HomeMy Public PortalAbout6223 CLOVERLY AVE_Building__ APPUCAMON FOR.. oULMNG pERMF
COUNTY OF LOS ANGELES BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS
- �"��. �<'�7:0"✓�-''tr �'
I hereby affirm that I,have a certificate of consent to self -BUILDING ADDRESS
.insure, .4f
or a certificate of Workers' Compensation Insurance,or'a certified G'
- - -
copylthereof(Sec.3800,Lab.C.) A ,- CITY / ZIP
/1/ LOCALITY.—L�dl/J�!!C/
Policy No. Company 6 L K 'SIZE OF LOT - NO.OF BLDGS.NOW ON LOT-
El
OT❑ Certified copy is hereby furnished. - - NEAREST CROSS ST. -
r TRACT - BLOCK LOT NO. - - ��
El Certified copy is filed with.the county building inspection
department. art /,� :, USE ZONE MAP NO.
Date Plicant l� ,�/ (,!, � ASSESSOR MAP BOOK. PAGE PARCEL SPECIAL CONDITIONS.
CERTIFICATE/OF EXEMPTION FROM WORKERS' OWNER TEL No.
COMPENSATION INSURANCE &q641-04K p S WITHIN 1000 FT:OF SCHOOL? YES NO
(This section need not'be completed if the permit is for one hundred ADDRESS
dollars ($100)•or less.)` ' - d'� 1— -:DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY
I,certify that in the performance of''the work for which this permit CIT ZIP ;® , 3
is issued, I shall not employ any person in any manner so as to gRCHITECT �R ENGINEER - TEL NO: /�'��/Y9►-�' '
become subject to the Workers'Compensation'Laws. STATISTICAL CLASSIFICATION APT CONDO
Date- - Applicant - ADDRESS - - _ - CLASS NO.- DWELLUNITS -
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 `G Z "'FRONT
comply with such provisions or this permit shall be deemed revoked., ADDRESS a LIC.NO_r1
LICENSED CONTRACTORS DECLARATION SIDE
CITY - - _ LIC.CLASS PL
I hereby affirm that I am licensed underprovisions of Chapter 9 SEWER MAP -
P
(commencing with Section 7000,)of Division 3 o the Business NEW El,and SQ. .T.SIZE NO.OF STORIES NO.OF FAMILIES - - -.
6K d
Professions Code,and my,license is In full force and
�l,effect. �
PG
License Number�r�1,�J¢Y��?Lic.Class 4t— a�.S DESCRIPTION OF,WORK ADD- ❑ VALUATIpO�N el: >, - Q
Contractor, f �+.�e otz�la_t� /a-��` a!/j ALTER ❑
El am exempt under Sec. �J^ ` 1 REPAIR 11 $ 0
BA P.C. for this reason Go. DEMOL ❑ LDMA P/C°# W
Date: - USE OF EXISTING BLDG. - URM - ❑ -
•i7" SignatureZ
APPLICANT(PRINT) TEL NO. LDMA Perm#
ars
❑-1,as owner of the property, or my employees with wages as Z c
their sole compensation, will'do the work,and the structure is ADDRESS _ _ _-'-
not intended or offered for sale (Section 7044, Business and FINAL DATE Q •w.�:r K
Professions Code.)
WILL THE APPLICANT OR FUTURE BUILDING'OCCUPANT A HAZARDOUS MATERIAL __
OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE J - -tl „-” - -�
❑ I, as Owner Of the property, am exclusively contracting With AMOUNTS SPECIFIED ON THE HAZARDOUS MATE_RIALS WFORMATION GUIDE? FINA Q -'3 ISL :�..-_�,5 °'-"'�'^`u
licensed contractors to construct the project (Section 7044, ves❑ No❑ Tr
HEX.
Business and Professions Code.) _ _t-•i:.' ,IWILL ITHE 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 - ({ :.IL'
GUIDELINES. - / I •-J�$ - '.
I hereby affirm that there is a construction lending agency for YES❑ NO❑ �- x(/y^
w tneperformanCe Of the Work for which this permit IS issued.(Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING ,\ .-1'[i i i'cl` e^?•�Y;=.
3097, CIV.C.) CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, VVV 1=€`4'' ' »I '' '`
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 SCACMD. - / )• „ ,r, •f-€ I ''i'J
o Lender's Address '
O - OWNER OR AGENT
o I certify that I have read this application and state under penalty
C of perjury that the above information is correct.I agree to comply P.C.FEE PERMIT FEE
with all county ordinances and State laws relating to building
m construction,and hereby authorize representatives of this County ISSUANCE FEE ry /
(0 to enter on thea ve-mentioned property for inspection purposes. (�(�,
a
�,� _r INVESTIGATION FEE - TOTAL �3 - -
� re of Applicant�ent Date '
SEE REVERSE FOR EXPLANATORY LANGUAGE
DEPARTMENT OF BUILDING AND SAFETY' �' APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES
WM. J. FOX. CHIEF ENGINEER•1yt E UE L 0 M
FOR APPLICANT TO FILL IN FOR OFFICE USE ONLY
DISTRICT NO. PLAN CK.NO. PERMIT NO.
BUILDING
ADDRESS Cloverly Ave• 3,70 7,q-
LOCALITY T�i RECEIVED BY DATE-OF APFL. DATE ISSUED
NEAREST
CROSS T. I+Y-endon St. s Temple City -�' �-•��y —,7BUILDING
OWNER Meeker Land Company ADDRESS �o of-�L•- / ;L�
MAIL 11236
DDRESS E. Live Oak Ave. LOCALITY
A
NEAREST'
Arcadia TEL. DO-72151 CROSS ST.
CITY NO.
FIRE NO.0 ARCHITECT p TEL. ZONE PLANS TYPE. GROUP
ENGINEER Geo•A•Bissell HO. FL--74420 �.
BLDG. y �' r ORD.NO.
ADDRESS SETBACK LINE edyl,02. 45e I 3p,;e
a' APPROVED
CONTRACTOR - - NOL BY DATE'
USE �� APPROVED
ADDREBB ZONE/;j BY DATE
LEGAL ` CORRECTIONS-
DESCRIPTIONBLOCK
LOT NO, to
TRACT''': 1/fr7 1/r7 '
NO.OF
SIZE OF LOT -54x108 I NOW ON LOTS none 3 7d 7
USE OFnone NO.OF NO.OF 6
EXISTING BLDG. - FAMt LIE. ROOMS
DESCRIPTION OF WORK �'r�� ,� ( ry ml , R
NEW x ALTERATION ADDITION /) �/ j / // ��++'�•• O
REPAIR MOVING DEMOLISH IO-I� \! � bl. �'�/' +/ L �'"L ey. (,7
T. NO.OF
SIZE 1161 6 1 J
ROOMS STORIES _ �
WALLr
COVERING Plaster ROOF Como / / /+
I COVERING Compo f � `�Z. yJ'�f ! /�XUSE OF
BUIILDIINGW Residence
Plan 4-B
Garage 18 x 20
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPROVALS
APPLICATION AND STATE THAT THE ABOVE IS CORRECT - INSPEC •OR DATE
FOUNDATION: LOCATION r'
AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES FORMS,MATERIALS
AND STATE LAWS REGULATING BUILDING CONSTRUCTION.
FRAME: FIRE STOPS, / • :{"'�; ,�/ s. r'_
SIGNATURE OF LAND C 1. BRACING,BOLTS
PERMITTEE
LATH, INT. /
AUTHORIZED AGT
LATH, EXT.
7GA63SA-3 7-49 s ��O Q P.C.$ pPLASTER, INT.
FEE
VALUATION � '�4/ FEE 4 ���0 FINAL
J ` • o r TEMPLE CITY
76A698A CE#809- 1-61 H YY! ,PLu VAT90N FOR Ib UILONG PERf�lj T
COUNTY!OF LOS ANGELES BUILDING
DEPARTNMiT OF COUNTY ENGINEER ADDRESS 3
BUILDING AND SAFETY DIVISION LOCALITY
JOHN A. LAMBIE, COUNTY ENGINEER NEAREST
WILLIAM A. JENSEN SUPT OF BUILDING CROSS ST.
Di ICT N G TYPE t PRO S
FOR APPLICANT TO FILL IN ``j , 0.. corlsr..
BUILDINGfa STATISTICAL CLA ATION S ER MAP
ADDRESS 6.s/2 3 AV, ��o1'�J?C�/ �y� BK ' PG'
b -T CLASS..NO. _ DWELL.UNITS^^ �
LOT NO. BLOCK ,WATER - NOT REQUIRED I _ECEIVED
/ .CERTIFICATE:
TRACT �[7�TA •, _ -� - MAP 1b HCGRc EI STATE MAJOR SECO LOCAL
,/ I��NO OFBLDGS.•" NO: ('/
SIZE OF LOT. �r� / 7 G��'y-�/'�+NOW ON LOT USF ZONE, SPECIAL
USE OF CONDITIONS
EXISTING.BLDG,. Y's 1.'i .
OWNER i/ . Hell_15, i No -
,�{{ S BAIL, "'EXIST.
ADDRESS' SET,BP.CK.. YARD HWY, STREET NAME WIDTH' '
�FRONTav��(�/
'ARCHITECT OR TEL. - - - t P. L.
ENGINEER NO. SIDE'
ADDRESS -• i '' .- .1' a
P.L..
TEL
�j ,INSPECTION RECORD „..� O
CONTRACTOR O.
.�J::J - „__ ,
ADDRESS'.I/- /Z./.'V/J.. %B/1/17if�i /S!'•,�%''� �',�1,.,, !i'�•a" 1,'/ t/ Y" �� :� 06
O
DESCRIPTION -OF'WORKCL
NEW W Aqo/ ALTER REPAIR DEMOLISH - /, f `/. -// //, r ./ '� �r •, i� mrr Z
�IZFT �p }r !ST OF:,; NO-.OFY:V.'.,� —
IZE A STORIES'. 'FAMILIES
USE OF, 1. '� .,S,T Gs-'sem. . .. /P/,� ��✓l�sl ��G•L � I
STRUCTURE �L� ��,,,- Li - 1 j
� 110 3 �,"% 6 3 �sA��:i era<C p, ifs, �
_ _ �.,.
'SIGNATURE OF'
APPLICANT.
VALUATION
•A'P2ROVALS DATE- INSPECTORIS SIGNATURE
S
FEE.' $--^ I TEE "$ � FOFORMION: LOCATION
F
FORMS: MATERIALS
_t +• .. -
FRAME: FIRE v7.�7J.
' ! HEREBY-ACKNOWLEDGE THAT.�I HAVE READ 7H75 APPLICATION BRACING, BOLTS
AND STATE THAT THE'ABOVE.IS CORRECT AND AGREE-TC'COMPLY FURNACE: LOCATION,
.WITH ALL.'COUNTY ORDIWPNCES'ANC LAWS,AWS, REGULATING GAS VENT DUCTS
BUILDING'CONSTRUCTION I'CERTIFY THAT IN DOING-THE WORK AM .
//
.AUTHORIZED'HEREBY I WILL NOT EMPLOY ANY PERSON IN VIOLA- ! !'Z
TION OF"THE LABOR CODE'�OF THE STATE OF CALIFORNIA RELAT- LATH, INT:: .✓ \
ING TO WORKMEN'S COMPENSATION INSURANCE. - ' .. � �.-cp / 1: �. �'�• ^�
LATH,EXT:
SIGNATURE OF HOUSE,NUMBER-COR-
PERMITTEE RECT AND POSTED `�f� y'� �..-•i. �j.�0/,�r�A,.
ADDRESS X03!" /% N . /SY•- /
FINAL '
CLYDE N. DIRLAM/PRINCIPAL STR , "L ENGINEER
PLAN CHECK.VALIDATION CK. M.O. CASH- PERNIIT VALIDATION CK. WO. CASH
!` t
WORKERS' COMPENSATION DECLARATION
I-herebyaffirm that I have a certificate:of consent to self
insure, r a certificate of Workers Compensation.Insurance,
or a certified.copy thereof (Sec. 3800, Lab. C ): -. ` COUNTY OF LOS'ANGELES BUILDING ARID SAFETY
Policy No Company i
Certified,copy-is hereby furrnshed fi FOR'APPLICANT.TO FILL IN ADDRESS!p �
. Certified co is filed with the court bujldiri ins ec- BUILDING 2
PY Y 9 P ADDRESS Zz3 'Lp
tion;department. �-/
_, ,
CITY' C ) ZB
/GL
Date Applicant LOCALITY
O:OF LDGS...,.
CERTIFICATE OF'EXEMPTION FROM WORKERS'.; SIZE.OF LOT - NOW ON LOT NEAREST-
CERTIFICATE
COMPENSATION INSURANCE ',` CROSS
r. .. _ _
(This'section need not' a completed if tFie permit-is for one TRACT BLOCK LOT NO.
ASSESSOR
hundred dollars ($100).or.less.)' c TEL MAP BOOK ' PAGE PARCEL'
OWNER �JB ✓ -. N �1 USE ZONE MAP .
I certify that in the performance of the,work for which this NO.
permit,is issued,,)shall not employ any p'rson in an manner ADDRESS Ze L'1O�/ z a.'
so as to become subject to therWorker ion taws. O
SPECIAL
CITY . ZIP
CONDITIONS
Dat �✓ pplicant. ARCHITECT TEL. TYPE FIRE
NOTICE TO APPLICANT: If; of r makin :this-Certi ate of ENGINEER NO: DISTRICT GROUP "P OC SED BY ;. O
g.. � CONST ZONE• F---• •
Exemption, you 'should be 'me subject. to the. Workers'
Compensation,provisions of'the'Labor Code; you must.-forth- ADDRESS .:3j-
with,,comply with such. provisions or this permit shall be STATISTIC LCLASSIFICATION _ CONDO.:.
N "
deemed revoked.= CONTRALTOIJ
L Z'
LICENSED CONTRACTORS DECLARATION', ' CLASS NO' DWELL UNITS
I hereby affirm that :am'Iicensed under provisions of Chapter 9 ADDRESS / ~
(commencing with Section 7000)of Division 3 of the Business
LIC. SEWER MAP
CITY lam //�/� CLASS {
and'Professions Code,and my license is in full force and effect: _ BK. -PG. VALIDATION _
SQ. FT. NO..OF NO. OF CHECK - "
License Number Lie.'Class SIZE ' STORIES FAMILIES "ONE -
Contractor Date __
DESCRIPTION OF WORK ��]¢L/ NEW
•❑ V
:.
ALU
ATION
I am.,exempt under`Sec `t %tG�` ADD ' ❑ S D '
ALTER ❑'
B.&P.C. for this reason REPAIR-❑ $ 1r
Date: USE'.OF L
EXISTING BLDG. DEMO ❑
Signature FINAL
APPLICANT TEL.
OWNER-BUILDER DECLARATION (PRINT). NO.
DATE } +
Thereby affirm that I am.exempt'from the'Coniractor s License
Law fo-r the following reason (Section 70315, Business and ADDRESS FICA,t
Professions Code)., PRESENT By .:
r
BUILDING !
❑ I;, as owner of the property, or.my employees with ADDRESS `� { ` ACCT,
wages as thejrsole compensation will-do the work and J — . L,
the structure is not intended or offered for'sale(Section LOCALITY jl t7 68. y
3
7044, Business'and Professions Code )•• ' MOVING TEL — .m
❑
1,,as owner of the-property, am exclusively contracting
CONTRACTOR NO. i E G
with licensed contractors to construct the proje&.(Sec-. : µ'(!1j}`-� :' ja 'Q p
tion 7044,'Business and,Professions Code.,) ADDRESS. v
REQUIRED' TOTAL SETBACK FROM EXIST.: "HECK -66.6-3 '
CONSTRUCTION LENDING AGENCY SET BACK. YARD HWY PROP. LINE WIDTH._
I herebyaffirm that there is a construction`lend in agency for FRONT' �'�
the'performance of the:work for.which' permit9s issued t-H ° tit °�
(Sec. 3097, Civ. C:):. SIDE::
Lender's Name. i 4�f[f�h[i_ rf
m LDMA Ref. #
P.C.-Fec $ Permit Fee- .�'`•!� � ...
•
3 s1
Lender's Address �- _
o -1 certify that I have read this application and state that the Issuance Fee �/ C/ CDMA Pit#
above information is correct. I agree to comply;with'all County Investigation_Fee' i
8 ordinances and. Tate Iaws'relating to%building construction, Total Fee /J CDMA Perm. #
a and hereby a ori r entatives of this County.to enter
upon the ab e-m ti� roperty or.inspectionpurposes:
" ^,+^ SEE REVERSE FOR EXPLANATORY LANGUAGE
.7 /....
ignature of Applicant or Agent- Date _ ;