HomeMy Public PortalAbout5751 CLOVERLY AVE_Building__ 6.here a ORKERS COMPENSATION DECLARATION
Flyracbr thatel haverkcertificate of consent to self APPLICATION FOR �.UI�LDING PERMIT_
• in6ure,.nr a certifrcoRe of Workers' Compensation Insurance,
or a cerfifie d copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Y
Policy No. Company -
Certified copy is hereby furnished. BUILDING
FOR APPLICANT TO FILL IN ADDRESS
'Certified`copy is filed with the county building inspec- BUILDING ;
tion department. ADDRESS 5-t ` i'•eA
Date Applicant CITYp l CT ZIP - LOCALITY ' 7
CERTIFICATE OF EXEMPTION'FROM WORKERS' NO. OF BLDGS. NEAREST
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS ST.
(This section need not be completed if the permit is for one - ASSESSOR
hundred dollars ($100)or less..) TRACT BLOCK LOT NO. MAP BOOK' PAGE PARCEL
TEL
OWNER' S �✓ - .__ NO: � _qq USEFE
NE MAP
I certify that in the performance of the work for which this NO.
permit is issued, I shall not employ any person in any manner t SPECIAL - �
ADDRESS %'' r2 \i/' CONDITIONS 10
so ds'to�/b�com'e subject to the Workers'Compensation Laws. f V
/� mt
CITY `� _ZIP _
Date Applicant
ARCHITECT OR TEL. D IC „ GROUP, TYPE FIRE _ PROCE SED BY-.
NOTICE TO' APPLICANT: If, offer making this Certificate of ,LSiR �.
ENGINEER NO. CONST. ZONE
Exemption, you should become subject to the Workers' � � � � 6.l
Compensation provisions of the Labor Code,-you must.forth- RA-
ADDRESS -5t- (((��� �
with comply with'such. provisions or this permit shall be y
deemed-revoked. .{^ TEL. L.� STATISTICAL CLASSIFICATION APT. CO O. Z
CONTRACTOR J'f/ NO. Z _
LICENSED CONTRACTORS DECLARATION LIC. } \� CLASS NO. - DWELL. UNITS
1.hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS Otf' S• (C NO.(•(
(commencing with Section 7000)of Division 3 of the Business and LIC. SEWER MAP
Professions.Code, and my license is in full force and effect. CITY _ CLASS BK PG VALIDATION
SQ. FT: ~NO. OF NO_OF _ - CHECK
License Number Lic.Class �� SIZE STORIES FAMILIES ONE
{` DESCRIPTIOWOF WORK NEW _ . L _
S ( VA UATI N
Contractor �F jr 00919-e'l Date $
Q
La �/Jac,l` ADD
am exempt under Sec. - ❑
ALTER
B.&P.C. for,this reason ` REPAIRUSE OF
.
Date: EXISTING BLDG. DEMOL
1n1 I
Signatures t'y +11 A�l� APPLICANT TEL. FINAL
r, �-B ALDER D CLARATION (PRINT) NO'�T/ ` t�(G DATE �/� - z-7.
I hereby affirm that I am exempt from.the Contractor's License ADDRESS (/) ��� � O 1 1 A
Law for the following reason (Section 7031.5, Business and FIN # o o '° `o o_�
Professions Code): PRESENT BY "
BUILDINGL
El 1, as owner of the property, or my employees with ADDRESS_ °
.-.2.0 92.5: ,
wages as Their sole compensation,will do the work and " °2 0'9.2 5� ;
the structure is not intended or offered for sale(Section LOCALITY
7044, Business and Professions.Code). MOVING' TEL."
0. 0 1 2"8 7
I, as owner of the property, am exclusively contracting CONTRACTOR NO.
" with licensed contractors to construct the project (Sec-.
tion 7044, Business and Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCY SET�BACK YARD HWY UIRED TOTAPROP.LINE.SETBCK 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
m P.L.
Lender's Name
o LDMA Ref. #
Lender's Address
P:C. Fee.$ ._. - Permit-Fee _... _ .:
_
>
..I certify.that I have read this application and state that the _< Issuance Fee S V - LDMA P/C#
above information is correct. I agree to comply with all County. Investigation'Fee
ordinances and State laws.relating to building construction, Total Fee .4.0 LDMA Perm. #
t� and hereby authorize representatives of this County to enter
upthe DveSntioKdd property or inspectionurposeS.
0 � t
at 1 � SEE REVERSE FOR EXPLANATORY LANGUAGE
igna re.�f Applicant or Agent -- Date
I ,
COUNTY OF LOS ANGELES TEMPLE CITY r # 0508 BUILDING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ALTERATION/REPAIR
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 BL 0508 0506020066
PHONE (626) 285-0488 ERT
LEGAL ID NO OF CONST BUILDING ADDRESS
TR 6561 LT 706 UN 002 SQ FT STORIES TYPE 5751 CLOVERLY AV
STRUCTURE 2800 VN TEMP CA 917802552
ASSESSOR INFORMATION NUMBER NEAREST CROSS STREET WORKMAN
8587-010-010 THOMAS PAGE 596 GRID J3 LOCALITY TEMPLE CITY, C
TENANT EXIST BLDG USE RESID USE ZONE R-1 ISSUED ON PROCESSED BY EXPIRES ON
EXIST OCC GRP 06/02/05 JK 05/28/06
OWNER TEL NO BLDGS NOW ON LOT VALUATION FINAL DATE FINAL BY — COD
—
DISNEY JO ANNE M (626) 287-4778— 4,400
5751 CLOVERLY AV — 5
TEMP 917802552 FEES PAID D R P ON OF WORK
RE—ROOFING, REPLYWOOD 30 YEAR DEMENTIONAL FIBERGLASS SHINGLE
FEE DESCRIPTION QUANTITY UOM AMOUNT ALL NEW MATERIALS HOUSE AND GARAGE
APPLICANT TEL NO
SAME AS OWNER — AA BLDG PERMIT ISSUANCE 27 75
AC STRONG MOTION RESID 4400 00 VAL r 0 50 SPECIAL CONDITIONS
D2 PERMIT W/O EN—HC 4400 00 VALA 132 60
TOTAL FEES 160 85
CONTRACTOR TEL NO APPROVALS DATE INSPECTOR SIGNATURE
SAME AS OWNER —
LIC NO — LOCATION AND SETBACKS
SOILS ENGINEER APPROVAL
ARCHITECT OR ENGINEER TEL NO FOUNDATION/TRENCH FORMS
LIC NO SLAB/UNDER FLOOR <
RAISFD FLOOR FRAMING
e
MAP NO SEWER MAP BOOK PAGE FIRE ZONE CMP UNDERFLOOR INSULATION
150H265 3 01 9
FLOOR SHEATHING
NO OF FAMILIES DWELLING UNITS APT/GOND STAT CLASS
NO 21 ROOF,SHEATHING D
SCHOOL WITHIN HAZARDOUS SHEAR PANELS 7
AIR QUALITY 1000 FEET MATERIALS
NO NO NO FRAME INSPECTION — —
REQUIRED TOTAL SETBACK FROM EXIST FIRE SPRINKLER HANGERS
SET BACK YARD HWY PROP LINE WIDTH
FRONT PL— INSULATION/WEATHER STRIP
SIDE PL—
INTERIOR LATH/DRYWALL
EXTERIOR LATH
RATED FLOOR/CEIL ASSEM
RATED WALL ASSEMBLIES
RATED SHAFTS/OPENINGS
T—BAR CEILINGS
LOT DRAINAGE
REPORT ID DPR261 ROUTE TO BS0508