HomeMy Public PortalAbout5734 CLOVERLY AVE_Building_10/20/2014_�� C O U N T Y O F L O S ! N 4 G E L E S s
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S P E C I A L C O N D I T I O N S :
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�� I
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from
the Contractors' State License Law for the reason(s) indicated
below by the checkmark(s) I have placed next to the applicable
item(s) (Section 7031.5, Business and Professions Code): Any
city or county that requires a permit to construct, alter, improve,
demolish, or repair any structure, prior to its issuance, also
requires the applicant for the permit to file a signed statement
that he or she is licensed pursuant to the provisions of the
Contractors' State License Law (Chapter 9 (commencing with
Section 7000) of Division 3 of the Business and Professions
Code) or that he or she is exempt from licensure and the basis
for the alleged exemption. Any violation of Section 7031.5 by
any applicant for a permit subjects the applicant to a civil
penalty of not more than five hundred dollars ($500).):
L) I, as owner of the property, or my employees with wages as
their sole compensation, will do (✓) all of or (_) portions of the
work, and the structure is not intended or offered for sale
(Section 7044, Business and Professions Code: The
Contractors' State License Law does not apply to an owner of
property who, through employees' or personal effort, builds or
improves the property, provided that the improvements are not
intended or offered for sale. If, however, the building or
improvement is sold within one year of completion, the Owner -
Builder will have the burden of proving that it was not built or
improved for the purpose of sale.).
L) I, as owner of the property, am exclusively contracting with
licensed Contractors to construct the project (Section 7044,
Business and Professions Code: The Contractors' State License
Law does not apply to an owner of property who builds or
improves thereon, and who contracts for the projects with a
licensed Contrba for pursuant to the Contractors' State License
Law).
(_). I am exemdt from licensure under the Contractors' State
License Law for the following reason: � _
By my signature below I acknowledge that, except for my
personal residence in which I must have resided for at least
one year priorlto completion, of the improvements covered by
this permit, I cqnnoI legally sdll a structure that I have built as an
owner -builder if it has not been constructed in its entirety by
licensed contractors. I understand that a copy of the applicable
law, Section 7044 of the Business and Professions Code, is
available upon request when this application is submitted or at
the following Web site: httD://www.leainfo.ca.aovlcalaw.html.
Date:
Signature of Property Owner or Authorized Agent
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm under penalty of perjury that I am licensed under
provisions of Chapter 9 (commencing with Section 7000) of
Division 3 of the Business and Professions Coded my
license is in full force and effect. /
7N'cense Class J License Ko'.�
/D—ate+2Contractor Signatu
WORKERS'COMPENSAT)64EIiI YRATIO
WARNING: FAILURE TO SECUR"ORKEF# COMPENSATION
COVERAGE IS UNLAWFUL, AND SH L SUBJECT AN
EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO
ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION
TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED
FORIN SECTION 3706 OF THE LABOR CODE, INTEREST, AND
ATTORNEY'S FEES.
I hereby affirm under penalty of perjury one of the following
declarations:
I have and will maintain a certificate of consent to self -
insure for workers' compensation, issued by the Director of
Industrial Relations as provided for by Section 3700 of the
Labor Code, for the performance of the work for which this permit
is issued.
Policy No.
I have and will maintain workers' compensation
insurance, as required by Section 3700 of the Labor Code, for
the performance of the work for which this permit is issued. My
workers' compensation insurance carder and policy number are:
Carrier Policy Number Expiration Date
Name of Agent Phone Number
_ 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 of
California, and agyyyree that, if I should become subject to the
workers' compation provisions of Section 3700 of the Labor
Co)�I shall fo with comply with those provisions
Sig ure o dplicant Date
OBBYIST ORDINANCE CERTIFICATION
Complete this section for permits In
Unincorporated Los Angeles County only
This is to certify that 1, as permit applicant, am familiar with the
requirements of Los Angeles County Code Chapter 2.160 et seq.,
(relating to the Los Angeles County Lobbyist Ordinance) and that
all persons acting on behalf of myself complied and will continue
to comply therewith through the application process.
Applicant (Print Name) Applicant Signature
Company Name Date
JOB ADDRESS
LOCALITY
HAZARDOUS MATERIAL DECLARATION
Will the applicant or future building occupant handle a hazardous
material or a mixture containing a hazardous material equal to or
greater than the amount specified on the hazardous materials
information guide?
Yes ❑ No ❑
Will the intended use of the building by the applicant or future
building occupant require a permit for construction or
modification from the South Coast Air Quality Management
District (SCAQMD)? See permitting checklist for guidelines.
Yes ❑ No ❑ !
I have read the hazardous materials information guide and the
SCAQMD permitting checklist, I understand my requirements
under the Los Angeles County Code Title 2, Chapter 220'
Sections 220.100 through 220.140 concerning hazardous
material reporting and for obtaining a permit from the SCAQMD.
ASBESTOS NOTIFICATION
❑ Notification letter sent to AQMD and/or EPA
❑ I declare that notification of asbestos removal is not
applicable to addressed project.
DECLARATION REGARDING CONSTRUCTION LENDING
AGENCY
I hereby affirm under penalty of perjury that there is a
Construction lending agency for the performance of the work for
which this permit is issued (Section 3097, Civil Code).
Lenders Name
Lenders Address
By my signature below, I certify to'each of the following:
I am the property owner or authorized to act on the
property owner's behalf.
I have read this application and the information I have
provided is correct.
I agree to comply with all applicable city and county
ordinances and state laws relating to building
construction.
I authorize represent ives of this county to enter the
abov -Ide tified pro for ins action purposes.
Sig lure Prope r Authorized Agent
V
COUNTY OF LOS ANGELES
TEMPLE CITY
N 0508
BUILDING PERMIT
•' DEPARTMENT OF PUBLIC WORKS
9701 LAS TUNAS
ALTERATION/REPAIR
BUILDING AND SAFETY /
LAND DEVELOPMENT
TEMPLE CITY CA 91780
BE 0508 1501290036
PHONE: (626) 285-0468
EXT:
ILEAL ID:
NO.
OF CONST
I BUILDING ADDRESS:
ITR: 65611 LT: 698
UN: .002
SQ. FT STORIES TYPE
1 5734 CLOVERLY AV
ISTRUCTURE:
V-B
TEMP CA 917802551
I
IASSESSOR INFORMATION NUMBER:
I
NEAREST CROSS STREET:
18587-011-D20
THOMAS PAGE: 596 GRID: J3 LOCALITY: TEMPLE CITY
(TENANT:
EXIST BLDG USE: RESID
USE 20NE: R-1
ISSUED ON: PROCESSED BY:
IEXIST OCC GRP:
101/29/15 SR
10WNER:
1WE I, DEI
TEL. NO:
IBLOGS. NOW ON LOT:
1
VALUATION:
12,000
IFINAL DUE FINAL BY: CODE:
1
I5757 34 CLOVERLYAV
I
(P 917802551
TEM91780255
1
FEES PAID
DE I 1'IO OF WORK
IRE-STUCCO FRONT ELEVATION, RIGHT ELEVATION, LEFT ELEVATION
IFEE DESCRIPTION:
QUANTITY: DOM: AMOUNT:IPART
OF REAR ELEVATION
(APPLICANT:
TEL. NO:
I
I
ILOPEZ, JUAN
(886) 860-1003-
IAA BLDG PERMIT ISSUANCE
27.80
1
122632 GOLDEN SPRINGS
IAB STATE GREEN BLDG FEE
12000.00 VAL 1.00
ISPECIAL CONDITIONS:
I➢IAMOND BAR CA 91765
1AC STRONG MOTION RESID
12000.00 VAL 1.20
1
ID2 PERMIT W/O EN-HC
12000.00 VAL 250.20
TOTAL FEES 280.20
ICONTRACTOR:
TEL. NO:
(APPROVALS DATE INSPECTOR SIGNATURE
IALL ISO RESTORATION SERVICES INC.
(714) 944-0004-
I
122632 GOLDEN SPRINGS DRIVE
LIC. NO
I
ILOCATION AND SETBACKS 1
(DIAMOND BAR, CA 91765
908870 *
I
I
ISOILS ENGINEER APPROVAL
(ARCHITECT OR ENGINEER:
TEL. NO:
(FOUNDATION/TRENCH FORMS
LIC. NO:
SLAB/UNDER FLOOR
(RAISED FLOOR FRAMING I
(MAP NO: SEWER MAP BOOK: PAGE:
FIRE ZONE: CMP:(
I I I
1UNDERFLOOR INSULATION
3 0011FLOOR
SHEATHING
IND. OF FAMILIES: DWELLING UNITS:
APT/COND: STAT CLASS:
NO 21
IROOF SHEATHING
SCHOOL WITHIN HAZARDOUS
1
SHEAR PANELS
(AIR QUALITY: 1000 FEET
MATERIALS
1
I
1 NO NO
NO
(FRAME INSPECTION I
IIFIRE SPRINKLER HANGERS
(INSULATION/WEATHER STRIPI
(INTERIOR LATH/DRYWALL
I
(EXTERIOR LATH
(RATED FLOOR/CEIL ASSEM. i
(RATED WALL ASSEhBLIES
IRATED SHAFTS/OPENINGS
I
1T-BAR CEILINGS
1* ADDITIONAL DATA ON FILE
I
ILOT DRAINAGE
I
(REPORT I➢: DPR261
ROUTE T0: 850508
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from
the Contractors' State License Law for the reason(s) indicated
below by the checkmark(s) I have placed next to the applicable
item(s) (Section 7031.5, Business and Professions Code): Any
city or county that requires a permit to construct, alter, improve,
demolish, or repair any structure, prior to its issuance, also
requires the applicant for the permit to file a signed statement
that he or she is licensed pursuant to the provisions of the
Contractors' State License Law (Chapter 9 (commencing with
Section 7000) of Division 3 of the Business and Professions
Code) or that he or she is exempt from licensure and the basis
for the alleged exemption. Any violation of Section 7031.5 by
any applicant for a permit subjects the applicant to a civil
penalty of not more than five hundred dollars ($500).):
U I, as owner of the property, or my employees with wages as
their sole compensation, will do (,/) all of or (_) portions of the
work, and the structure is not intended or offered for sale
(Section 7044, Business and Professions Code: The
Contractors' State License Law does not apply to an owner of
property who, through employees' or personal effort, builds or
improves the property, provided that the improvements are not
intended or offered for sale. If, however, the building or
improvement is sold within one year of completion, the Owner -
Builder will have the burden of proving that it was not built or
improved for the purpose of sale.).
U I, as owner of the property, am exclusively contracting with
licensed Contractors to construct the project (Section 7044,
Business and Professions Code: The Contractors' State License
Law does not apply to an owner of property who builds or
improves thereon, and who contracts for the projects with a
licensed Contractor pursuant .to the Contractors' State License
Law).
U- I am exempt from licensure under the Contractors' State
License Law for the following reason:
By my signature below I acknowledge that, except for my
personal residence in which I must have resided for at least
one year prior) to completion of the improvements covered by
this permit, Ic�'nnot legally sell a structure that I have built as an
owner -builder if it has not been constructed in its entirety by
licensed contractors. I understand that a copy of the applicable
law, Section 7044 of the Business and Professions Code, is
available upon request when this application is submitted or at
the following Web site: http://www.leoinfo.ca.aov/calaw.html.
Date:
Signature of Property Owner or Authorized Agent
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm under penalty of perjury that I am licensed under
provisions of Chapter 9 (commencing with Section 7000) of
Division 3 of the Business and Professions Code, and my
license is in full force and effect. _.O_. 10111
License Class License o. �v� V
Date / T Contractor Signature
WORKERS' COMPENSATI DE 'ION
WARNING: FAILURE TO SECURE ORKER ' COMPENSATION
COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN
EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO
ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION
TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED
FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND
ATTORNEY'S FEES.
I hereby affirm under penalty of perjury one of the following
declarations:
I have and will maintain a certificate of consent to self -
insure for workers' compensation, issued by the Director of
Industrial Relations as provided for by Section 3700 of the
Labor Code, for the performance of the work for which this permit
is issued.
Policy No.
I have and will maintain workers' compensation
insurance, as required by Section 3700 of the Labor Code, for
the performance of the work for which this permit is issued. My
workers' compensation insurance carrier and policy number are:
Carrier Policy Number Expiration Date
Name of Agent Phone Number
_ I certify that, in the performance of the work for which this
pPate
sued, I shall of employ any person in any manner
scome su to the workers' compensation laws of
Cand agre if I should become subject to the
wmpens io rovisions of Section 3700 of the Labor
CII forth ith mply with those provisions
Sf plica t Dle
BBYIST ORDINANCE CERTIFICATION
Complete this section for permits in
Unincorporated Los Angeles County only
This is to certify that I, as permit applicant, am familiar with the
requirements of Los Angeles County Code Chapter 2.160 et seq.,
(relating to the Los Angeles County Lobbyist Ordinance) and that
all persons acting on behalf of myself complied and will continue
to comply therewith through the application process.
Applicant (Print Name) Applicant Signature
Company Name Date
JOB ADDRESS
LOCALITY
HAZARDOUS MATERIAL DECLARATION
Will the applicant or future building occupant handle a hazardous
material or a mixture containing a hazardous material equal to or
greater than the amount specified on the hazardous materials
information guide?
Yes ❑ No ❑
Will the intended use of the building by the applicant or future
building occupant require a permit for construction or
modification from the South Coast Air Quality Management
District (SCAQMD)? See permitting checklist for guidelines.
Yes ❑ No ❑
I have read the hazardous materials information guide and the
SCAQMD permitting checklist, I understand my requirements
under the Los Angeles County Code Title 2, Chapter 220'
Sections 220.100 through 220.140 concerning hazardous
material reporting and for obtaining a permit from the SCAQMD.
ASBESTOS NOTIFICATION
❑ Notification letter sent to AQMD and/or EPA
❑ I declare that notification of asbestos removal is not
applicable to addressed project.
DECLARATION REGARDING CONSTRUCTION LENDING
AGENCY
I hereby affirm under penalty of perjury that there is a
Construction lending agency for the performance of the work for
which this permit is issued (Section 3097, Civil Code).
Lender's Name
Lender's Address
By my signature below, I certify to;each of the following:
I am the property owner or authorized to act on the
property owner's behalf.
I have read this application and the information I have
provided is correct.
I agree to comply with all applicable city and county
ordinances and state laws relating to building
co uction.
I uthnze repr s ntatives of this county to enter the
hove -i entifie pr rtY for inspection purposes.
Signa a of Pr Owner or Authorized Agent