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HomeMy Public PortalAbout6029 AGNES AVE_Building__ 7 { , APPLICATION FOR COUNTY OF LOS ANGELES DEPARTMENT OF COUNTY ENGINEER B U I L D I N G PERMIT BUILDING AND SAFETY DIVISION BUILDING FOR APPLICANT TO FILL IN ADDRESS BUILDING / ),4 � ADDRESS Cy,./�/�/-��E r K (� 7 LOCALITYNEAREST Cz;t� d CITY 4--A L - �/1-1/ZIP /� / 90 CROSS ST NO OF SLOGS ASSESSOR SIZE OF LOT C> x JO NOW ON LOT 7-" MAP BOOK PAGE PARCEL JJ 7.� ^j C DISTRICT GROUP TYPE FIRE PRO SED BY TRACT(�js^z f BLOCK(JY LO i -J� S,✓O8 CONU Z3 �•lw� TEL �/ OWNER �jbV,, J � i� NO ,99G 4�5'� STATISTICAL CLASSIFICATION „$EWE/R,�j1Ap ADDRESS [ 02-17 u AGAJ S �J�j' CLASS NO DWELL UNITS c BfC 3 ?G CITY ��/h�L `� Zlp lC USE ZONE MAP NO ARCHITECT OR TEL / SPECIAL ENGINEER SC� NO ( CONDITIONS ADDRESS ROAD DEPARTMENT APPROVAL REQUIRED YES❑ NO ❑ CONTRACTOR TEL BLDG SETBACK FROM J NO, FRONTPROP LINEOF ✓ (STREET) LIC ADDRESS NO HIGHWAY + YARD _ TOTq SETBACK FROM TYPE OF EXISTING LIC - FRONT PROP LINE HIGHWAY WIDTH CITY CLASS CONSTRUCTION LENDER + '� - d U NAME AND BRANCH BLDG SETBACK FROM c CD ADDRESS CITY SIDE PROP LINEOF (STREET) V SQ FT NO OF NO OF CHECK HIGHWAY + YARD = TOTAL SETBACK FROM TYPE OF EXISTING W SIZE io ` STORIES FAMILIES ONE SIDE PROP LINE HIGHWAY WIDTH O LLJ DESCRIPTION OF WORK NEW El + _ N 7 ADD ❑ CORNER CUTOFF YES ❑ NO E] q, Z nALTER +-) C- IN OPEN SPACE YES ❑ NO ❑ REPAIR❑ USE OF IN COASTAL PERMIT ZONE YES ❑ NO ❑ EXISTING BLDG EMOL ❑ APPLICANT`,,/�qf (PRINT) a/r'�/`/W �! /._'�v C NOL BY (SIGNATURE " ri ~ I HEREBY AC N WLEDGE HAT I AVE READ THIS APPLICATION AND STATE THA HE ABO IS CO RECT AND AGREE TO COMPLY WITHALL ORDINANCES AND LAWS REGULATING BUILDING CON STRUC TION I CERTIFY THAT IN DOING THE WORK AUTHORIZED HEREBY I WILL NOT EMPLOY ANY PERSON IN VIOLATION OF THE LABOR CODE OF THE STATE OF cA4irORNIA IN RELATING TO WORKMEN 5 COM NSAT ON INS URAN SIGNATURE OF FINAL 7 7 BY LAODR DATE (J /f NO j 7 PC Fee$ Permit Fee Q Issuance Fee � / O�� Tota e S -� L PLAN CHECK VALIDATION CK M 0 CASH PERMIT VALIDATI N cK M O C � t CASH 76AG38A CE*803B 12/75 - F 2 6 1 �t�AR 22 it 6 1 Jl 5r J 0 0 g@L ` 76A638A CEN803 5 65 APPLICATION FOR BAI G PERMI COUNTY OF LOS ANGELES BUILDING DEPARTMENT OF COUNTY ENGINEER ADDRESS Q , y c G BUILDING AND SAFETY DIVISION LOCALITY JOHN A LAMBIE COUNTY ENGINEER NEAREST COLEMAN W JENKINS SUP T OF BUILDING CROSS ST Wa DISTRICT NO GR TYPE P S B FOR APPLICANT TO FILL IN b corlsT BUILDING ^^ y STATISTICAL CLASSIFICATION SEWER MAP ` ADDRESS �j G _7 � Al, G CLASS NO DWELL UNITS BK�� PG (j LOT NO (S S8 BLOCK USE ZONE MAP Li TRACT SPECIAL V Sum JQb NO OF BLDGS CONDITIONS SIZE OF LOT NOW ON LOT USE OF /. EXISTING B L Oc 6,e BLDG SETBACK FROM 1 OWNER !`� NOL ^ ' !`S �� FRONT PROP LINE OF - (STREET) p,[A 7 TYPE OF EXISTING SETBACK HIGHWAY + YARD - TOTAL ADDRESS Odi N A6-AIZ75 HIGHWAY WIDTH FROM C L -s-� T + _ CITY BLDG SCTBACK FROM ARCHITECT OR TEL ENGINEER NO SIDE PROP LINE OF (STREET) TYPE OF EXISTING SETBACK HIGHWAY + YARD = TOTAL ADDRESS HIGHWAY WIDTH FROM C L CONTRACTOR NO I + LIC CORNER CUTOFF YES NO O ADDRESS NO im CITY LIC SEE REVERSE SIDE FOR SPECIAL APPROVALS G DESCRIPTION OF WORK w n. NEW ADD ALTER REPAIR DEMOLISH N SQ FT NO OF NO SIZE STORIES FAMILIFS USE OF STRUCTURE SIGNATURE OF APPLICANT VALUATION$ APPROVALS DATE INSPECTOR SSIGNATURE P C PMT V "V FOUNDATION LOCATION FEE$ FEE$ FORMS MATERIALS FRAME FIRE STOPS / I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION BRACING BOLT AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY FURNACE LOCATION WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING GAS VENT DUCTS 9UILDING CONSTRUCTION I CERTIFY THAT IN DOING THE WORK ' AUTHORIZED HEREBY I WILL NOT EMPLOY ANY PERSON IN VIOLA LATH INT TION OF THE LABOR CODC OF THE STATE OF CALIFORNIA RELAT ING TO WORKME CO ENSA ON I�URANCE V LATH EXT SIGNATURE O HOUSE NUMBER COR i� PERMITTEE RECT AND POSTED 6621 ADDRESS F I N A L PLAN CHECK VALIDATION CK M O CASH JOHN F LEWIS PRINCIPAL ST IRRAL ENGINEER PERMIT_VALIDATIONM D CASH Lf g 1 6 9� JAN27 1 0 0 0^ lz 76A638A CE+803 5 65 APPLICATION FOR BU ILDI G PERM01 COUNTY OF LOS ANGELES BUILDING �- DEPARTMENT OF COUNTY ENGINEER ADDRESS BUILDING AND SAFETY DIVISION LOCALITY /!7 /�L t C17 JOHN A LAMBIE COUNTY ENGINEER NEAREST COLEMAN W JENKINS SUP T OF BUILDING CROSS ST woo RO FF DISTRICT O GR TYPE PR FOR APPLICANT TO FILL IN CONST BUILDING JJ �^ L_f STATISTICAL C A SI FICA TION _ S ER b"P ADDRESS [�UG JBK }� r Q CLASS NO DWELL UNITS r_ PG LOT NO �`�v A/- s U BLOCK USE ZONENOP TRACT SPECIAL p SIZE OF LOT So " I l d NO OF BLDGS CONDITIONS ` NOW ON LOT USE OF n EXISTING BLDG LL 6- —L '7� BLDG SETBACK FROM OWNER ,�� NO �J/^ -/ s FRONT PROP LINE OF (STREET) / �f 66 �I a TYPE OF EXISTING SETBACK HIGHWAY + YARD - TOTAL ADDRESS 6o� 4�- t HIGHWAY WIDTH FROM C L CITY 7'2tW L G fil + _ ARCHITECT OR TEL BLDG SETBACK FROM ENGINEER NO SIDE PROP LINE OF (STREET) TYPE OF EXISTING SETBACK HIGHWAY + YARD = TOTAL ADDRESS n HIGHWAY WIDTH FROM C L i TEL + _ CONTRACTOR NO LIC CORNER CUTOFF YES NO Q ADDRESSalp NO CITY CLA I SEE REVERSE SIDE FOR,SPECIAL APPROVALS O DESCRIPTION OF WORK �Jq - 0/ s a NEW ADD ALTER REPAIR DEMOLISH SIZE ago- 3� S �3 .1/ ,�., _ - /.,J,f., ? FT NO OF NO OF STORIES FAMILIFS USE OF STRUCTURE SIGNATURE OF / Lj -T'�" APPLICANT VALUATION$ 0-. APPROVALS }� DAIT E INSP OR SSIGNATURE P C PMT FOUNDATION LOCATION rI FEE$ FEE$ FORMS MATERIALS is FRAME FIRE STOPS IE: ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION BRACING BOLTS AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY FURNACE LOCATION WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING GAS VENT DUCTS SUILDI NG CONSTRUCTION I CERTIFY THAT IN DOING THE WORK AUTHORIZED HEREBY I WILL NOT EMPLOY ANY PERSON IN VIOLA LATH INT TION OF THE LABOR CODE OF THE ST TE OF CALIFORNIA RELAT ING TO WORKMOQPEN ATION IN RANCE LATH EXT a 3 +{ l SIGNATURE HOUSENUMBER COR PERMITTEE RECT AND POSTED ADDRESS �rm' 614pa 77CO FINALV11 f1fl— i B JOHN F LEWIS PRINCIPAL,STR URAL ENGINEER PLAN CHECK VALIDATION CK M O CASH _ PERMIT VALIDATION CK M C CASH LAC09 1 7 0-0 JAN27 1 D 1 1.50- 4 76A638A CE#803162 APPLICATION FOR BUILDING PERMIT COUNTY OF LOS ANGELES BUILD I NG aJ DEPARTMENT OF COUNTY ENGINEER ADDRESS c>[i BUILDING AND SAFETY DIVISION LOCALITY JOHN A LAMBIE COUNTY ENGINEER NEAREST WILLIAM A JENSEN SUP T OF BUILDING CROSS ST DIIF CT NO GROUP ITYPE ESSED BY FOR APPLICANT TO FILL IN !�/} CONS BUILDING � STATISTICAL CLASSIFICATION SEWER MAP ADDRESS D dZ ' SK CLASS NO DWELL UNITS LOT NO d G(. `BLOC WATER CERTIFICATE NOT REQUIRED ❑ RECEIVED ❑ TRACT (Q MAP HIGHWAY NO OF BLDGS NO (CIRCLE) STATE MAJOR SECOND L(CAL) r a SIZE OF LOT NOW ON LOT USE ZONE 9PECIAL USE CONDITIONS EXISTING BLDG e TEL JJ G/,/ OWNER 'WJ NO (pi6 BUILDING YARD HWY STREET NAME EXIST SETBACK WIDTH ADDRESS FRONT ARCHITECT OR TEL P L ENGINEER NO SIDE P'L ADDRESS \ d TE ///� u CONTRACTOR � NO (� ADDRESS.— S Q DES RIPTIO F ORS u EW DO ALTER REPAIR VILEMOLISH Z SO FT NO OF NO OF GI?.11� (/' •/ SIZE I STORIES FAMILIES USE OF STRUCTU E on SIGNATURE OF APPLICANT VALUATION $ 176 g� APPROVALS DATE INSPECTOR 5 SIGNATURE PC _ PMT FOUNDATION LOCATION FEE $ FEE $ FORMS MATERIALS FRAME FIRE STOPS IH ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION BRACING BOLTS AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY FURNACE LOCATION WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING GAS VENT DUCTS BUILDING CONSTRUCTION I CERTIFY THAT IN DOING THE WORK AUTHORIZED HEREBY I WILL NOT EMPLOY ANY PERSON IN VIOLA LATH INT } TION OF THE LABOR ODE, OF THE STATE OF CALIFORNIA RELAT I ING TO WORKMEN S C MP IT 11' !7eINSURNCLATH EXT SIGNATURE OF HOUSE NUMBER COR PERMITTEE RECT AND POSTED ADDRESS FINAL PLAN CHECK VALIDATION CK M o cnsH JOHN F LEWIS PRINCIPAL STRUCTURAL EN R PERMIT VALIDATION CK M O CASH LAL,o 6 3 2 7"o j@v 1 D 4 00- � 76A638A CE4803 8 64 APPLICATION FOR BUILDIN6 PERMIT f COUNTY OF LOS ANGELES B U I L D I N G I DEPARTMENT OF COUNTY 1 ENGINEER ADDRESS • BUILDING AND SAFETY DIVISION LOCALITY JOHN A LAMBIE COUNTY ENGINEER NEAREST COLEMAN W JENKINS SUPT OF BUILDING CROSS ST DISTRI TUO. GROUP TYPE P ESSED BY FADDRESS R APPLICANT TO FILL IN _ f � ) CONST t STATISTICAL CLASSIFICATION T S WER MAP 1 e� i CLASS NO DWELL UNITS BK _ PG i (d l BLOCK USE ZONE MAP NO -- SPECIAL NO OF BLDGS CONDITIONS ` NOW ON LOT BLDG SETBACK FROM TEL FRONT PROP LINE OF ' (STREET) NO - TYPE OF EXISTING SETBACK GHWAY + YARD - TOTAL P HIGHWAY WIDTHF OM C L CITY / C, ABLDG SETBACK FROM ARCHITECT T OR TEL ENGINEER NO SIDE PROP LINE OF (STREET) TYPE OF EXISTING SETBACK HIGHWAY + YARD = TOTAL ADDRESS I - r HIGHWAY WIDTH FROM C L 2 TEL f + = O CONTRACTOR NO U LIC ` ADDRESS NO I CORNER CUTOFF YES NO O CITY Cl SEE REVERSE SIDE FOR SPECIAL APPROVALS Ll DESCRIPTION OF WORK h - Z NEW ADD ALTER REPAIR DEMOLISH I o v SQ FT NO OF NO SIZE STORIES FAMILIFS USE OF STRUCTURE I t � SIGNATURE 0 APPLICANT VALUATION$ r 1 APPROVALS DAITE \ INSPECTOR SSIGNATURE P C �� PMT FOUNDATION LOCATION �J FEE$ FEE$ FORMS MATERIALS FRAME FIRE STOPS I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION BRACING BOLT / f AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY FURNACE LOCATION WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING GAS VENT DUCTS SUILOI NG CONSTRUCTION I CERTIFY THAT IN DOING THE WORK �L ` AUTHORIZED HEREBY I WILL NOT EMPLOY ANY PERSON IN VIOLA LATH INT I TION OF THE LABOR CODC OF THE STATE OF CALIFORNIA RELAT ING TO WORKMEN S COMPENSATION INSURANCE LATH EXT SIGNATURE OF HOUSE NUMBER COR PERMITTEE RECT AND POSTED A ADDRESS G Fl NAL I PLAN CHECK VALIDATION CK M o CASH JOHN iF LEWIS PRINCIPAL ST RAL ENGINEER PERMIT VALIDATION CK- MO CASH - 3 2 4 110Jull30 r 0 4 00- Y_ r 76A638'ACF*803I64 APPLICATION FOR BUILDING PERMIT COUNTY OF LOS ANGELES BUILDING t `yC DEPARTMENT OF COUNTY ENGINEER ADDRESS J BUILDING AND SAFETY DIVISION LOC A LIT Y JOHN A LAMBIE COUNTY ENGINEER NEAREST_ COLEMAN W JENKINS SUPT OF BUILDING CROSS ST FOR APPLICANT TO FILL IN DIST�4T Ng GROUP TYPE P ` c sseD BY .-5` / 9" C0NST G I BUILDING /''- STATISTICAL �CLASSIFICATION, SEWER MAP ADDRESS Q . ,i- IG C CLASS NO DWELL UNITS BK G LOT NO -S� I�b/ BLOCK USE ZONE No TRACT I L/ SPECIAL NO OF BLDOS CONDITIONS SIZE OF LOT 6-0 NOW ON LOT USE OF EXLST" c74, BLDG SETBACK FROM TEL �` -7 FRONT PROP LINE OF �>t/ (STREET) OWNER J NO TYPE OF EXISTING SET_B_AC HIGHWAY YARD = TOTAL ADDRESS Aw // HIGHWAY TH F OM C L _ CITY /�^�„ IL� ) �� + �v LOG SETBACK FROM ARCHITECT O TEL B _ ENGINEER NO SIDE PROP LINE OF (STREET) TYPE OF EXISTING SETBACK HIGHWAY + YARD = TOTAL ADDRESS ���� HIGHWAY WIDTH FROM C L C TEL + = O CONTRACTOR / NO V ADDRESS LIC CORNER CUTOFF YES E:]NO NO CC O CITY CLI` SEE REVERSE SIDE FOR SPECIAL APPROVALS u W DESCRIPTION OF WORK \ ydr .A 71; v NEW ADD ALTER REPAIR DEMOLISH ,fit " o/4 J/ `A';m SQ FT NO OF NO OF dl ('�f� SIZE STORIESbjyj", fFAMILIES �R- ,l;— USE OF i� tT' f� STRUCTURE ' i- L. . r- t SIGNA URE OF WA J APPLICANT VALUATION$ ® �f APPROVALS QATE INSPECTOR SSIGNA U FEE$ FEE$2-2 `J FORMS FOUNDATION LOCATION MATERIALS FRAME FIRE STOPS I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION BRACING BOLT �►'v AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY FURNACE LOCATION WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING GAS VENT DUCTS / ✓f SUILOING CONSTRUCTION I CERTIFY THAT IN DOING THE WORK AUTHORIZED HEREBY I WILL NOT EMPLOY ANY PERSON IN VIOLA LATH INT TION OF THE LABOR CODC OF THE STATE OF CALIFORNIA RELAT ING TO WORKMEN S CO ENSATION INSURANCE LATH EXT r SIGNATURE O HOUSE NUMBER COR PERMITTEE RECT AND POSTED ' ADDRESS FI NAL PLAN CHECK VALIDATION CK M o CASH JOHN F LEWIS PRINCFPAL'STR RAL ENGINEER PERMIT VALIDATION CK M 0 CASH WORKERS COMPENSATION DECLARATION I hereificate of consent to se insure bor a certificate ofave Workers Compensation Insuran elf ,.,-APPLICATION- F®R BUILDING PERMIT or a'lertified copy thereof (Sec 3800 Lob C ) _ - COUNTY OF LOS ANGELES BUILDING AND SAFETY ` Policy No " Company ❑ Certified copy is hereby furnishedFOR APPLICANT TO FILL IN BUILDING ADDRESS (U ` Certified copy is filed with the county building inspec BUILDING ; tion department ADDRESS Applicant CITY�C .��" r 5V74� r 1 ZIP LOCALITY ERTIFICATE OF EXEMPTION FR6M WORKERS--` r NO OF BLDGS NEAREST t rs F COMPENSATION INSURANCE s SIZE OF LOT NOW ON LOT CROSS ST (Thisisection need not'be completed if the-permit is for one ^I ASSESSOR h hundred dollars ($100)or less ) TRACT BLOCK LOT NO - MAP BOOK PAGE + PARCEL TEL! OWNER ' NO E�YS USE ZONE MAP " I certify that in the performance of the work for which,this NO B permit is issued I shall not employ any person in any manner �. SPECIAL so as to become subject to the Workers Compensation Laws ADDRESS — /SUS w '\ CONDITIONS ro O t < _ U Date ApDlcant A t CITY ,,- ZIP it ARCHITECT,OR TEL DISTRICT GROUP TYCONSPE FIRE PROCESSED BY O NOTICE TO APPLICANT If after making this Certificate of � T ZONE Exemption you should become subject to the Workers ENGINEER NO , ' U Compensation provisions of the Labor Code you must forth a with comply with such provisions or this permit shall be ADDRESS D- �p TEL STATISTICAL CLA ICATION ' APT CO deemed revoked NDO N CONTRACTOR O LICENSED CONTRACTORS DECLARATION LIC�y//�t/ VCLASS NO DWELL UNITS �� �,p I hereby affirm that I am licensed under provisions of Chapter 9, ADDRESS NO 5'3713 (commencing with Section 7000)of Division 3 of the Business and , LICSEWER MAP P ' Professions Code and my license is in full force and effect CITY /.���t��i� CLASS 4-3 BK PGVALIDATION SQ FT NO OF NO OF CHECK L License Number �2g3/ 19WR Lc Class SIZE` STORIES FAMILIES ONE =r DESCRIPTION OF WORK /l�G°'�.Gf/ ti [:] VALUATION Contractor Dote f ^ ADD ❑ $ ❑ I am exempt under Sec N �'��` ALTER ❑ f6 B&P C for this reason /�-� E ��-'�c- REPAIR ❑ $ Date -EXISTING BLDG ��/17 1�� DEMOL ❑USE F 2 6�FI Signature APPLICANTr TEL FINAL # • o e s • O BUILDER DECLARATION PRINT �!/fGld�l�' �_NO?SG7SOE7 DATE I hereby affirm at I am exempt from the Contractor s License ) a - 33.00 33.OO Law for the following'reason (Section 7031 5 Business and ADDRESS FINAL Y `-'`--"F" -�•-pay--����.�- t-.-� -�--- ^:_ _ r-a1.�. .m-� nam�r- o-o •-- M, --,_ " Professions Code) R r - "^By rt °v '� 3 a Q�c� - ❑ BUILDING ' j as owner of the property'or my employees with ADDRESS t `� (L+�+ $8 wages as their sole compensation will do the work and ) the structure is not intended or offered for sale(Section ` LOCALITY 1 7044 Business and Professions Code) 's MOVING ' TEL ❑ I as owner of the property am exclusively contracting CONTRACTOR y ' NO with licensed contractors to construct the project (Sec tion 7044 Business and Professions Code) ADDRESS 9 1 REQUIRED , TOTAL SETBACK CONSTRUCTION LENDING AGENCY F SET BACK YARD `HWY, PROP LINE a WIDTH t I hereby affirm that there is a construction lending agency for FRONT the performance of the work for which this permit is issued P L y (Sec 3097 Civ C ) SIDE t PL s Lender s Name _ /1 LDMA Ref 11 is m " 6 P C Fee$ Permit Fee Lender s Address n� J� ��I certify that I have read this application and state that the .� _ Issuance Fee °/ � " TDMA P/C q above information is correct I agree to comply with all County Investigation Fee /', 0 ordinances and State laws relating to building construction g Total Fee ✓ LDMA Perm M 1 N and hereby authorize representatives of this County to enter m upon the above mentioned propert r ction purposes SEE REVERSE FOR EXPLANATORY LANGUAGE t e oture of Applicant or Agent Ddl., In y i OF WORKERS COMPENSATION DECLARATION j APPLICATION FOR BUILDING PERMIT 1 hereby affirm that I have a certificate of consent to self insure or a certificate of Workers Compenstton Insurance or � a certified copy thereof (Sec 3800 Lab C ) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No �6'-(; f Company S/¢T4` A:C4/J - BUILD F-1 Certified copy ts,hereby furnished A FOR APPLICANT TO FILL IN ADDRESS ' N Certified copy is filed with the county building inspec BUILDING / / 71 tion department ADDRESS © q A LOCALITY ' 1 Date r )L S V Applicant - CITY NEAREST ZIP CROSS ST k CERTIFICATE OF EXEMPTION FROM WORKERS tNO OF BLDGS ASSESSOR 1 COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL ` t(This section need not be completed if the permit is for one - 4-4 USE ZONE ESPECIAL hundred dollars ($100)or less ) TRACT BLOCK LOT NO / =Re } TEL �/�^ r certify that to the performance of the work for which this OWNER (mac NO 7,y ONS O permit is issued I shall not employ any person in any manner DISTRICT GROUP TYPE FIRE JCE:ED BY U so`as to b come subject to the Worke m tion Laws ADDRESS PE ZONE Date S Applicant CITY ZIP STATISTICAL CLASSIFICATION APT CONDO (~j NOTICE TO APPLICANT If after making this Certificate of ARCHITECT OR TEL - W Exemption you should i become subject to the Workers ENGINEER NO CLASS NO _DWELL UNITS H Compensation provisions of the Labor Code you must forth ADDRESS - " _ SEWER MAP Z with comply with such provisions or this permit shall be f�' ( G/ r deemed revoked t CONTRACTOR�.1 t a /��� ;y NO T�1Aa BK EPG VALIDATION LICENSED CONTRACTORS DECLARATION ` LIC I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS ��f A c NO 3 17 GIF O 11 VALUATION (commencing with Section 7000)of Division 3 of the Business andLIC yProfessions Code and my license is in full force and effect s CITY CLASS (. $ Qv �g 1 SQ FT NO OF NO OF CHECK License Number 3-7 / 6 ta— 'Lic Class SIZE STORIES FAMILIES ONE Contractoit ��� �g��,- ate 1 DESCRIPTION OF WORK � /D 0,0o P NEW $ � ADD ❑ ❑ I am exempt from q the licensing requirements as I am a C ``d It,� , licensed architect or a registered professional engineer ALTER ❑ FINAL ;2 0 9 0 5 A ❑ / i acting to my professional capacity (Section 7051 � REPAIR DATE Business and Professions Code) USE OF FINAL o m o 0 EXISTING BLDG'' DEMOL ❑ FIo 2 1 6 0 By Lic or Reg No Date APPLICANT - TEL OWNER BUILDER DECLARATION - (PRINT) wNO e o a 2 1 6 0= I hereby affirm that I am exempt from the Contractor s License "`'_"Law for the following reason,(SectionL7031^5-Busmessland-- ADDRESS------- _ �� ` 0 612-,5---8-1 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 __ :20906A with licensed contractors to construct the project (Sec tion 7044 Business and Professions Code) a ADDRESS # o oto 0 0 1 REQUIRED TOTAL SETBACK FROM EXIST CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP LINE WIDTH h j e o 34 0 0 1 hereby affirm that there is a construction lending agency for FRONT the performance of the work for which this permit is issued P L 0 0 0 34 0 0 E (Sec 3097 Civ C ) I SIDE ' YPL 082,5-81 Lender s Name rr1� JZ m } Lender s Address T P C Fee$ qC Q PermitFee � { w I certify that I have read this application and statetthat the Issuance Fee above information is correct I agree to comply with all County Investigation Fee w , ordinances and State jaws relatin to building construction Y m g g Total Fee and hereb authorize representatives of this County to enter e < up e toned property for inspectio pu°rpos s m t a j SEE REVERSE FOR EXPLANATORY LANGUAGE f t ' Signature of Applicant or Agent Date ` t©s 1 �