HomeMy Public PortalAbout6002 CLOVERLY AVE_Building__ sWORK=RS'COMPENSATION DECLARATION
hereby affirm .that I have a certificate of consent to self APPLICATION FOR BUILDING PERMIT
or.9 C .tificate of Workers' Compensation Insurance,.
o nsurE;r r certified�opy then, of (Sec. 3800, Lab. C.)
• � COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy Company
(E' Certified copy is hereby furnished. FOR APPLICANT TO FILL'IN BUILDING
ADDRESS
Certified copy is filed with the county building inspec- BUILDING /J
tion department. ADDRESS ®( LOCALITY v T
NEAREST
Dote 1 Applicant CITY ZIP !&W449CROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKERS'. NO. OF•BLDGS. ASSESSOR
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 NE7 MAP
TRACT BLOCK LOT NO. �G.-� NO.
hundred dollars ($100)or less.) TEL a i. SPECIAL
that in the performance of the wor this OWNER G/ . NO s7 CONDITIONS
IL
I certify P DISTRICT G OUP JTYPE FIRE PROCESSED BY O
permit is issued, I shall not employ an son in any man r i CONST. ZOtyE c� _ U
so as to become subject to the Wo rs'Co ensati n ADDRESS 3
I P CITY v ZIP
Date Appli n ARCHITECT OR TEL. �r�y{ STATISTICAL CLASSIFICATION APT. O.
NOTICE TO APPLICANT: If, after making this,Certificate of ENGINEER NO `�v� CLASS NO. DWELL. UNITS LLI
Exemption, you should become'subject to the Workers''
Compensation provisions of the Labor Code, you must forth- ADDRESS SEWER MAP
with comply with such provisions or. this permit shall be
TEL. ! BK. PG, VALIDATION
deemed revoked.
CONTRACTOR NO. lam— V
LICENSED CONTRACTORS DECLARATION LIC.
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS A4 O. VALUATION n
(commencing with Section 7000)of Division 3 of the Business and LIC. c/
Professions Code, and my license is in full force and effect. CITY CLASS $ ,
SQ. FT. ��JJ NO.OF NO.OF CHECK
License Number Lic.Class SIZE (i STORIES FAMILIES ONE
Contractor Date DESCRIPTION OF WORK
NEW $
ADD
I am exempt under Sec. D ALTER FINAL t`
E] DATE/?
B.BP.C, for this reason REPAIR
USE OF FINAL
Dote: EXISTING BLDG. DEMOL By 1 , �, �O O 6 8 n
Signature APPLICANT TEL. n
g r
OWNER-BUILDER DECLARATION PRINT NO. - 7 -t ij t l
I hereby ffirm that I am exempt from the Contractor's License ' '" # 0 0 0 0 0.�
Law f the following reason (Section 7031.5, Business and ADDRESS
Pions Code): PRESENT o 0 87.38
ro sc
BUILDING
I, as owner of the property, or my employees with ADDRESS '0 0 0 87.3 8t=.-.
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section LOCALITY 7• 1 d a 8
7044, Business and Professions Code). MOVING TEL. O O
1, as owner of the property, am exclusively contracting CONTRACTOR NO.
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.L.
(Sec. 3097, Civ. C.). SIDE.
FO P.L.
< Lender's Name y
P.C. Fee$ Permit Fee
Lender's Address
I certify that I have read this application and state that the Issuance Fee
above information is correct. I agree to comply with.all County Investigation Fee
ordinances and State laws relating to building construction, Total Fee
d and herel4y..atrthoriz resentotives of this County to enter
m upo a above-menti property for inspection purposes.
2
a SEE REVERSE FOR EXPLANATORY LANGUAGE r
es
Signature of App!Kglor Agent Date 's i -
WORKERS'COMPENSATION DECLARATION
affirm that I havecertificate of consent to Self A P P LI CAT I O NI . FOR BUILDING P E RM I T
"' insure, or o certificate of Workers' Compensation Insurance, �. ,
or a certified copy thereof (Sec. 3800, Lab. C.)
�'��TCun 1 COUNTY OF 40S ANGELES BUILDING AND SAFETY
Policy No..Sg�nc{�. Company d '
❑ Certified copy is hereby furnished. FOR APPLICANT TO'FILL INS ADDRESS
Certified copy is filed with the county building inspec- BUILDING
tion deportment. pp ADDRESS
Date Applicant CITY / ZIP LOCALITY
LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' �nV/�S NO. OF BLDGS. NEAREST
COMPENSATION INSURANCE SIZE OF LOT (/A 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
OWNER (moi/` TEL7 �I3O� USE ZONE 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 SPECIAL
ADDRESS 4
so as to become subject to the Workers'Compensation Laws. CONDITIONS U
CITY ZIP
Dote Applicant ARCHITECT OR TEL.
NOTICE TO APPLICANT: If, after making this Certificate of ,�-��" DISTRICT kOUP TYPE FIRE PROCESSED BY
ENGINEER NO. CONST ZONE
Exemption, you should become subject to the Workers' y (3
Compensation provisions of the Labor Code, you must forth- ADDRESS (a(J � a
with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION APT. CONDO. U1
deemed revoked. CONTRACTOR NO. z
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. DWELL. UNITS
—
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS 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+YL-0yGq Lic.Class SIZE STORIES FAMILIES ONE ;@ 9.5.1.2 A
M o VALUATION o 0
Contractor�M �C�. t�oW(L Date �3-'�� DESCRIPTION OF WORK EA.DD Q $ �¢�s{ ;R �t '�v.
❑ I am exempt under Sec. ALTER ❑ ('(J (/ , v JJ 000 0
B.BP.C. for this reason REPAIR ❑ $
DUSE OF
ate: DEMOL
EXISTING BLDG. ❑
Signature APPLICANT /�Sy� TEL. �pp� FINAL �Q
OWNER-BUILDER DECLARATION PRINT DATE L, �—
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and ADDRESS `%iz�T FINAL
Professions Code): PRE EN By
F-11,I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and ® 5.
the structure is not intended or offered for sale(Section LOCALITY
7044, Business and Professions Code). MOVING TEL.
❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO.
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code).
REQUIRED TOTAL SETBACK FRom
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 _
LDMA Ref.,# s
P.C. Fee$ Permit fee
Lender's Address
g I certify that I have read this application and state that the Issuance Fee LDMA P/C#
above information is correct. I agree to comply with all County Investigation Fee
0 ordinances and State laws relating to building construction, Total Fee LDMA Perm. #
d hereb uthorize esentatives of this County to enter
M
u o the o -me lone roperty for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date
WORKERS'COMPENSATION DECLARATION
e�+orato self
a certif carte of Worke s' Compensation a certificate of coent Insurance, APPLICATION FOR BUILDING PERMIT
r or a certified eopy thereof (Sec. 3800, Lab. C.)
_ •.000NTY'OF LOS ANGELES BUILDING AND SAFETY
Policy No. Compariy BUILDING
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN. ADDRESS
❑ Certified copy is filed with the county building inspec- BUILDING
Tion department. ADDRESS r LOCALITY
NEAREST
Date
Date Applicant CITY �
V I �� ZIP ��� CROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKERS' /� /� NO. OF BLDGS. ASSESSOR
COMPENSATION INSURANCE SIZE OF LOT L/ t/ NOW ON LOT - MAP BOOK PAGE PARCEL
(This section need not be completed if the permit is for one USE ZONE MAPQ
hundred dollars ($100)or less.) TRACT BLOCK LOT NO. NO.
7 15e #219,Y
TEL. SPECIAL }
IL
I certify that in the performance of the hich this OWNER NO. CONDITIONS 0
permit is issued, I shall not employ a erson in any nner DISTRICT GROUP TYPE FIRE PRO SSED BY O
ADDRESS / / 5, 61
p CONST. ZONE U
so as tobecomesubject to th W ers'Compensation ows. Q C� d k-3
Date Applic nt CITY ZIP v •STTATISTICAL CLASSIFICAION !1 APT. �ONDO.
NOTI O APPLICANT: If, a er making this Certificate of ARCHITECT OR TEL. O 2
ENGINEER N CLASS NO. DWELL. UNITS
Exemption, you should become subject to the Workers' H
Compensation provisions of the Labor Code, you must forth- ADDRESS SEWER MAP
with comply with such provisions or this permit shall be TEL. L / O
deemed revoked. CONTRACTOR NO. `� BK. PG, VALIDATION
LICENSED CONTRACTORS DECLARATION LIC.
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. VALUA ON
0
(commencing with Section 7000)of Division 3 of the Business and LIC. /1
Professions Code, and my license is in full force and effect. CITY CLASS $ �D ,
SQ. F.TNO.OF •�J NO.OF CHECK
License Number lic.Class SIZE STORIES ! FAMILIES ONE
Contractor Date DESCRIPTION OF WORK
NEW ❑ $
ADD 27.3.5A
❑ I am exempt under Sec. L
ALTER ❑ FINAL
_
B.&P.C. for this reason � ���� DATE # 0 0 o'o 2 3 REPAIR ❑ J � �•
Date: USE OF
F BLDG. DEMOL ❑ FIN ;1 - 176.91
By / ?
Signature APPLICANT TEL. e, _
g OWNER-BUILDER DECLARATION PRINT �r �G'� NO. �/" I1 0 0 1 7 9 1 v
I hereby affirm that I am exempt from the Contractor's License w �� 100. 1 8 5
Law for the followADDRESS ing reason (Section 7031.5, Business and 0 9-
Professions Code): PRESENT
❑ BUILDING
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 C6CALITY
7044, Business and Professions Code). MOVING TEL.
❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO.
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code). 93322 A
REQUIRED TOTAL SETBACK FROM EXIST.
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH `# 0 0 0 0 0 1
1 hereby affirm that there is a construction lending agency for FRONT 0 2 1 6 3
the performance of the work for,which this permit is issued P.L.
(Sec. 3097, Civ. C.). SIDE '0',02
o
P.L.
e
Lender's Name
Lender's Address 11h yP.C. Fee$ Permit Fee 3
I certify that 1 have read this application and state that the Issuance Fee V
above information is correct. I agree to comply with.all County Investigation Fee
$ a d'nonc tate aw sting to building construction, Total Fee. -
u an reby authorize represerif 'ves of this County to enter
Pon Ihe.above-mentioned ro ty for inspection purposes. ,
SEE REVERSE FOR EXPLANATORY LANGUAGE
^ ®s
Signature of Applicant cAgent Date
WORKERS'COMPENSATION DECLARATION
insure, or aherey fcertif cane of Worke s' Compen at oof n eInsuran e, APPLICATION FOR BUILDING PERMIT
or a certified copy thereof (Sec. 3800, Lab. C.).
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company BUILDING
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS L
❑ Certified copy is filed with the county building inspec- BUILDING // .r� ,,) /J l
tion department. ADDRESS p,j�V /V ,` L. !/ LOCALITY
^7 NEAREST
Date Applicant CITY - ZIP l/ CROSS ST.
CERTIFICATE.OF EXEMPTION FROM WORKERS' NO. OF BLDGS. ASSESSOR
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL
(This section need.not be completed if.the permit is for one USE ZONE MAP 15V #245'
1.hundred dollars ($100)or less.) TRACT. OCK LOT NO. NO. C=R0U 7
T' SPECIAL
r SPECIAL
I certify that in the performance of the work for which this OWNER r /V NO. �Io—OG CONDITIONS
permit is issued, I shall not employ any person in any manner > i DISTRICT .GROUP TYPE FIRE PROC SSED BY O
so as to become subject to the Workers' ensation Laws. ADDRESS 10491 CCONST. ZONE . V
S '
X-6-3 ell �� -3
CITY ZIP �J/�"2. O
Date Applicant STATISTICAL CLASSIFICATION APT. CONDO. V
NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL.ENGINEER NO.. CLASS NO. d r DWELL. UNITS LU
Exemption, you should become subject to the Workers' 0.
Compensation provisions of the Labor Code, you.must forth- ADDRESS SEWER MAP
with comply with such provisions.or this permit shall be
deemed revoked. TEL'
CONTRACTOR' NO. BK.4 PG,/J-04/ VALIDATION
LICENSED CONTRACTORS DECLARATION LIC.
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS ' NO. VALUATION
(commencing with Section 7000)of Division 3 of the Business and LIC.
Professions Code, and my license is in full force and effect. CITY CLASS $��� '- ►
SQ. FT. NO. OF, NO. OF CHECK
License Number Lic.Class SIZE 197, STORIES FAMILIES ONE
Contractor Date DESCRIPTION OF WORK
NEW ❑ $
F-1I am exempt under Sec. ADD ❑
ALTER ❑ FINAL / 4 7 3 6 A
B.BP.C. for this reasonREPAIR DATE f1zL�' c o 0 0 0 1 .
USE OF
Date: EXISTING BLDG. DEMOL ❑ By AL �� �~�~ 2'-'- '2'a'5'0
Signature APPLICANT TEL. . \
OWNER-BUILDER DECLARATION PRINT pV NO. Lz � o o 2 8,
I hereby affirm that I am exempt from the Contractor's License ADDRESS Q� 6t' 24-83
Law for the following reason (Section 7031.5, Business and
Professions Code): PRESENT
❑ BUILDING
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.
❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO.
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 HFRONT$
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.).
m Lender's Name
Lender's Address Permit Fee
I certify that l have read this application and state that the Issuance Fee 0
above information is correct:I agree to comply with.'all County Investigat on Fee F
g ordinances and.State:laws'relating to building construction, Total Fee tl • 'w
d and hereby authorise representatives of this County to enter
m ul o the above-riieq Vad property for.inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of pp icant or Agent Date
®s
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 BUILDING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ALTERATION/REPAIR
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 BL 0508 1203060004
PHONE: (626) 285-0488 EXT:
ILEGAL ID: NO. OF CONST I BUILDING ADDRESS: I
1TR: 6561 LT: 302 ! SQ. FT STORIES TYPE ! 6002 CLOVERLY AV !
1 ISTRUCTURE: 2200 V-B I TEMP CA 917802025 1
(ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET: WOODRUFF !
15385-007-013 ! THOMAS PAGE: 596 GRID: J3 LOCALITY: TEMPLE CITY, Cl
ITENANT: !EXIST BLDG USE: RESID USE ZONE: R-2 JISSUED ON: PROCESSED BY:
(EXIST OCC GRP: 103/06/12 SR
I I I I
(OWNER: TEL. NO: 1BLDGS. NOW ON LOT: VALUATION: IFINAL DATE FIN CODE: 1
1HEPLER ROBERT R JR;CINDI A (626) 309-9308- 3,500 ` !
16002 CLOVERLY AV I I I
ITEMP 917802025 I FEES PAID IffESCRIPTION OF WORK v !
I I IRE-ROOF OVER EXISTING 3-TAB COMP I
I IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT: ! I
(APPLICANT: TEL. NO: I I I
ISAME AS OWNER - IAA BLDG PERMIT ISSUANCE 27.80 1 I
I IAB STATE GREEN BLDG FEE 3500.00 VAL 1.00 ISPECIAL CONDITIONS: 1
1 1AC STRONG MOTION RESID 3500.00 VAL 0.50 ! 1
I ID2 PERMIT W/O EN-HC 3500.00 VAL 115.80
I TOTAL FEES 145.10
ICONTRACTOR: TEL. NO: I 1APPROVALS DATE INSPECTOR SIGNATURE 1
ISAME AS OWNER - I I !
I LIC. NO I ILOCATION AND SETBACKS 1 ! !
I ! ISOILS ENGINEER APPROVAL 1 1 !
I ! I I I I
(ARCHITECT OR ENGINEER: TEL. NO: ! IFOUNDATION/TRENCH FORMS I I
! LIC. NO: I 1SLAB/UNDER FLOOR I I I
I I I I ! I
! I IRAISED FLOOR FRAMING I !
I I ! I I !
IMAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP: 1 !UNDERFLOOR INSULATION I I I
1150H265 3 001' I 1-1 I
I I (FLOOD SHEATHING
INO. OF FAMILIES: DWELLING UNITS: APT/COND: STAT CLASS: I I I I
1 0 NO 21 1 IROOF SHEATHING I I
I I I ! I !
1 SCHOOL WITHIN HAZARDOUS ISHEAR PANELS I I I
(AIR QUALITY: 1000 FEET MATERIALS ! 1 1
I NO NO NO (FRAME INSPECTION I I
I I ! I I I
! I IFIRE SPRINKLER HANGERS 1 !
! ! I ! I I
I I IINSULPTION/WEATHER STRIP( I I
I I I I I I
! 1 11NTERIOR LATH/DRYWALL I I I
I I I ! I I
1 ! (EXTERIOR LATH I I !
IRATED FLOOR/CEIL ASSEM. 1 ! I
! I ! I I I
I I IRATED WALL ASSEMBLIES I I 1
IRATED SHAFTS/OPENINGS I 1
I i I I I I
1 ! IT-BAP. CEILINGS I I
! ! ILOT DRAINAGE ! 1 I
I IREPORT ID: DPR261 ROUTE TO: BS0508 I I I I
I ! I I I I