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HomeMy Public PortalAbout5701 CLOVERLY AVE_Building__ WORKERS' COMPENSATION DECLARATION hereby affirm that I have certificate of consent to Self APPLICATION FOR BUILDING PERMIT, insure, or a certificate of Workers' Compensation Insurance, or a certified copy thereof (Sec. 3800, Lab. C.)) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No./:�.iD� Z Company V/r7/� �/V17 BUILDING Elt70 Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS 6 ❑ Certified copy is filed with the county building inspec- BUILDING tion tion department. ADDRESS CG Date Applicant CITY ZIP LOCALITY NO. OF BLDGS. NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NOW ON LOT CROSS ST. COMPENSATION INSURANCE ASSESSOR (This section need not be completed if the permit is for.one TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL hundred dollars ($100) or less.) TEL.7� OWNER 4-1.49 NO. USE ZONE MAP I certify that in the performance of the work for which this SPE permit is issued, I shall not employ any person in any manner ADDRESS Q 0 74z 9 e A P4 CONDITIONS 0- so as to become subject to the Workers'Compensation Laws. /�,. ' O CITY. F�fJc V7, / Kgl_Lo ZIP Date - Applicant ARCHITECT OR TEL. 0 PP DISTRICT GROUP TYPE FIRE PROCESSED BY NOTICE TO APPLICANT: If, after makingthis Certificate of ENGINEER NO. CONST. Z NE F_ Exemption, you should become subject to the Workers' �O f j w Compensation provisions of the Labor Code, you must forth- ADDRESS 4 ✓ a with comply with such provisions or this permit shall be TEL `��2 STATISTICAL CLASSIFICATION APT. CONDO. N deemed revoked. CONTRACTOR� / v �%' NO. Qp w Z LICENSED CONTRACTORS DECLARATION LIC CLASS NO. DWELL. UNITS — I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO'4q42 2�m SEWER MAP (commencing with Section 7000)of Division 3 of the Business LIC. . and Professions Code,and my license is in full force and effect. CITY CLASS BK li PG � VALIDATION SQ. FT NO. OF NO. OF CHECK License Number `t�l Lic. Class SIZE d STORIES FAMILIES ONE I/ w�, VALUATION Contractor s Date `� ("L 6—4 ^%/ DESCRIPTION OF WORK �s� /� (, NEW ❑ DI' $ ©U© ❑I am exempt under Sec. d LADD El ► n ALTER ❑ B.BP.C. for this reason G S o�O REPAIR $ Date: USE OF EXISTING BLDG. DEMOL El Signature T 'gr (fir/�dli. APPLICANT TEL. FINAL OWNER-BUILDER DECLARATION' (PRINT) NO. I hereby affirm that I am exempt from the Contractor's License DATE Law for the'•following 'reason (Section 7031.5, Business and ADDRESS FINAL it U Professions Code): PRESENT BY BUILDING ❑ I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and , �'/(.— L r•��{ ;a:,_, the structure is not intended or offered for sale(Section LOCALITY J 1�� U :•r_(r 7044, Business and Professions Code.) MOVING TEL. CONTRACTOR NO. ❑ I, as owner of the property, am exclusively contracting _.. with licensed.contractors to.construct the project (Sec- ADDRESS )I=t L 70 s 3� tion 7044, Business and Professions Code.) _ :- REQUIRED TOTAL SETBACK FROM EXIST. '_ � 'L' 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.L. (Sec. 3097, Civ. C.). SIDE P.L. . Lender's Name iJl "J $ (j LDMA Ref. # 'I•=�-F--* Li fit t P.C. Fee Permit Fee G 717' _ Al ;�a ' Lender's Address a 1 certify that I have read this application and state that the Issuance Fee LDMA P/C# , 8 above information is correct. I agree to comply with all County Investigation Fee ordinances and State laws relating to building' construction, Total Fee LDMA Perm. # a and hereby authorize representatives of this County to enter uIne above-mentioned property for inspection purposes. o / SEE REVERSE FOR EXPLANATORY LANGUAGE - ^ Signature of Applicant or gent Date COUNTY OF LOS ANGELES TEMPLE CITY # 0508 BUILDING PERMIT DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS RESIDENTIAL ADD BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 BL 0508 9905070006 PHONE (626) 285-0488 EXT LEGAL ID NO OF CONST NEW BUILDINGADDRESS TR 6561 LT 702 SQ FT STORIES TYPE OCCUP GROUP 5701 CLOVERLY AV STRUCTURE 443 1 VN R3 TEMP CA 917802552 ASSESSOR INFORMATION NUMBER. GARAGE NEAREST CROSS STREET LIVE OAK 8587-010-001 OTHER 90 1 THOMAS PAGE 596 GRID J3 LOCALITY TEMPLE CITY, C TENANT EXIST BLDG USE USE ZONE ISSUED ON PROCESSED BY EXPIRES ON EXIST OCC GRP 05/10/99 UT /06/99 OWNER TEL NO BLDGS NOW ON LOT VALUATION FINAL DATE FINA Y CODE LEE VINCENT,LAI S (626) 285-1697- 34,000 5701 CLOVERLY AV 6 TEMP 917802552 F ES PAIDUE—s—ERTMON OF WORK - 1-STORY ADDITION OF 2 BEDROO AND CONVERT 1 BEDROOM TO FEE DESCRIPTION ''M AMOUNT FAMILY ROOM AND 1 OPEN PATIO APPLICANT SAME AS OWNER - AA BLDG PERMIT ISSUANCE 27 75 AC STRONG MOTION RESID QUO 00 VAL 3 40 SPECIAL CONDITIONS AX BUILDING REVIEW_F� 54 70 62 PERMIT W/ENE�R6�YTO646 31 TAjOO 00 FEES VAL 732 16 CONTRACTOR TEL NO �O�j V/� APPROVALS DATE INSPECTOR SIGNATURE SAME AS OWNER - LIC NO LOCATION ARCHITECT OR ENGINEER TEL NO FOUNDFOUNDATION/TRENCH FORMS / LIC NO / 1111111 SLAB/UNDER FLOOR L RAISED FLOOR FRAMING MAP NO SEWER MAP BOOK PAGE FIRE ZONE C�POiu 3 n n D (� �C n /1 0 n/J USDEREVEORFLNSULSTION 0 FAMILIES C U ILIA \`1JIJ1V1/ rL1^l(I�IJ�((u NO 21 �(� ND LEVEL FLOOR SHEATH SCH55L WITHIN HAZARDOUSi El SHEATHINGi AIR QUALITY 1000 FEET MATERIALS Q ❑ NO NO NO ❑ ® ° ®y IRE DEPT FRAME INSPECT REQUIRED TOTAL SETBACKR EXIST 71� O�� BLDG DEPT FRAME I SPEC SET BACK YARD: HWY PROP LINE WIDTH FRONT PL- SIL. Servlce SHEAR PANELS SIDE PL- L INTERIOR LATH/DRYWALL EXTERIOR LA LOT DRAINAGE DETECTIONS FIRE DEPARTMENT APPROVAL REPORT ID DPR261 ROUTE TO BS0508