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Home My Public Portal About5724 CLOVERLY AVE_Building__ APPLICATION FOR BUILDING PERMIT COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDI G�j�D,DR SS I hereby affirm that I have a certificate of consent to self Insure BUILDING ADDRESS 2 nIb Vit V -1 or a certificate of Workers Compensation Insurance or a certified C copy thereof(Sec 3800 lab C) C�I{�� SIC CITY l r ��' ZIP 017 Policy NO 3 bb 4S company IH.��. �K V` to LOCALITY y SIZE OF LOT NO OF BLDGS NOW ON LOT Certified copy is hereby furnished I NEAREST CROSS ST ❑ Certified copy Is filed with the countyygldIn I spectlon TRACT BLOCK LOT NO de artm nt `/ /] USE ZONE MAP NO r P r _ e1( ASSESSOR MAP BOOK PAGE PARCEL Date 8 "V •Applicant, SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER TEL NQ COMPENSATION INSURANCE �� $/ 22�— WITHIN 1000 FT OF SCHOOLS ves No This section need not be completed If the permit Is for one hundred ADDRESS ( P P - 15}Z 4 C(omC* V DISTRICT GROUP TYP NST FIRE ZONE PROCESSED BY dollars($100) or less) - �f , CITY IP I certify that In the performance of the work for which this''permit' ( y/ �e-.g 6 s Issued I shall not employ any person in any manner so as to y C// become subject to the Workers Compensation Laws ARCHITECT ORE (NEER - - TEL NO - - STATISTICAL CLASSIFICATION � APT CONDO 1 Date Applicant ADDRESS CLASS NO 4491 DWELL UNITS NOTICE TO APPLICANT If after making this Certificate-of REQUIRED TOTAL SETBACK FROM EXIST Exemption- you Should become subject Jo the Workers CONTRACTOR TEL NO SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code you must forthwith hv r`,a :43 1 33^2 q i FRONT comply with such provisions or this permit shall be deemed revoked ADDRESS LIC NO - PL 3o Z �- ��Co X31 . 04 C6 SIDE LICENSED CONTRACTORS DECLARATION CITY LIC CLAS PL I hereby affirm that I am licensed underprovlsions of Chapter 9, s SEWER MAP (commencing with Section 7000)of Division 3 of the Business and SQ FT SIZE NO OF STORIES I NO OF FAMILIES Professions Code and my license is In full f ce and effect "2-2— i F; _P • NEW ❑ BK PG d License WuwNer�7 p Lic 7 D DESCRIPTION OF WORKr ADD E] VALUATION Q Contractor 1`a Ro�FilCfEi Date (6'2(01 / C),q ,-k f ALTER ❑ p�� M 0 ElI am exempt under Sec REPAIR ❑ $ 0 B&PC for this reason G � e� � Le_T DEMOL ❑ V LDMA P/C# �. W Date USE OF EXISTING BLDG V URM ❑ CO Signature APPLICANT(PRINT) TEL NO LDMA Perm# 1 T n 8 Z El as owner of the`'property or my employees with wages as - 2-- l I Z nil` their sole compensation wlll'do the work and the structure Is, ADDRESS 0 not Intended or offered for sale (Section 7044 Business and FINAL DATE Q 3303 U5.55 Professions Code) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE J 1 ITEMS El I as owner of the property am exclusively contracting with AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDES FINAL BY 5 licensed contractors to construct the project (Section 7044 TOTAL 125 ®55 Business and Professions Code) YES C1 No❑ r WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING CHECK - 125.55 OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR GUIDEUNES CHANGE , - 000 I hereby affirm that there is a construction lending agency for YES❑ No❑ _ N the performance of the work for which this permit is issued(Sec rnI HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING 3097 CIV C) CHECKLIST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE (1/11111�f 1ft(11 10/�L/OC N i TITLE 2 CHAPTER 2 20 SECTIONS 2 20 100 THROUGH 2 20 140 CONCERNING HAZARDOUS Lsilv/vVvU IJWO 1 O 7 Lenders Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD `o Lenders Address 3035 1 AM11:41 O OIYNER OR AGENT 3 ' o I certify that I have read this application and state under penalty 0 of perjury that the above Information Is correct I agree to comply PC FEE PERMIT FEE w with all county ordinances and State laws relating to budding CO construction and hereby authors a representatives of this County - ISSUANCE FEE 7 30 M to enter n th abov entson d property for Inspection rpos s m �t9 2 INVESTIGATION FEE TOTAL FEE Sgdrm of ow�t a Age SEE REVERSE FOR EXPLANATORY LANGUAGE APARTMCOUNTY OFT OF LLOS ANGELES T 1 n APPLICATION FOR PERMIT WM. J FOX. CHIEF ENGINEER ING AND SA 1J U I L D N G FOR APPLICANT TO FILL IN ° FOR OFFICE USE ONLY BUILDING rj/ ��o+V fyeyd�� DISTRICT NO PLAN CK NO PERMIT NO ADDRESS Z LOCALITY /'e V RECEI ED/BY�l DATE OF APP DATE ISSUED NEAREST CROSS ST l� V //// VA J' IT BUILDING OWNER // hj�`� e!(t) R. ADDRESSMAIL ADDRESS (�0 �d /'�Uh1�? l d �' e/ld'ant e LOCALITY V NEAREST- TEL CROSS ST CITY NO �� FIRE f OF TYPE GROUP}1, PL ARCHITECT OR TEL ZONE PLANS /'" ENGINEER NO BLDG /� ORD NO ADDRESS '�-- SETBACK LINE ), TT /fie APPROVED C 0NTRACTOR At IA JUS NOL• Q BY DG4TE TAA. �P soM �� USE APPROVED ADDRESS �2-� AA. kwk u ZONE v By, DATE LEGAL CORRECTIONS DESCRIPT 'Api BLOCK TRACT NO OF BLOBS SIZE OF LOT�� I NOW ON LOT # (04 l USE OF NO OF NO6OF,.,,m..� _ c EXISTING BLDG FAMILIES ROOMS DESCRIPTION OF WORK NEW ALTERATION I I el ADDITION r REPAIR MOVING DEMOLISH 9q FT NO OF SIZE / 0 ROOMS STORIES • ZD r WALL ��drS ' ROOF COVERING ` �� 4 ' �' COVERING O, BUILDING �� 7 moi/ '�',� �`��7 0 1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPROVALS APPLICATION AND STATE THAT THE ABOVE IS CORRECT FOUNDATION LOCATION INSPECTOR DATE AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES FORMS,MATERIALS AND STATE LAWS REGULATING BUILDING CONSTRUCTION FRAME FIRESTOP9, SIGNATURE OF Airs..,e BRACING.BOLTS / J PERMITTE LATH, INT � AUTHORIZED AGT i� LATH, EXT cC 76A638A 9-48 DSS-3 SOM SETS $ n FFEE y{ PLASTER, INT Y� � PLASTER,E `c�VALUATION f FINAL rt+-A..,2 ,q y�� WORKERS' COMPENSATION DECLARATION �.APPLICAION FOR BUILDING PERMIT- I�ierekiy (•,ffirm that I have a certificate of consent to self � , Jhe,o y a irm tj ate of Workers Compensation Insurance, - t 11 or : certified copy thereof (Sec 3800, Lab4 C ) x, COUNTY OF;,OS+;,' LES M4 BUILDING AND SAFETY Policy No - Company copy hereby,furnished FOR APPLIC NT T,Ok' ILL IN; t BUILDING - % ❑ Certified co is hereb furnished c_ ; , ADDRESS l/(•� ❑ Certified copy is filed with the county building inspec- BUILDING tion department _ ADDRESS • ++ � _. ._ - - I �� ') 1 Date Applicant CITY ZIP LOCALITY NO OF BLDGS NEAREST - + CERTIFICATE'OF EXEMPTION FROM WORKERS' SIZE OF LOT NOW ON LOT CROSS ST ' MCOMPENSATION INSURANCE - ASSESSOR (This section need not be completed if the permit is for one TRACT BLOCK LOT NO MAP BOOK ��,J�J / PAGE PARCEL��a hundred,dollars ($100) or less ) TEL OWNER USE ZONE MAP } I certify that in the performance of the work for which this NO t '. permit,is issued, I shall not employ any person in any manner ADDRESS - Z L/ SPECIAL K CONDITIONS + CL so as to,b=co esu act to the,Wor ers Compensatio Laws + _ O l/� CITY ZI Date_Applicant ARCHITECT O iy EL -7 D DISTRICT GROUP TYPE FIRE PROCESSED BY O NOTICE TO APPLICANT If, after making his ertifi ate f - ENGINEER �" NO 1 v 6 I-- Exemption, Exemption, you should become subject to he Workers' CONS ZO E w Compensation provisions of the Labor Code, you must-forth- ADDRESS 3 a �� LSa�t� a with comply with such provisions or this permit shall be TELJN STATISTICAL CLASSIFICATION _ APT CONDO 7 Z deemed revoked CONTRACTOR NO 1 — LICENSED CONTRACTORS,DECLARATION _ UC CLASS NO DWELL UNITS ` I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO _ , (commenting with Section 7000)of Division 3 of the Business UA W LIC SEWER MAP and Professions Code,and my license is in full force and effect CITY CLASS BK PG VALIDATION • SQ FTfL4 NO OF I NO OF CHECK ' License Number Lic Class SIZE STORIES Q/v FAMILIES f ONE VALU TION A� Contractor Date DESCRIPTION OF WORK NEW ElI am exempt under Sec ADD f El,t ALTER ► B&P C for this reason ''v)'" REPAIR ❑ $ ' USE OF Date EXISTING BLDG �GL, �l{' T DEMOL ❑ Signature { { APPLIC T i (T FINAL NT ' - NOLZ -� � _ OWNER BUILDER DECLARATION _DATE 7S I hereby affirm that I am exempt from the Contractor's License Lthe following reason (Section 7031 5, Business and ADDRESS U D v FINAL p a �Frofr ons Code) L PRESENT- _ gyA�tT.�I BUILDING -A , as owner of the:property, or my employees with ADDRESS %,J J`'u 050.50 wages as their sole compensation,will do the work and gi '- 4.' the structure is not intended or offered for sale(Section LOCALITY 7044, Business and Professions Code ) MOVING TEL `} -� A(1 Tns ❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO ti with licensed contractors to construct the project (Sec-44JJ�� 711.17 ADDRESS -tion 70 , Business and Professions Code ) ">� :�+ ."u �' CONSTRUCTION LENDING AGENCY REQUIRED TOTAL SETBACK FROM* EXIST � .?-ITE15 -- YARD HWY SETBACK PROP LINE WIDTH " �l I hereby affirm that there is a construction lending agency for FRONT_ y k2 '�`T{'_ITA } m ` the performance of the work for which this permit is issued P L (Sec 3097, Civ c ) SIDE CHECK 761.67 s Lenders Name +J/t, �,}7+,. EHANGE - aO D LDMA Ref # PC Fee$ '�V Permit Fee Lender's Address 0 1 certify that I have read this application and state that'the Issuance Fee 3o LDMA P/C# 0000-0001 6/14 '96 8 above information is correct I agree to comply with all County Investigation Fee - Ej ? 1 A�11�SQ R ordinances and State laws relating to building construction, a Total Fee / �� LDMA Perm # a and hereby auth`orize representatives of this County t enter' upon the ab ve mentioned pr erty for"mspecyPon u pass - < SEE REVERSE FOR EXPLANATORY LANGUAGE a Signature of Atphcorft or A e Date `