HomeMy Public PortalAbout5616 CLOVERLY AVE_Building__ 76AGSBA`188 7 12 54 '
'damPLICA TION FOR' BUIL®I IVG PERMIT � 1
s DIVISION OF BUILDING AND SAFETY BUILDING
Deportment of County Engmeer ADDRESS
County of Los Angeles LOCALITY
WM J FOX COUNTY ENGINEER NEAREST
CASSATT D GRIFFIN, SUP T,OF BUILDING CROSS ST "
DISTRICT NO GROUP TYPE SEWBER MAP
PG
A - FOR APPLICANT TO,' FILL IN T y
BUILDING ro ` CONST 7
ADDRESS rr 1 • MAPq `� STATE YES NO`
NUMBER ! , H
LOT NO S o^C.. i �L BLOCK USE ZO E SPECIAL
- CONDITIONS
TRACTNO OF
SIZE OF LOT Cf
/1-7 /.D ✓ II NOW ON LOTS BUILDING EXISTUSE _
_SETBACK YARD HWY STREET NAME WIDTH
EXISTING BLDG / FRONT
OWNE SIDE
MAIL P L
ADDRESS
_ TEL I DWELL 1 UNIT t' 5 INDUSTRIAL
CITY gym. �f/� NO ZS -
2 DUPLEX_UNIT 6 PUBLIC BLDG
ARCHITECT 20FTEL
EN
GIN� �,,- NO 3 APT UNITS 7 ADDN ALT ETC
ADDRESS 4 COMMERCIAL S MISCEL
t TEL
CONTRACTOR NA INSPECTION RECORD -
ADDRESS
DESCRIPTION OF WORK
NEW A ADD ALTER REPAIR DEMOLISH `
SO FT NO OF NO OF ,
SIZE / STORIES FAMILIES
USE OF STRUCTfJRE
i
SIGNATURE OF���
APPLICANT � APPROVALS
ADDRESS DATE INSPECTOR S SIGNATURE
FOUNDATION LOCATION I '
$ ,L- (j(/4/ P �/� FORMS MATERIALS 4' ly I�5 'Iii--/-�C,,,{p�`•�'
LVALU2ATIO1,/ FEEs ,�- 0-® FBRACING BOLTS
RAME FIRE S
FEE FURNACE LOCATION -
GAS VENT, DUCTS 1
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS
APPLICATION AND STATE THAT THE ABOVE IS CORRECT
AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES LATH INT CO r
AND STATE LAWS REGULATING BUILDING CONSTRUC-
TION . % LATH EXT
SIGNATUREF HOUSE NUMBER COR-
PERMITTE RECT AND POSTED
ADDRESS FINAL ,, 10 tie S
Va& J.•FOX. Couxrr EsGmEm VALIDATION
� '2 9- Mit 14: 1 6 1 5:0 0 e a ��Co sa'6 y3�a�.-� 1,4 ,1 3'2.0 0
-- DEPUTY � DEPUTY
BY BY -
® DEPUTY DEPUTY
WORKERS'COMPENSATION DECLARATION
hereby affirm that I have a certificate of consent to self A P P L I CAT I O N � F O R' BUILDING PERMIT , .
insure, or a certificate of Workers Compensation Insurance,
or a certified cop thereof (Sec 3800, Lab C )
416-347-8c4 COUNTY OF LOS ANGELES , BUILDING AND SAFETY
Policy No ompany State Fund x ,� `
BUILDING
Certified copy is hereby furnished FOR APPLICANT TO,FILL-IN ADDRESS- 5616 Cloverly St
y❑ Certified copy is filed with the county building inspec- BUILDING
tion department > ADDRESS 5616 CloveHy St. -- LOCALITY Tem rl e C1 t
NEAREST `-
Date Applicant CITY Temple City z1p91780 ROSS ST
CERTIFICATE OF EXEMPTION FROM WORKERS' NO OF BLDGS ASSESSOR
r COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL'
(This section need not be completed if the permit is for one US ONE MAP
hundred dollars ($100)or less ) TRACT BLOCK LOT NO Y NO
TEL _ SPECIAL }
IL
I certify that in the performance of the'work for which this OWNER N - CONDITIONS ° i 0
permit is issued, I shall not employ an person in an manner DISTRICT GROUP TYPE FIRE P ESSED BY O
p p y y p i ADDRESS - l !`�/ '^ CONST' / ZONE V
so as to become subject to the Workers'Compensation Laws L UVA ` l{J V
Date Applicant CITY "ZIP STATISTICAL CLASSIFICATION APT CON V .
NOTICE TO APPLICANT If, after making this Certificate of' ARCHITECT OR _ TEL p W
ENGINEER NO CLASS NO _DWELL UNITS
Exemption, you should become subject to the Workers d
Compensation provisions of the Labor Code, you must forth- ADDRESS SEWER MAP N
with_comply with such provisions or this permit shall be rZ
deemed revoked r CONTRACTOR Cedar Roofs CO. _ NO 284-7167 BK PG rVTELALIDATION t
LICENSED CONTRACTORS DECLARATION LIC
I hereby affirm that I am licensed under pro'visi'ons of Chapter 9 ADDRESS P.O. BO 8 NO 157613 VALUATION r -
(commencing with Section 7000)of Division 3 of the Business and UC
Professions Code, and my license is in full force and effect CITY Alhambra CLASS C-39 $ ,
157613 Lic Class C-39 SIZE STORINO IEES MILLIIES CHECK
License Number -
,'a
DESCRIPTION OF WORK Remove existing n NEW ❑ $
ControctorCedar Roofs Co.' Date 10/10/84
❑ I am exempt under Sec roofing & re-roof with FG shgl s ADD ❑
ALTER L
B&P C for this reason ver CH_ext, ply -Class "A„ CO] DA EZ,- -� 0 8 9 6 A
REPAIR
USE OF FINPA
Dat EXISTING BLDG residence - DlsnoL ❑ BY M M
Signature L�/�CW//7 ./%O d���«/ APPLICANT TEL
OWNER-BUIL ER DECLARATION PRINT Robert Bretonne N0284-7167 ► I , 0 7 8 0 Q
I hereby affirm that I am exempt from the Contractor's License ADDRESS 508 S. h1a reno Alhambra 91803
Law for the following reason (Section 7031 5, Business and o a o 7 x Q Q=
Professions Code) U
❑ BUILDING - I 0. 1 6-8 4
I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section LOCALITY
" 7044, Business and Professions Code) MOVING TEL
❑ C NTRACTOR NO J
I, as owner of the property, am exclusively contracting ,
with licensed contractors to construct the project (Sec- ADDRESS ° ?
tion 7044, Business and Professions Code)
REQUIRED TOTAL SETBACK FROM EXIST
CONSTRUCTION LENDING AGENCY , SET BACK YARD HWY PROP LINE WIDTH
I hereby affirm that there is a construction lending agency for FRONT
the performance of the work for which this permit is issued P\
(Sec 3097, Civ C ) SIDE
m PL
o Lender s Name ,
l
P C Fee Permit Fee 67..50
Lender s Address
I certify that I have read this application and state that the Issuance Fee 10.50
above information is correct I agree to comply with all County Investigation Fee x" i
ordinances and State jaws relating to building construction, Total Fee
d and hereby authorize representatives of this County to enter _
upon the above-mentioned property for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date ®s