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HomeMy Public PortalAbout5813 CLOVERLY AVE_Building__ 180 mmiir 76A638A CEtt803 S 66 APPLICATION FOR BUILDING PER pT COUNTY OF LOS ANGELES BUILDING / DEPARTMENT OF COUNTY ENGINEER ADDRESS 1 BUILDING AND SAFETY DIVISION LO C A L I TY JOHN A LAMBIE COUNTY ENGINEER NEAREST �3 j COLEMAN W JENKINS SUP T OF BUILDING CROSS ST' DIS-T�T NO �G TYPE P FOR APPLICANT TO FILL IN v CONST BUILDING - STATISTICAL C IFICATION - SEWER MAP _ ADDRESS vQj l CLASS NC WELL UNITS BK� PG �3 LOT NO lJ EIOCK USE ZONEMAP d , NO �� t TRACT 7 o SPECIAL NO OF BLDOS 4 LCONDITIONS 'SIZE OF LOT NOW ON LOT USE OF EXISTING D BLDG SETBACK FROM _WU TEL /�O/A�/� FRONT PROP LINE OF t - (STREET) OWNER_ NO D(b�j (! TYPE-OFA EX ISTI NO SETBACK- �HIOH WAYi `�" YARD— — TOTAL HIGHWAY WIDTH FROM C L ADDRESS _ _ -� CITY V BLDG S TBACK FROM ARCHITECT OFJ f TEL SIDE PROP LINE OF (STREET) ENGINEER NO TYPE OF EXISTING SETBACK HIGHWAY } YARD` _ .._.TOTAL HIGHWAY WIDTH FROM C L ADD/�RESS _ _ , 17 A % O QD NOTE L � I _ - +_ — _ O p�ADDRESS( a 'WmLIC CORNER CUTOFF ` YES NO V NO CITY O LI` -- SEE REVERSE-SIDE FOR SPECIAL APPROVALS O DESCRIPTION OF WORK u l W CL NEW ADD ALTER REPAIR DEMOLISH SQ FT" NO OF NO OF SIZE STORIES FAMILIES v _ USE OF STRUCTURE ©Vt) \ S \ a SIGNATURE 6F APPLICANT VALUATION$ �?to O APPROVALS DATE INSPECTOR'S SIGNATURE r P C PMT FOUNDATION LOCATION FEE$ FEE$ OFORMS MATERIALS FRAME„FIRE STOPS, ` I HEREBY ACKNOWLEDGE THAT I HAVE READ'THIS PPLICATION BRACING BOLTS _ AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY FURNACE LOCATION WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING GAS VENT DUCTS 9UILDI NG CONSTRUCTION I CERTIFY THAT IN DOING THE WORK AUTHORIZED HEREBY IWILL NOT EMPLOY ANY PERSON IN VIOLA I LATH INT TION OF THE LABOR CODE OF THE STATE OF CALIFORNIA RELAT ING TO WORKMEN SCO MPENSATION INSUfiANCE LATH EXT ' SIGNATURE OF2V 4 HOUSE NUMBER COR- .. PERMITTEE RECT AND POSTED ' ADDRESS Fl NAL. ` PLAN CHECK VALIDATION CK M o CASH PERMIT VALIDATION CK JOHN F LEWIS RINCIPAL TR URAL ENGINEER - M C CASH lF1l�0 3 3 5:� AUG3 0 1 D 0,Ci'4�” T 5t1 _ 1 - i APPLICATION FOR BUILDING PERMIT COUNTY OF'1LGS A"GELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS 1 2 C i I hereby affirm that I have J a Certificate of consent to self insure, BUILDING ADDRESS 6 or a certificate of Workers' Compensation Insurance, or a certified e,0, G copy thereof (Sec. 3800,Lab. C.) CITY- ' ZIP LOCALITY Policy No./A GS^B yS� Company Sfa YL � SIZE LCT NO.OF.BLDGS.NOW ON LOT ❑ Certified copy is hereby furnished. NEAREST CROSS ST. !O Certified copy is filed with the county building inspection TRACT BLOCK LOT NO. department. -y' 1 USE ZONE MAP NO. Date Applicant /dQ ��1C� �ipy ASSESSOR MAP BOOK PAGE PARCEL SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER TEL NO. COMPENSATION INSURANCE W,4,47` fa Q n 0 WITHIN 1000 FT.OF SCHOOL? YES No This section need not be completed if the permit is for one hundred ( ADDRESS P SQ � DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY dollars ($100)or less.) CITY ZIP �• "1 _ J I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws. ARCHITECT OR ENGINEER TEL NO. -STATISTICAL CLASSIFICATION APT NDO Date Applicant ADDRESS CLASS NO. DWELL UNITS NOTICE TO APPLICANT.' If, after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST Exemption, you Should become subject to the Workers' CONTRACTOR TEL NO. �, SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith Alq D c v r FRONT comply with such provisions or this permit shall be deemed revoked. AilbRESS LIC.NO _ P L LICENSED CONTRACTORS DECLARATION &� .r, m� S SIDE CITY LIC.CIL ASS P L I hereby affirm that I am licensed underprovisions of Chapter 9 �O �dVr'a C SEWER MAP } (commencing with Section 7000)of Division 3 of the Business and SQ.FT.SIZ� NO.OF STORIES NO.OF FAMILIES NEW ❑ BK PG a Professions Code,and my license is in full force and effect. ! oil.License Number 6s7a t tf Lic. Class � DESCRIPTION OF WORK ADD VALUATION g � ContractorT(�I✓moh4 .CddF.' Date 2-20-9Y / �S ALTER ❑ /s �O 0 � O Q S iS sr REPAIR El ~ El am exempt under Sec. $ U BAP.C.for this reason DEM IL ❑ W LDMA P/C# CL Date: USE OF EXISTING BLDG. URM ❑ 1 Z Signature APPLICANT(PRINT) TEL NO. LDMA Perm# ❑ I, as owner of the property, or my employees with wages as tG•4 B T, ��''�� Q g 1' their sole compensation, will do the work and the structure is ADDRESS , not intended or offered for sale (Section 7044, Business and �9/f .� �A O Ch /`dr/G� FINAL DATE Q '^ -_ J '•_ Professions Code.) In WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL 1Z,IS.�J J S OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE .t. ITEMS: EI S: ❑ I, as owner of the property, am exclusively contracting 44, AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? Q FINAL BY/� � .� licensed contractors to construct the project (Section 7044, YES❑ NO 0- 2 •. Business and Professions Code.) - WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING - OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH -:+:-.=•? CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR GUIDELINES. i HANfw,l= - a I!I I hereby affirm that there is a construction lending agency for YES ElNo N the performance Of the work for which this permit Is Issued(Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING O 3097,CIV.C.) CHECKLIST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, _ N TITLE 2.CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING HAZARDOUS Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD. o Lender's Address - i=1f OWNER OR AGENT O 0 1 certify that I have read this application and state under penalty of perjury that the above information is correct.I agree to comply P.C.FEE PERMIT FEE ,� . NN with all county ordinances and State laws relating to building (1 �' < construction, and hereby authorize representatives of this County ISSUANCE FEE 00 4Q ' to enter upon t abo menti reed pr perty for inspection purposes. INVESTIGATION FEE TOTAL FEE � - 1 -5S- GgnaWre of Applicant or Agent Dale ' SEE REVERSE FOR EXPLANATORY LANGUAGE