��/ y • . �! ` / I certify that In the performance of'the work for'which this permit © ZI { ` is issued I shall not employ any'person In any,manner so as to ARCHITECT OR ENGINEER TEL NO become subject to the Workers Compensation,Laws STATISTICAL CLASIF�ICATION I APT CONDO Date Apphcant ' r ADDRESS -` CLASS N( DWELL,UNITS i NOTICE TO APPLICANT If after ,making this Certificate Of REQUIRED TOTAL SETBACK FROM EXIST ' Exemption you should' become subject +4o the WorkersCO CT L r ,SET BACK YARD HWY PROP LINE T WIDTH Compensation provisions of the Labor Code`you must forthwith FRONT comply with such provisions or this permit shall'be deemed revoked ADDRE LIC N pi L t r v ��.' O�- O TV5 SIDE [L LICENSED CONTRACTORS DECLARATION CI - ,ql Llc c s PL 0 1 hereby affirm'that I,am licensed unde'rprovisions of Chapter 9 B� �7 �r SEWER MAP (commencing with Section 7000)of Dlvision,3 of the Business and SO FT SIZE NO OF STORIES NO F FAMILIES Professions Code an m lip nse Is to full forceand fect NEW BK PG O0 r DESCRI N OF'WORK, / ADD l �❑ VALUA 0NNj�(� ® J W License Number Lic Class ! 07 �`3G l.�C $ `r Ck1 � Contractor ate• "= ALTER ❑ ❑ I am exempt under Sec c REPAIR ❑ _ Y ae $ > '❑ , k. BBPC-for this reason DEMOL LDMA P/C d Date i' USE OF EXISTING BLDG - - + URM£ ❑ t - .t _ _ 4 Signature - APPLICANT(PRINT)„ _ _ TEL NO , LDMA Perm# j _ , i ❑ I as owner of the property or my employees wdh wages as Z i{ t o IL ^ their'sole compensation.will do{the work-and the structure is ADDRESS - O ` .F i jfi i125.95 '_ not intended'or offered for sale (SecUon'7044 Business and FINAL DATE Q Professions Code) r G f `�!X11 1 - , WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL -� k ❑ I as owner Of the property am exclusive) contractin with OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE y g AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE'S • FINAL BY + j - t �- �- licensed contractorsvto construct the project (Section 7044 r11 ❑ NQ❑ - i i t}"" 12`59 - __e__s t, Business and Profession's Code) I� 1 WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING , 1„HEC►, ) ` 125.59 OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH ' ' r CONSTRUCTION LENDING AGENCY C GOAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FOR UIDE - , ` ✓ , , f ilhi.1GC ' + of5f5 VES❑ + r I hereby affirm that there is a construction lending agency for NOD r C J t��J the performance of the work for which this permit Is issued(Sec a IHAVEREAD THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING ' F (��} J q 3097 CIV C) , CHECKLIST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE , r , _ - -1 l 13-1 II 01 -4 if�f(3 TITLE 2 CHAPTER 2 20 SECTIONS 2 20 100 THROUGH 2 20 140 CONCERNING HAZARDOUS 4 S Lenders Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD m Lender s Address - r OWNER OR AGENT 3 1 certify that,) have read this apphca ton and state under penalty a P C FEE - w PERMIT FEE 0 of perjury thatCjtheformat) iscorrect I agree to complywdh alt countc an ate laws relating to bwldmgm construction ut representatives'of this CountyISSUANCE FEEtoe rill d property for Inspection purps INVESTIGATION FEE TOTAL FEE Y AW-nl a Date y r SEE REVERSE FOR EXPLANATORY LANGUAGE