Loading...
HomeMy Public PortalAbout6220 CLOVERLY AVE_Building__ APPLICATION FOR-BUILDING PERMIT FOR APPLICANT TO FILL-IN (Print or type only) BUI`.OING4 _ � {�U.�;,'3� - COUNTY OF LOS ANGELES _ ADDRESS _ DEPARTMENT OF COUNTY ENGINEER CITY l�'J //I '� z I P BUILDING AND SAFETY DIVISION { �y O OF BLDGS BUILDING _ SIZE OF LOT / V V NOW ON LOT ADDRESS TRACT �;/ BLOCK LOT NO Z-7— LOCALITY �G TEL NEAREST OWNER (/ �NO„ CROSS ST ` _ ASSESSOR ADDRESS �6ta.c �-- MAP BOOK' PAGE-' PARCEL �r � DISTRICT GROUP TYPE FIRE ESSE`O BY ot_gCITY' IQ"r LijG% A/J ZIP ? 1�D t' CONS' - ZONE ARCHITECT OFT TELENGINEER NO NO _ STATISTICAL CLASSIFICATION SEWER MAP ADDRESS CLASS NQ �_DWELL UNITS BK PG CONTRACTOR TEL USE ZONE MAP LIC l NO _ OO ADDRESS - - -- NO --- /v SPECIAL LIC CONDITIONS CITY - CLASS ROAD DEPARTMENT APPROVAL REQUIRED YES NO ❑ CONSTRUCTION LENDER NAME AND BRANCH BLDG SETBACK FROM - y, FRONT PROP LINE OF (STREET) ADDRESS- CITYHIGHWAY + YARD —_ TOTAL SETBA-C ROM TYPE OF EXISTING V SQ FT NO OF ' NO OF CHECK FRONT PROP LINE HIGHWAY WIDTH SIZE STORIES® FAMILIES ONE O + DESCRIPTION OF WORK ��j/- ®�� NEW - W BLDG,SETBACK FROM N ADD ❑ SIDE PROP. LINE OF (STREET) Z_ ALTER ❑ HIGHWAY } YARD TOTAL SETBACK FROM TYPE OF EXISTING REPAIR =❑ SIDE PROP LINE HIGHWAY WIDTH USE OF EXISTING BLDG DEMOL ❑ APPLICAN /��i �L . �, CORNER CUTOFF YES ❑ NO ❑ (PRINT) {/ O• ,� l6jJ IN OPEN SPACE - YES ❑ NO ❑ _ BY (SIGNATURE) -- _ - - Q IN COASTAL ZONE YES ❑ NO - VALUATION - - - ' - CATEGORICAL EXEMPTION YES❑ NO IHEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION ENVIRONMENTAL , AND STATE THAT THE ABOVE IS CORRECT'AND AGREE TO COMPLY IMPACT EXEMPTION DECLARATION SIGNED (DATE) WITHALL ORDINANCES AND LAWS REGULATING BUILDING CON- STRUCTION I CERTIFY THAT IN DOING THE WORK AUTHORIZED IMPACT REPORT PROCESSED (DATE) HEREBY I WILL NOT EMPLOY ANY PERSON IN VIOLATION OF THE LABOR CODE OF TH TATE OF CALIFORNIA IN RELATING TO WORKMEN'S COMPE AT H SIGNATURE OF ` Fj� _PERMITTEE _ _ - - _ ADDRESS f ' AIV FINAL TEL DATE CIT _ ` NO r 11 U\E (.HLCKS PA) -113LL- 10 FEE � ' — rPMT FEE HARVEY T. BRANDT, COUNTY_ENGINEER ._zG PLAN CHECK VALIDATION CK M 0 CASH _ PERMIT VALIDATION CK M CASH -gf1�sEP 6 i A., 1 5.00 .b8 76-A638A CE 4803 12/72. 4� ©s 7tlA6�k8A~ CE#MN�IEV 6/78) APPLICATION FOR, BUILDING PERMIT COUNTY OF-LOS ANGELES BUILDING AND SAFETY FOR APPLICANT TO FILL IN BUILDING .`, ADDRESSBUILDINq ADDRESS LOCALITY NEAREST d � - CITY�� G ✓ ZIP CROSS ST O OF BLD6S ASSESSOR SIZE OF LOT NOW,ON LOT _ MAP BOOK PAGE PARCEL " DISTRICT GROUP TYPE FIRE- OCE D BY TRACT 7 �� , BOCK ti , �, LO L NCO(r vC�j� Ory � CONS 7041F OWNERO�/IrJil�6�7 Q STATISTICAL CLASSIFICATION S SER M� ADDRESS CLASS NO DWELL UNITS BPG - CITY1ZIP ARCHITECT OV TEL VALUATION $ C;2,4q_&-n - ENGINEER NO ADDRESS BLDG SETBACK FROM ' TEL FRONT PROP LINE OF (STREET) CONTRACTOR NO HIGHWAY + YARD _ TOTAL SETBACK FROM TYPE OF EXISTING LIC FRONT PROP LINE JHIGHWAY WIDTH ADDRESS NO LIC + CITY CLASS BLDG SETBACK FROM CONSTRUCTION LENDER NAME AND BRANCH SIDE PROP LINE OF (STREET) , HIGHWAY + YARD = TOTAL SETBACK FROM TYPE OF EXISTING 106 ADDRESS CITY SIDE PROP-LINE HIGHWAY WIDTH O SO FT NO OF NO OF CHECK + = V SIZE STORIES FAMILIES ONE DESCRIPTION OF WORK NEW ❑ PC Fee$ Permit Fee O ADD .❑ Issuance Fee _ n ✓�.�� ALTER JC~ R AIR ❑ Total Fee= USE OF DEMOL ❑ EXISTING BLDG / p(yC Z APP'RANT � �� O�4E_✓''NIV TELa QO _ BY(SIGNATURE) i I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL ORDINANCES W AND LAWS REGULATING BUILDING CONSTRUCTION I CERTIFY THAT IN DOING THE 0 S _ WORK AUTHORIZED HEREBY I WILL NOT EMPLOY ANY PERSON IN VIOLATION OF lJ ' THE LABOR CODE OF THE STATE OF CALIFORNIA IN RELATING TO WORKMEN S COM - - , • z 4'S G, 1 A PENSATION INSURANCE 1 #,O 0'0p0.O 1 SIGNATURE OF n PERMITTEE 2,0 o 3 4 b o ADDRESS TEL O ;o o o 3(,006 CITY NO p Q 6 2 3'-7 9 USE ZONE MAP ©O S E Q SPECIAL � CONDITIONS FINAL IBY DATE APPLICATIO FOR BUI 'ING PERMIT FOR APPLICANT TO FILL INBUILDNG (Pftni or rYce only) > - ADD EISS C F BUILDING L/ ADDRESS GITY m L 17 V ZIP h N OF BLDGS LOCALITY SIZE OF / V NOW ON LOT / NEAREST - CROSS ST ASSESSOR TRAC "? BLOCK LOT NO &-2 MAP,BOOK - PAGE CEL - QQ� TE / DISTRICT GROUP •TYPE FI PROC SED Y OWNER ,V e- I' N � / = CONST, Z D E ADDRESS L ��K L STATISTICAL CLASSIFICATION SEWER WP ClTY5qi4lJ ji ZIP / CLASS NO. -DWELL UNITS .,BK _PG,, . ARCHITECT 6R TEL ENGINEER NO /ONE NAA ADDRESS - - - - O SPECIAL TEL. CONDITIONS CONTRACTOR ry - - ROAD DEPARTMENT APPROVAL REQUIRED YES❑ f4❑ LIC. ADDRESS NO BLDG SETBACK FROM LIC FRO T PROP LINE OF - (ST,REETI, CITY CLASS _ TOTAL SETBACK FROM TYPE OF' EXISTING HIGH AY } YARD FRONT PROP LINE CONSTRUCTION LENDER � - HIGHwA-v, „WIDTH, NAME AND BRANCH ADDRESS - CITY - + SQ FT NO OF NO. OF CHECK BLDG. TBACKFROM "'"' p SIZE STORIES FAMILIES ONE SIDE PRO (STREET) C') OCTA .B-ACK FRO YPE OF EXISTING DESCRIPTION OF WORK NEW HIGHWAY }' YARD - HI WAY WIDTH � '❑ SIDE PROP. LINE C~_7 + _ w ALTER ❑ N 1A,/ ��''� ISI CORNER CUTOFF YES ❑ _ NO ❑ Z REPAIR ❑ USE OF EXISTING BLDG DEMOL ❑ IN OPEN SPACE YES,[] NO, ❑.', .,_ �, AP PRINT) / �fjpL IN COASTAL ZONE YES C] NO ❑, BY (SIGNATURE) ENVIRONMENTAL CATEGORICAL EXEMPTION YES❑ NO ❑ a - IMPACT EXEMPTION DECLARATIOWSIGN ED - _ (DATE) i VALUATION W O IMPACT REPORT PROCESSED (DATE) I HEREBY ACKNOW EDGE THAT I HAVE READ THIS�APPLICATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY i���S l�JrT� / O�/fi` it�� WITH ALL" ORDINANCES AND LAWS REGULATING BUILDING-CON- J ��� 6� " !6i" I STR UTION I CERTIFY THAT IN DOING THE WORK AUTHORIZED HEREBY I WILL NOT EMPLOY ANY PERSON IN VIOLATION OF THE LABOR CODE OF'TH TATE OF CALIFORNIA IN RELATING TO WORKMEN'S CO MPEN T H SURA NCE NAL SIGNATURE OF DTE IA /Fw' I VV BY PERMITTEE �/ f ` - (J ADDRESS V !YL� PC $ � ,/ 'PMT Q - '• FEE FEE A f /� ` NEL CIT � �L PLAN CHECK VALIDA ON CK M O CASH PERMIT VALIDATION CK M " CASH o a 4 1 0 4 8.7 5�,&5` Ulf - - - - 76A638B CE#803A-5/73 - - - - - -• - - - - DEPARTMENT OF BUILDING AND SAFETY APPLICATION FOR PERMIT COUNTY OF LOS ANGELES U ' M WM. J. FOX. CHIEF ENGINEER BING FOR APPLICANT TO FILL IN FOR OFFICE USE ONLY DISTRICT NO. "PLAN CK.NO. PERMIT NO. BUILDING ADDRESS Z�d Cloverly Ave. �• J" b 3 70 U S-6 03 LOCALITY / Gr RECEIVED BY DATE OF APPL. DATE ISSUED NEARER, Flaherty-St. , Temple City �a BUILDING A i Z , OWNER Meeker Land Company ADDR MAIL 11236 E. Live Oak Ave. LOCALITY C�ADDRESS NEAREST ' Clry Arcadia E Y�rte/ FIRE NO.OF TYPE GROUP ARCHITECTal O A•Bissell No. FL-7J+ 20 ZONE PLANS ENGINEER lTe BLDG. ORD.NO. / _ _ r ADDRESS BETBACK,LINE D APPROVED CONTRACTOR Nps. BY DATE USEAPPROVED ADDRESSZONE-2 ON7E BY DATE LEGAL- DESCRIPTION LOOT NO. 22 BLOCK v CO/�)RRECTIONS TRACT 17179 - f �} O xl O NO.OF BLOTS. none SIZE OF LOT � H' NOW ON LOT USE OF none NO.OF NO.0P6 EXISTING BLDG. FAMILIES ROOMS Q ' �c�C) Al/14-74�Al DESCRIPTION OF WORK'// jy�9 NEW X ALTERATION ADDITION I !G 7- AlG7R � /-l. � �/J•` v REPAIR MOVING DEMOLISH (2, u4 I 9 7 A�, 1 V27 1 SIZE 111$�" ROOMS 6 STORIES WALL ROOF COVERING Plaster I COVERING W•Shgles• USE BUILDI DNG /yam-NEW Residence (' S �((� /` A/✓Z}�l > � Plan 1-CIfp- Garage 18 x 20 1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPROVALS APPLICATION AND STATE THAT THE ABOVE IS CORRECT ION: LOCATION INSPECTOR DATE r� AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES FOUNDA - y FORMS.TMATERIALS AND STATE LAWS REGULATING BUILDING CONSTRUCTION. FRAME: 91DNATURE OFM R LAND Y BRACING,BOLTS PERMITTE LATH, INT. AUTHORIZED LATH, EXT. 76A639A-3 7-4e $ �� p,C L4 PLASTER, INT. FEE • ,= PLASTER,EXT. $ Z 7 VALUATION t� FEE 3 / FINAL � RKERle, MPENSATIONDECLARATION hereby irm ( aver certificate of consent to self ; y A P P L I CAT.I ON- FOR :B U I L'D[N G. -PERMIT T �� insure,cyr ahcertificate oi'Workers' Compensation Insurance, y - - or acertified copy thereof•(Sec 3800, Lab C ) - COUNTY• OF LOS•ANGELES`. BUILDING•AND•SAF&Y Policy No- Company - - - -- Certified co R IN is hereb .furnished ., „ FOAPPLICANT TO FILL BUILDING .�. ADDRESS' /) Certified copy'is filed with the county building inspec- ' BUILDING p� Y' r - ti on department• s',^t:,i`` ,- >. t ADDRESS A' ® l��V�-K t I Date : ' Applicant :^ .,_c. •i ,' • •tC. CITY ZIP G LOCALITY ' CERTIFICATE OF EXEMPTION FROM-WORKERS' - _ NO OF BLDGS - NEAREST_ COMPENSATION-INSURANCE r, y SIZE OF LOT NOW ON LOT CROSS ST J (This'section.heed'not,be+completed if•the permit is for one n-•-y- -�- `�"-- - - -- s ASSESSOR'•' - - -' '••;?r` hundred dollars ($100)or,less ) , TRACT BLOCK LOT NO MAP BOOK - PAGE I PARCEL , _ � TEL - - '� i " - OWNER - r N C'-�4 USE O�IE rN P- - 1 I'certify That in'the performance of the work'for which.this' /,� _ Er V� permit is issued, I shall not employ any person in any"manner . L� � «�__ �y, - CIAL• dso as to-become subject to the Workers',Compensation Laws ADDRESS 6 - U Z• NDITIONS t,- a +V CITY .i ZIP. �U O _ O Date'" 'Applicant ARCHITECT OR TEL NOTICE'TO-APPLICANT If,'after making This Certificate of ENGINEER NO DISTRICT GROUP NPE. • FIRE PRO ESSED BY Exemption,%you should become subjecl2'to""the •Workers' _ ��[/ CONSTa, ZONNTE W Compensation provisions.of the Labor'Code, you must,forth- ADDRESS &nE -•Y L�y - - v y with •comply with,such•provisions or.this•permit,shall be - .. , _, __ -•y TEL STATISTICAL CLASSIFICATION APT C DO deemed revoked ,, ;• .t .,'F„ •; _ CONTRACTOR NO _ � _. LICENSED CONTRACTORS DECLARATION <',', -- - --LIC - - - - CLASS NO + _ DWELL UNITS I hereby offirm,that I am licensed under provisions of Chapter 9 ADDRESS NO - (commencing with Section.7000)of NVision 3 of the Business and _ w - _ . _ . AIC E P SEWER MA Professions Code,'and my license'is m full force and effect CITY CLASS ' " BK "'-s VAL'IDATION t " SQ FT NO OF I _ _ NO OF CHECK t -i• 'License Number + Lic Cldss 7 SIZE STORIES / FAMILIES ,ONE !•+ a : r a .-VALUATION- NEW- DESCRIPTION _VALUATION- z DESCRIPTION OF WORK NEW- Contractor• �Date ADD s ,. t I am exerts t under Sec - • y�. P ALTER B 8P C for this reason /� REPAIR - _ - - DdTe USE OF DEMOL ❑ i �_1 8.3,6_A EXISTING BLDG - - �� Signature _ APPLPR NT -' NOTEL' FINA ; # 0 0 0 0.0 1 OWNER-BUILDER DECLARATION _ _ _ YDAT r . - - r - -•••. I hereby affirm-that I'am exempt from the Contractor,'s License ADDRESS FIN ' "f , J -'-,419,'8 8 • Law for the following reason (Section 7031 5, Business and Prdfe"ssions'Code) ... - PRESENT By �• BUILDING 1 7q I, as owner of the property, or my:employees with - ADDRESS- 7" cadges as Their sole compensation,will do the walk and +. 'Y ^i�_iz 4 9 8 8 c�- the structure is not intended or offered for sale(Section LOCALITY -r- 7044, Business and Professions Code) - P •' = MOVING' "' '', - `- , , •'-TEL^• - ;, " - _r -• --a•=h -- -• 0 U, 1-2--8 5 -� I, as owner of the property, am exclusively contracting CONTRACTOR ' NO I _ ? �� °� (• OW- with Iicensed-contractors to construct'the-project (Sec- ADDRE55� ~� I • tion 7044, Business and Professions Code) REQUIRED _ TOTAL SETBACK FR 'i CONSTRUCTION LENDING-AGENCY SET BACK L-YARDHWY 1 - PROP LINE WIDTH_,' " '� - •f s _ _ o 1 I hereby affirm that there is a construction lending agency for FRONT \' r the performance of the,work for which this-permit•is issued ---- -P L -:(Sec 3097, Civ C ) SIDEPL �- Lender's Name LDMA Ref # v 3aa 1 P C Fee S- -• -- Permit Fee Lender's Address "• > .I certify.that I have read this application and,state_that the _ Issuance Fee [V[ ,-`� LDMA%P/G#1 a 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 v and ereby authorize representatives of this County to enter ' up h!2 ve-men oned perty for inspection purposes d ` SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of App scant or Agent - -•-Date - --._..- _ - ._ �..'y _ - _ .. _,... _ _�_.._-_ _ .... -, ..__ _ _'. _ .,_ •_..t� /'•� ' - - i ORKERS' COMPENSATION DECLARATION I ereaffirm that I hove,a certificate of consent to self insure, or a certificate of Worker's' Compensation Insurance,,' ^ i c APPLI��T ®� ®� BUILDING- P E R11�!T u or a certified copy thereof (Sec'3800, Lab C ) COUNTY-OF'LOS ANGELES ` BUILDING AND SAFETY Policy No Company BUILDING Certified copy isohereby furnished FOR APPLICANT TO.FILL IN ADDRESS aCertified copy is filed with the county,building inspec- BUILDING tion department Al ADDRESS Date_ Applicant CITY �� zip LOCALITY CERTIFICATE OF .kXEMPTION FROM WORKERS' - �r NO OF BLDGS NEAREST-_ ='COMPENSATION INSURANCE SIZE OF LOT X / OW ON LOT- CROSS ST (This section,need not be completed if the permit,is for one TRACT' BLOCK` LOT NO ASSESSOR ,.; hundred dollars ($100)or,less ) - MAP BOOK PAGE PARCEL TEL Ute' NE" MAP -. certify that in•the'performance'of the work for which.'this OWNER (� NO permit is issued,'I'shall not employ any p rson in any"manner r SPECIAL ADDRESS O, ✓ -L --U CONDITIONS sobs to,become sublect to the Work rs= `Laws /1 ^ M° O �w��wvv��' CITY Z� Li Y� ZIP 7 r V Dot Applicant a' NO I TO PUCANT If, after making This.Certificate of AR HITECT O TEL DISTRICT GROUP TYPE FIRE PROCESSED BY 0 Exemption, you should become= sublect• to the Workers" ENGINEER NO �� CON51T ZONE ry = U' Compensation provisions of,the Labor,Code, you must forth- ADDRESS i L R •V/ ¢ �� W with comply with such provisions or this permit shall, be -WE STATISTICAL CLASSIFI TION r. APT CO N deemed revoked L, - CONTRACTOR _ f Z LICENSED CONTRACTORS DECLARATION , • LIC ,. CLASS`NO, DWELL UNITS I hereby affirm that.l annlicensed 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 " Lic Class SIZE STORIES- FAMILIES ONE z VA L TION DESCRIPTION OF WORK NEW D s Contractor 'Date O f 1 7 . , ADD d lot exempt under Sec }T ALTER WJ t B&P C for this reason REPAIR Q s. PG Dote USE CF O EXISTING BLDG DEMOL Q 9 7.8 A Signature APPLICANT STEL FINAL PRINT �� { NO� o 0 0 o e„ OWNER-BUILDER DECLARATION DAT I hereby`offirrn that I am exempt from the Contractor's License qq yy Law for the following,reason (Section-"7031-5i Business-arid ADDRES�O►D� d (� v �"`�� FIN * ' . ' � ° a 4 9 8'8 Oessions Code) ;, • p : By o o 0 9BUILDING �' 99 I, as owner of the property, or my employees with ADDRESS tQ Zyi. U wages as their sole compensation;will do the work and LOCALITY the structure isnot,intended-or offered for-sole(Section _ 7044, Bustness,and-Professions Code), •- a MOVING TEL" ' I,as owner of the,property, om exclusively contracting CONTRACTOR NO f� with licensed contractors-to construct the project (Sec- ADDRESS' tion 7044, Business and,Professions Code). �, REQUIRED - TOTAL SETBACK d 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 ti Lender's Name h P L Q LDMA Ref # ' J P C Fee$ a Perrriit Fee. �J Lender's Address n R, I certify'that I have read this application and state that the Issuance Fee tJ LDMA P/C# above information is correct I agree to comply with all County Investigation Fee, o ordinances and State`laws relating to building construction, - - - o N- and hereby outhtirae representatives of this County to enter Total Fee LDMA Pernie# up o abo -mention d prop for inspection purposes t ,a .SEE'REVERSE FOR EXPLANATORY LANGUAGE r -Signature of,Applicant or Agent Dolt;' .* ' _4 APPLICATION FOR BUILDING PERMIT COUNTY OF LOS,ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS I hereby affirm that I have a certificate of consent,to self,Insure, B ILD N ADDRE 2-Zov ora certificate of Workers' Compensation Insurance, or a certified ei Al ,luer 1v copy thereof (Sec 3800,Lab,C) I e ,C ZIP 1� (� /,/ LOCALITY Policy No Company SIZE )FONO OF BLDG NOW ON LOT ❑ Certified copy IS hereby furnished NEAREST CROSS ST El Certified copy is filed with the county building Inspection TRACT BLOCK LOT NO - department' USE ZONE MAP NO, Date Applicant ASSESSOR MAP BOOK PAGE PARCEL SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS'. WNER- TEL NO - COMPENSATION INSURANCE WITHIN 1000 FT OF SCHOOL? Yes No This section need not be completed if the permit is for one hundred D R SS ( DISTRICT GROUP TYPE CONST FIRE ZONE PROCESSED BY dollars ($100)or'less) 4120 I certify that in the performance of the work.for which this permrjZY ZIP it O-. _� IS Issued, I'shall not employ any person in any manner so aS to -•Ti become subject to the Workers'CC en tion Laws ACHT OR ENGINEER EL NO STATISTICAL CLASSIFICATION T ` 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' CONT R R TEL NO SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you,:must forthwith FRONT comply with such provisions or this permit shall be deemed revoked ADDRnS LIC NO PL LICENSED CONTRACTORS DECLARATION PILE CITY LIC CLASS PL I hereby affirm that I am licensed underprovisions of Chapter-9, SEWER MAP I (commencing with Section'7000)of bivislon 3 of the Business and SOFT SIZE NO OF STORIES NO OF FAMILIES Professions Code,and my license is in full force and effect I A NEW ❑ BK PG DESCRI TION OF WOR - ADD ❑ VALUATION CL License Number � Llc Class � Z v 00 `r`' Contractor Date ALTER ❑ $ - cc s ed El am exempt under Sec r REPAIR $ Q B&PC for this reason DEMOL ElLDMA P/C# U Date USE OF EXISTING BLDG _ URM ❑ d Signature APPLICANT(PRINT) TEL NO LDMA Perm# 8 Z ❑ I, as owner of the property, or my employees with wages as Z their sole compensation, will do the work and the structure Is ADDRESS 0 not Intended or offered for sale (Section 7044, Business and FINAL DATE Q — 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 _ f ITEMS � El 1, as Owner of the property, am exclusively contracting with AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE'SFINAL BY < L -a licensed contractors to construct the project (Section 7044, ^T t_t't tiL •12 1 ® 35 YES❑ NO❑ "7 - Business and Professions Code 411Ai t 1,2 i o `• WILL THE INTENDED USE OF THE BUIDUNG BY THE APPLICANT OR FUTURE BUILDING CHCmK _ OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH CONSTRUCTION LENDING AGENCY 'COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKUST FOR �':SIHhl13� - �I GUIDELINES H {{YY I hereby affirm that there Is a construction lending agency for YES❑ NO❑ m the performance of the work for which this permit is issued(Sec I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING r ••��,T 3097,CIV C) CHECKUST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, I�It l — ILII /�I7 r•{ N TITLE 2 CHAPTER 2 20 SECTIONS 2 20 100 THROUGH 2 20 140 CONCERNING HAZARDOUS ' 3 Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD , .+ I I` .� �;�•1•y e I F'� 0- Lender's Address __ !i t S O OMER OR AGENT ` o I certify that I have read this application and state under penalty of perjury that the above information is correct I agree to comply PC FEE PERMIT FEE with all county ordinances and State laws relating to building J • construction, and hereby authorize representatives of this County r ISSUANCE FEE to enter on tbp above-men n roperty for inspection purposes a , e T= INVESTIGATION FEE TOTAL FEE, 12 SC-%a App al«Aa t SEE REVERSE FOR EXPLANATORY LANGUAGE WORKERS' COMPENSATION DECLARATION..o I IYereb a irm that I have a certificate of consent to selfe nsuVLynr grtificate,of Workers Compensation Insurance, APPLICATION -FOR BUILDING', P,E RM I T , . ora certified copy thereof (Sec' 3800, Lab C ) . r` COUNTY OF,L8S ANGELES BUILDING AND SAFETY Policy No Company ❑ Certified co s hereb furnished; - - FOR APPLICANT TO FILL IN•' BUILDING (0(9A In y py y ADDRESS "❑ Certified copy is filed with the county.butldmg-tnspec- MING ADORES$ Q (rr' tion department Date 'Applicant CITY �.' t lj . ` ZIP L 1 LOCALITY NO OF BLDG$ NEAREST CERTIFICATE'OF EXEMPTION,F WORKERS' SIZE-OF LOT NOW ON LOT` " CROSS ST ' COMPENSATION INSURANCE //JJ ASSESSOR `(This section need'not be completed if the permit is for one TRACT C7`� BLOCK LOT NO MAP BOOK­- ' PAGE ' PARCEL'- hundred dollars ($100) or'less ) r` TEL n ' OWNER IQ. !T U L l7- NO oC � US 01:1MAP I,'certify.that,m the performance of;the;work for which this s� rr erinrt is issued, I shall•not employ-anyerson in an manner ADDRESS �` �i'G b U svh GIv SPECIAL' • P P Y CONDITIONSCL so as'to become subject to the Workers' Compensation Laws y 'O- CITY-74 L l�" zIP Z -?O - Date - Applicant ARCHITECT O TEL DISTRICT, OUP TYPE - FIRE, OCESSED BY NOTICE TO APPLICANT,1If, after'makin this Certificate of ENGINEER ;NO 9 CONST , Z E - O .Exemptions you should. become-=subject' to -the Workers' , Compensation provisions df'the,Labor Code;you must forth- ADDRESS r. f w with comply with-,such,provisions or this permit shall, be TEL STATISTICAL CLASS FI ATIOM APT. CONDO` N deemed revoked „ CONTRACTOR NO Z LICENSED'CONTRACTORS DECLARATION` LIC' CLASS NO DWELL UNITS I hereby affirm,that I-am licensed.under provisions of Cheipter9 ADDRESS NO LIC SEWER MAP '. (commencing with Section-7000)of Division 3 of the Business -• ,' - and Professions Code,and my license is to full force and effect CITY CLASS BK PG; VALIDATION " •^ SO O FT NOF 'INC)-OF- 1 CHECK License Number ' Lic Class SIZE [ STORIES �• FAMILIES ONE VAL TI �� Contractor Date DESCRIPTION �OF WORK NEW ❑ ; TI( ❑lam - Rte/ j ADD 9 CCC��I ► exempt under Sec _ ALTER ❑ .._ _ , B'&P C for•this-.reason - $ USE OF REPAIR ❑ Date'' EXISTING BLDG �DEMOL ❑ 's -*�� _ APPLICANT -- iY Signature TEL r FINAL / •, rjr ' OWNER-BUILDER DECLARATION (PRINT) NO DATE I herebyaffirm that I am exempt from the Contractor's License P - t.-r•, 'L — '�"�. Law for_the follow_mg reason (Section 7031 5, Business and ADDRESS -FINAi g y. Professions.Code) - is PRESENTBy �- I, as owner of the property,•or my employees with ADDRESS _LDING `f'' Y�i{ es wages as their sole compensation,will do The work and t the'structure'is not intended-o�offered'fo(salb.(Section LOCALITY, l meg•'-' 7044, Business and Professions Code) - MOVING TEL y M CONTRACTOR NO I r'' ITEMS,.'. ❑ I;as owner of the property, am exclusively contracting t wish licensed contractors-to•construct^the project (Sec- TOTAL - ��,® �5 ADDRESS �.• 3 r• - i �` ^1 rtC tion 7044, Busmesrand Professions Code ) - !' 'I c REQUIRED = TOTAL•SETBACK FROM,- EXIST ;, '� .• ;•t - CHECK � .+ a CONSTRUCTION LENDING AGENCY` SET•BACK'- YARDy HWY PROP LINE WIDTH y. 1 ,I hereby affirm that,thefeais a constructiori lending agency for .FRONTI- A _ , NGE 4, .L the performance'of'the wo�k,for which this permit',is-issued PL r 4,.. Sec 3097;Civ C SIDE Lender's.Name $ _ LDMA,Ref # Lender's Address PC Fee$ Permit Fee < '62,79AM 9ilk` 0 I certify that I have read this application and state that the Issuance F 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 Fe e LDMA Perm # i Q and hereby authorize representatives of this County to enter N;' ��1•'; upo abov -men a ed - rty'for-msjiechon 'urpo` s � .� - ' ' "• - '" 3t, a ir `� J ti _ SEE REVERSE FOR EXPLANATORY LANGUAGE Y Signature o icant or Agent Dae 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 1301070011 PHONE (626) 285-0488 EXT LEGAL ID NO OF CONST BUILDING ADDRESS ITR 17179 LT 22 SQ FT STORIES TYPE 6220 CLOVERLY AV (STRUCTURE 19 V-B TEMP CA 917801601 ASSESSOR INFORMATION NUMBERNEAREST CROSS STREET GARIBALDI 15385-009-002 I THOMAS PAGE 596 GRID J2 LOCALITY TEMPLE CITY CAI ITENANT IEXIST BLDG USE RESID USE ZONE R-1 JISSUED ON- PROCESSED BY IEXIST OCC GRP. 101/07/13 SR 1OWNER TEL NO IBLDGS NOW ON LOT VALUATION IF DATE FINAL BY CODE 1 ICHASE HELEN L (626) 285-6144- 1 6,500 1� I 16220 CLOVERLY AV 1_ ITEMP 917801601 FEES PAID OF WORK 1 RE ROOF, TEAR OFF EXISTIN COMP & WOOD SHEET W/7/16 OSB IFEE DESCRIPTION QUANTITY DOM AMOUNT 11NSTALL NEW CLASS A DIMENSIONAL COMP SHINGLES 1APPLICANT TEL NO I I IWARREN CROSS (626) 786-2477- ;AA BLDG PERMIT ISSUANCE 27 80 1 11522 MEADOW GLEN WAY IAB STATE GREEN BLDG FEE 6500 00 VAL 1 00 (SPECIAL CONDITIONS 1 IHACIENDA HTS 91745 IAC STRONG MOTION RESID 6500 00 VAL 0 70 1 I ID2 PERMIT W/O EN-HC 6500 00 VAL 166 20 I 1 I TOTAL FEES 195 70 I ICONTRACTOR TEL NO I 1APPROVALS DATE INSPECTOR SIGNATURE IWARREN CROSS ROOFING INC (626) 786-2477- j - 11522 MEADOW GLEN WAY LIC. NO I ILOCAT_CN AND SETBACKS I1 1HACIENDA HEIGHTS CA 91745 836560 II 1SOILS ENGINEER APPROVAL 1 1ARCHITECT OR ENGINEER TEL NO I (FOUNDATION/TRENCH FORMS 1 1 LIC- NO i (SLAB/UNDER FLOOR 1 I I I RAISELiFLOOR FRAMING I IMAP NO SEWER MAP BOOK PAGE FIRE ZONE CMP 1UNDERFIAOR INSULATION 1 1 1 1153H265 3 00, 1 1 1 .1 I FLOOR(SHEATHING INO OF FAMILIES DWELLING UNITS APT/COND STAT CLASS 1 _ 1 0 NO 21 IROOF SrIEATHING 1 1 SCHOOL WITHIN HAZARDOUS I , I� SHEAR�c'ANELS (AIR QUALITY 1000 FEET MATERIALS NO NO NO ' FRAME INSPECTION I 1 - 1 IFIRE S;RINKLER HANGERS I I I 11NSULATION/WEATHER STRIPI I IINTERIOR LATH/DRYWALL I 1EXTERIOR LATH I IRATED FLOOR/CEIL ASSEM I I I I I IRATED PALL ASSEMBLIES I I I IRATED :SLIAFTS/OPENINGS I I I i IT-BAR CEILINGS I I I * ADDITIONAL DATA ON FILE I I i LOT DRF:T-NAGE I 1 1 REPORT ID- DPR261 ROUTE TO DS0508 I I I 1