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HomeMy Public PortalAbout6236 AVON AVE_Building__ DEp&ATMENT OF RUMDING AND SAFETY 'APPZJMTION FOR PFJMMCr! COUNTY OF LOS ANGELES ® � wm. ,l. PDX. CHILr LNOtNLLR FOR APPLICANT TO FILL IN FOR OFFICE USE ONL? B U I LO I M O i S �TMaT lift` PLAN Cr- "c'. Paas 1T"0' IT ADOR[1f LOCALY �/��/ f �L:�� r.i..L"ZO n DATt or AP1fL CMIOrT IMULO CROBB 1T ^ ' ,'T .un-of" OWN LR ADole>caB - - MAIL r-- r} ADDREDS I If, /� fir" A T-rL- MLAIl�i.TT / J C I TY N O _ r7ow �NO.or ( TYP� ,_ BIROUT ARCHITECT OR -7L'L Zl,N< ILAMN CN OINI[A NO. +- V 1LDsL ORD.NO. ADORERS MEaMAC LINK / v!� A/lRQV= CONTRACTOR ` O, ^i/ ry OTT LIM ArIROYCD ADORPBS _ z amc r_ By fZ orackipTION I LOT No. " ( BLOCK = a CORRECTIONS TRACT BLDolL NO.Or 1 BIZ[ O/LOT 1 � I NOW ON LOT { uaE Or NO.Or ( NO.or _ CXISTINO BLDG. rAmmirs ROO>ttf DESMIPTIbi'r OF WORK NCw I ALTERATION ADDITION Y f O REPAIR � MOViNO O[MOLIf11 i Q M r-T. �� ` o Mo- Ur 2 k _BIZC r' ' ROOMS BTORICf > !f WALL ROOT r COYCRINO I COVLRINO UBE Or Ncv#-, ,r Bu1La1N�. f, 1 N[w[BY ACIPCOWLSD^t THAT I NAV! *C.40 T Mr APPROV.41•0 A►rL.ICATIO" AMD WTAII< NAT TNI A.3OVL If COWS --�-- AMO AOR[[ TO C WVkY 101311 ALL CDUNTY r*Off &ftCia rrt)ltbT1Dl1T I:DCAT7glR // !� 'iD�TZ ANO STAT! LAWS ALbULATTMO BUILDING CO%*T*UCTT1O=. rOfl10i IRATLITIALs BI ONAr MC Or B� ;7- -f s tJ►TR IIfT.! .400 to ♦NT1f0R/nD B...f we" SINS wT ?�r P.O.1 RA=TLM /I 7q FixPa�tle!+rl tx►. I vnawTleN , -tea =- ---� APPLICATION FOR BUILDING PERMIT A DIVISION OF BUILDING AND SAFETY ADDRESS DOR[ s �v Dvp"tmsnt of County n3ginow ConntT o! Los Ana*lss LOCALITY _L VfM. J. FOX. COUNTY ENaINE[R H£AR£ST CASSATT D. GRIFFIN, ivrT O► DUILDIMO "OSS ST. FOR APPLICANT TO FILL IN DISTRICT NO. GROUP TYT[ SEWER MAP BK PQ CONST BUILDING VAP STATE YES ALORESS lY NUMBER MWY LOT NO. " 8LOC K USE ZONE EPECIAL TRACT RACT / /) �I 1 A`� ( NO. OF SLOGS. / -+� SiZE_O_F LOT ! / ! rr%%% %__�J S+��IOINI' I YAn7 i ►+Wr STREET NAME SET BACK I _ ,)Sr OF i LxISTINC BLDG FRROL T I OWNER -3A ,- `r ?/ ) ed ] SIDE I P 1 MAIL 0-35 hild& ADDRESS � /I L TEL DWELL- I UNIT '5 INDUSTRIAL L U CI V S/[�TIt � f-I�L NO. < DUPLEX UNIT 6 PUBLIC BLDG. ' ♦RCNITECTOR TEL. • 1NEEA��/�- NO. 1 APT UNITS 7 AODN.. ALT., ETC. A^DRESS / COMMERCIAL B MISCEL. ��. TrL- CONTRA_CT_OR VO. INSPECTION-RECORD DESCRIPTION OF WORK Y r� -- NEYV A00 ALTER REPAIR C:M7_ISri • SO FT, r NO OF NO. CF _SIZE �`2+O STORIES FAMILIES j'� �/ + rr USE OF STRUCT [ AJC"`7 - L t.IGNATUP s OF APPLICI NT I AJTMYALR I ADDR[f1 CATE IRSPECI-R'S II16R;TtlRt --- - –---— --.-- ..---. .__._...._'-_.....�,..- _...__ ..._.-._.... ..�...�__-.-..._ y>` : ►C.'•:DAT/Olt: LOCATION y- J� I• G • FORMS. MATLRIALS .1J� P [ [RA�1IFiR!STMti. 11 VALVAT!" FL[ FURNACE' LOCATION. �� GAS Vr-4T r' A4I tf N[RttY ACKMt>WLILWE TNAT 1 AVL READ THIS %-tCAT►GAND ItTATc Tm, THS Y[ IS CO MCCT TH IIR. AMD AGR[[ " COSIIL WIT" A -I OROf1AAMC[S i. AMO STA!'[ LAWS • iM0 COMiTR116 vola JAM OcT. sfaMATURN OF swusc"UM•cw COO. pf"fTTcc *c AaoRrsa FINAL I' W%L J F= Cowcz Lr•atm YAL�Dl1T10lr �'8 t t= F823 i 4-00 ,• r r Dump" DCPC-.T �';4.� f;, ��✓"'�J.�.•'a��c'_ � ��.• -k �. �``='t�.�' - -°` �.'�.5.`.I�l,'�.Y�"^"�:�ca+rrti3i • �". ,+Mss-,- ��+�F�!�•—.`-. � t, -- - �r DEPARTMENT OF BUILDING APPLICATION FOR PERMIT q � COU TY OF LOS ANGELES ■ • . I-) BUIL,DINg F LED �� IJ 20NE ,- / E -F_ O. FLA" HK. t- [ 1 NO. !!fit I T RECEIPT NO. 1 ' / � 7�'• lamTYPE OF / .�/ �` O.( �,[ at-DG. I II III Iv t GROVP �� `/_ .,.. BLDG. SETBACK L DATE nF APrL. a cci:ca ar-"+I GATC Isfvco iii >v I � � ORO. NO- APPLICANT APPLICANT FILL INA ATA A[TTT Tn,,, ♦;,iE- �„ .AUA.AA,Y CvAt,AI\r.L FvIL'A1v:V c DWI NAME AeDDRD S!` �— G/ L •/' u W. ver— 'j �Z r 7 ^ L f-- IZI ADDRESS �,�:1 7 µ� !`iTf LOCALITY y Q Q U W; CITY _f� f' * M[AR[fT STATE CROSS II v < ICEN4E NO TEL. NO. •� �� MAIL V 2 O NAME ��y) / �� M. �,/• Y NAMC tA_ I, H "'" ACL_ � ; ADDR£53 �'�. t't( 1i7�� vf� t •^_ D 1 CITU — 7 f TEL NO. u Z (,S .S -�A •/-111 ` • 0 j_l.TY STATE J C LOT �/ 312E OF LOT ADO % i t.ICCNuS NO. (� WORK NO ��// • OU NO. OF SLDG3, CLASS OF I�IORK _I J y STOCK I NOW ON LOT I { �•'1 USE OF SLOG. NEW II ADDITION_ _I DEMOLISH I TpACT �J ��,! t/OW ON LOT L_ _ALTERATION REPAiR �- I DESCRIPTION OF R''�)RK USE OF INC _._.... r", M A a M F S I SIZE ONO. OF •. t•l_G. _�• `, /a I 57ORIT_S FAMILIEf ` )))) _OUNOATION I ;��- XTEPInq MAT t P,ER. I CORRr,c TIU:�I'S R !r f y-� '.• MATERIAL" 'vyll� I ._'7 ��_/�iw Z� L �K.AZiai. ? /_... rt :79_`.^i•_" •� .•.•1 b,.,�. _ .• jam —1. : •I-i I-vY-- . THICKNESS—BOTTOM - DEP?N IN ^rJUND � I � / , SUPERS--UCTURE �Lh -� {-�� . f' ��� (• R. W. PLATES (SILL) SIZ I SPACING SPAN GIRDERS JOISTS—FLOOR 1 "i. JOISTS--CEILING DF.ARING WALLS ---•�-.Yw� Z PARTITIONS .� ROOF f1AFTER3 - I COVE 1 G Aris PLICATEONSAND STATE L THAT THE EDGE TASOVCCIS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING &UIL"DINING,CONSTRUCTION. SIGN O w,N/'•[R OR AUTN 011121 AOlrn /J FINAL APPROVAL S U -_ VALATION / 00 10.1.71 -I INtPtCT 1 >t 1'1-NAMC / ' 76A698A SCE #803 4/70 '� " " APPLICATION FOR BUILDING P RMIT COUNTY OF LOS ANGELES ASSESSOR DEPARTMENT OF COUNTY-ENGINEER _ MAP BOOK PAGE PARCEL BUILDING AND SAFETY DMSION BUILDING JOHN A LAMBIE COUNTY ENGINEER ADDRESS N COLEMAN W JENKINS SUP T OF BUILDING LOCALITY FOR APPLICANT TO FILL IN NEAREST CROSS ST Print or tVDe onI DISTRICT NO GROUP 7 PE ESSED BY BUILDING / ' q ZI CONS ADDRESS4 7r STATISTICAL CLASSIFICATION SEWER MAP LOT NO U BLOCK CLASS NO� DWELL UNITS BKIM PGIO TRACT Q USE ZONE MAP NO OF BLOGS NO O© SIZE OF LOT NOW ON LOT i SPECIAL USE OF ` CONDITIONS EXISTING BLDG TELA OWNER NO BLDG SETBACK FROM ADDRESS FRONT PROP LINE OF (STREET) TYPE OF EXISTING SETBACK HIGHWAY } YARD = TOTAL CITY HIGHWAY WIDTH FROM C L ARCHITECT OR TELL } ENGINEER NO BLDG SETBACK FROM ADDRESS SIDEPROP LINEOF (STREET) 7 TETYPE OF EXISTING SETBACK HIGHWAY } YARD = TOTAL CONTRACTOR NOL ! HIGHWAY WIDTH FROM C L LIC a ADDRESS f NO ( (� + V LIC CITY CLASS CORNERCUTOFF YES ❑ NO cO CONSTRUCTION LENDER F- NAME AND BRANCH SEE REVERSE SIDEfFO�R SPECIAL APP/ROVALSa NO IF NO SIQZEFTADDRESS STORIES FA ]LIESNEW ❑ 411601-7,1/ Q G. ,X ! F�� �Mf --/U) �Z USE OF ADD ❑ / J � 7 �tv STRUCTURE , �14 ALTER01 i REPAIR❑ SIGNATURE O APPLICANT DEMOL ❑ v VALUATIONrS APPROVAL., DATE INSPECTOR S SIGNATURE P C PMT �^ FOUNDATION LOCATION FEES FEES ,,,)5,0 Q FORMS MATERIALS FRAME FIRE STOPS I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION BRACING BOLTS AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY FURNACE LOCATION WITH ALL ORDINANCES AND LAWS REGULATING BUILDING CON GAS VENT DUCTS STRUCTION I CERTIFY THAT IN DOING THE WORK AUTHORIZED HEREBY I WILL NOT EMPLOY ANY PERSON IN VIOLATION OF THE LATH INT LABOR CODE OF THE STATE OF CALIFORNIA IN RELATING TO WORKMEN S COMP NSATION IN RANGE LATH EXT SIGNATURE SIGNATURE OF�HOUSE NUMBER CORNUMBER COR PERMIT AND POSTED POSTED ADDRESS FINAL t JOHN F LEWIS PRI CIPAL STRUCTURAL ENGINEER PLAN CHECK VALIDATION CK M 0 CASH _ PERMIT VALIDATION (�j3 mo CASH ( gr_ 94APR 1 1 D 33,00- APPLICATION FOR r ` - BUILDING PERMIT BUILDING FOR APPLIC NT TO FIL IN ADDRESS BUILDING ADDRESS '���� ■ MAI LOCALITY I �_ ' „/ NEAREST CITY ryI ZIP CROSS ST Q—Y� OF BLDGS ASSESSOR _ r SIZE OF LOT OW ON LOT , MAP BOOK PAGE PARCEL DISTRICT GROUP TYPE FIRE RYSED BY TRACT BLOCK - LOT NO C �. i ) ON ST ` ' ZC r fTEL G.✓ F/ OWNER •�A NO STATISTICALICLASSIFICATION SEWER MAP f y ADDR.E.S.SS �� CLASS NO a DWELL--UNITS BK 0 CITY GI- J ZIP �/ //, USE ZONE NO ARCHITECT OR TEL SPECIAL ENGINEER NO /` CONDITIONS ADDRESS ROAD DEPARTMENT APPROVAL REQUIRED YES ❑ NO ❑ t TEL CONTRACTOR I) t , BLDG SETBACK FROM j FRONT PROP LINE OF (STREET) ADDRESS{ I d��� ��.• NO �tJ 1 ✓ TOTAL SETBACK FROM TYPE OF EXISTING LIC HIGHWAY + YARD = FRONT PROP LINE- HIGHWAY WIDTH CITY L F CLASS CONSTRUCTIO LENDER + _ } NAME AND ANCH z BLDG SETBACK FROM - - UU SIDE PROP LINE OF (STREET) ADDRESS CITY SQ FT NO OF NO OF CHECK HIGHWAY + YARD TOTAL SETBACK FROM TYPE OF EXISTING U SIZE STORIES FAMILIES ONE SIDE PROP LINE HIGHWAY WIDTH - + = Z DESCRIPTION OF WORK "0Lt J&JMlSL NEW ❑ r I t ' ADD CORNER CUTOFF YES ❑ NO ❑ ' V ALTER ❑ IN OPEN SPACE YES ❑ NO ❑ REPAIR ❑ USE OF E _ r ❑ IN COASTAL PERMIT ZONE YES ❑ NO ❑ EXISTINGBLDG �� �� of DEMOL APPLICANT /r TEL / (PRINT) �� " N 4 a BY(SIGNATURE) IHEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL ORDINANCES AND LAWS REGULATING BUILDING CONSTR CTION I CERTIFY THAT IN DOING THE s WORK AUTHORIZED HEREBY I WILL N LOY ANY PERSON IN VIOLATION OF ` THE LABOR CODE OF THE STA, F A IN RELATING TO WORKMEN S COM r PENSATION INSURANCE I x SIGNATURE OF FINAL �J� BY PERMITTEE DATE ADDR (EL PC Fee$ 0 Permit Fee rZ ITY � N Issuance Fee VALUATION$ 600 2� Total Fee PLAN CHECK VALIDATION cK O GASH _ PERMIT VALIDATION ? M o GASH t -o9 3 9 r AUG 2' 1 ® 1: 2"0 0 ®� 90 5��ut �� 23 ©; 720 � r _ µ w ®S 76A638B GE 98038 6/76 t WORKERS' COMPENSATION DECLARATION rafirm that I have a certificate of Inae,insure, oracertifcate of Workers' Compensation surn APPLICATION FOR BUILDING PERMIT, or a certified copy thereof (Sec..3800, lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No.—Com pany El Certified `���Certified copy is herebfurnished. FOR APPLICANT TO FILL IN ADDRESS ((�J((��Jll(Uf V ❑ Certified copy is filed with the county building inspec- BUILDINGA c2 36 A) �� tion department. ADDRESS JV Date Applicant CITY ELS. ZIP LOCALITY e7QtA iC✓. NO. OF BLDGS. NEAREST. CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT ttjio NOW ON'LOT CROSS ST. COMPENSATION INSURANCE ASSESSOR 11 (This section need not be completed if The permit is for one TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL hundred dollars ($100) or less.) C TEL. OWNER / f_—'NO. USE ZONE MAP2 I certify that in The performanc e work for which this �` NO. J ermit is issued, I shall not a oy any. erson in any manner ADDRESS34 v SPECIAL CONDITIONS so as to become subject to i e Workers'Compensation Law v/ CITY ,` ZIP Date, Applicant ARCHITECT OR TEL DISTRICT' GROUP TYPE FIRE PRO SSED BY NOTICE TO APPLI ANT:' If; after making Thls C tificate of ENGINEER 64 `{ NO. CONSr-= ZONE 0 Exemption, you should become subject-to The Workers' U� --3 Compensation 'provisions of the Labor Code, you must forth- ADDRESS 0- with with comply with such provisions or this permit shall be TEL. STATISTICAL CLASI;ATION A .` C N deemed revoked. CONTRACTOR NO. GG 111 Z LICENSED CONTRACTORS-DECLARATION LICCLASS NO. DWELL. UNITS — I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS (commencing with Section 7000)of Division 3 of the Businessr LIC. SEWER MAP and Professions Code,and my license is in full force and effect. CITY I/4 6 A CLASS 6- 1 BJA PG �v� VALIDATION SQ. FT. NO. OF. NO, OF CHECK License Numbers Lic. Class SIZE STORIES ' FAMILIES ONE ]. VALUATION ContractorPOC Dare I '.O. DESCRIPTION OF WORK NEW ❑ $ f� ❑I am exempt under Sec. ADD ❑ / ► ALTER ❑ B.&P.C. for this reason >JUSE OF w ' / REPAIR� $ Date: EXISTING BLDG. !/v s / DEMOL Signature APPLICANT ' TEL , g OWNER-BUILDER DECLARATION (PRINT). C NO FINA DA I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and ADDRESS Professions Code): PRESENT ° ❑ I, as owner of the property, or m employees with BUILDING ,-- 4,z P P Y YADDRESS wages as their sole compensation,will do.the work and the structure is not intended or offered for sale Section LOCALITY s s 7044, Business and Professions Code.) MOVING TEL. ElI, as owner of the ro erT CONTRACTOR NO. 0 4 p p y,am exclusively contracting #'- '°°I with licensed contractors,to construct the project (Sec- ADDRESS ? -�' '`1 -� tion 7044, Business and Professions Code._) ' -�'}`' •'.F° '_F. REQUIRED YARD HWY TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY. SET BACK 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 e LDMA Ref. # x. a �^ Lender's Address P.C.Fee$ Permit Fee J 0 1 certify that I have read this application and state that the Issuance Fee LDMA P/C# 0 information is correct. I agree to comply with all County Investigation Fee 0 ?a sand State laws relating to building construction, Total Fee LDMA Perm. # a and here y authorize representativ of this County to enter upon The bove-mentione r per for inspection purposes. 3-�3r SEE REVERSE FOR EXPLANATORY.LANGUAGE Signature of App i4ht Agent Date � . 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, BUILDING ADDRESS n 9 _V {3 or a certificate of Workers' Compensation Insurance,or a certified G copy thereof(Sec.3 00, ab. C.yy CITY- ZIP cc ri/y b LOCALITY Q_ C Policy No. Company SIZE OF LOT NO.OF BLDGS.NOW ON LOT . ❑ Certified copy is hereby furnished. NEAREST CROSS ST. Certified copy is filed with the county building inspection TRACT BLOCK LOT NO, USE ZONE MAP NO. department. /jV/�� ry �/ /- Date l S�q Applicant / 6 �" —Y LVC VlY ASSESSOR MAP BOOK PAGE �j PARCEL �3 C y d J� SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS': OWNER T L N / / YES NO COMPENSATION INSURANCE Y d{/)1• pWITHIN 1000 FT.OF SCHOOL? This section need not be completed if the permit is for one hundred ADDRESS ( P �/' � DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY dollars($100) or less.) CITY ZIP 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 ARCHITECT OR ENGINEER TEL NO. •J!� `� GG��s become subject to the Workers'Compensation Laws. STATISTICAL CLASSIFICATION APT CONDO 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' CONTRALTO L SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith, 0 ( FRONT comply with such provisions or this permit shall be deemed revoked. ADDRESS u/ 1 LIC.Nt`� r PL 0 L3 I SIDE LICENSED CONTRACTORS DECLARATION CITY LIC.CLASS P L I hereby affirm that I am licensed underprovisions of Chapter 9 SEWER MAP (commencing with Section 7000)of Division 3 of the Business and SQ.FT.SI NO.OF STEFEq NO,OF FAMILIES Professions Code,and my license is in full force and eff Ct. 0�J NEW 1:1 BK PG ' License Number Lic. Class DESCRIPTIQN OF WQRK 2 '„'�� ADD VLUATION� �,•� Q Contractor l?a w.. .T'Datdl / // cc �y � ALTER ❑ C/ ❑ I am exempt,under Sec !�' I” REPAIR ❑ $ 0 B.&P.C. for this reason DEMOL ❑ LDMA P/C# U W Date: USE OF EXISTING BLDG. URM ❑ _ (l Signature APPLICANT(PRINT) TEL NO. LDMA Perm# Z ❑ I, as owner of the property, or my employees with wages as O :: _$ their sole compensation, will do the work and the structure is ADDRESS //, �f not intended or offered for sale (Section 7044, Business and ``� >� I� ' 'rr L9 FINAL DATE Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCU ANT HANDLE A HAZARDOUS MATERIAL 3- '• J 3 ❑ I, as owner of the property, am exclusive) contracting with OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE + P y. Y g AMOUNTS SPEC D ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY licensed contractors to construct the project (Section 7044, YES E: DN NO) =g Business and Professions Code.) WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING '- ^x' OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH '• CONSTRUCTION LENDING AGENCY COAST AIR QUNJT,Y MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR GUIDELINES. I hereby affirm that there is a construction lending agency for YES❑ NO/❑ -{ w the performance of the work for which this permit is issued(Sec. TOTAL 1 55 - ;SO I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING 3097, Civ.C.) CHECKLIST. UNDERSTAN Y REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, a TITLE 2,CHAPTER 2.20 TIONS 2.20.100 THROUGH 2.20.140 CONCERNING HAZARDOUS �_{"� �_•! „•__ e,_3} Lender's Name MATERIALS REPORTIN D FOR OBTAINING A PERMIT FROM THE SCAQMD. - o Lender's Address t OWNER OR AGENT O 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 P.C.FEE •� r PERMIT FEE yn� With all c ty ordinances and State laws relating to building v 0 J �v l_fl?=I� _i;^` i I c construe o and hereby authorize representatives of this County ISSUANCE FEE .^,^.,i; •� __ oD CO to enter the above-menti ed pro erty for inspection purposes. 1-'�� '; '_'!' ID a INVESTIGATION FEE TOTAL FEE /D 3 Si,.Wr,-A A )icon)or Agent - Dale � SEE REVERSE FOR EXPLANATORY LANGUAGE l APPLICATION FQ R"BUILDING PERMIT COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDR ssn I hereby affirm that I have,a certificate of consent to self insure, BUILDING ADDRESS or a certificate of Workers' Compensation Insurance,or a certified � �� Z copy thereof(Sec.3800,Lab.C.) CITY s ZIP LOCALITY Policy No. Company SIZE OF LUT NO.OF BLDGS.NOW ON LOT ❑ Certified copy is hereby furnished. NEA ST CROSS ST. ❑ 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' OWNER TEL NO. COMPENSATION INSURANCE 7 WITHIN 1000 FT.OF SCHOOL? YES No (This section need not be completed if the permit is for one hundred DRESS p p DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY dollars($100)or less.) CIT ZIP 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 U4 I A -«'✓ become Subject to the Workers'Compensation Laws. ARCHITECT OR NGINEER TEL NO. STATISTICAL C SSIFICATION APT CONDO 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' CONTRACTOR 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. ADDRESS LIC.NO. P L LICENSED CONTRACTORS DECLARATION SIDE CITY LIC.CLASS P L I hereby affirm that I am licensed underprovisions of Chapter 9 SEWER MAP >' (commencing with Section 7000)of Division 3 of the Business and SQ,F . NO.OF STORIES NO.OF FAMILIES a Professions Code,and my license is in full force and effect. NEW ❑ BK PG , Q D CR TION OF WORK VALUATION V License Number Lic.Class i ADD �) Contractor Date ALTER ❑ $ ✓ `�oo ❑ I am exempt under Sec. cz��`�'��7 yet/ REPAIR ❑ $ O U B.BP.C.for this reasonLd t�2►9!G DEMOL ❑ L'DMA P/C# LU Date: USE OF EXIST B CL URM ❑ IN Signature -I� Z APPLICANT(PRINT) TEL NO. LDMA Perm# ?.J•;+j & ❑,I, as owner of the property, or my employees with wages as O :•" 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 i P,OfeSSIODS Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL S.� J ' OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE FINAL BY I, as owner of the property, am exclusively contracting With AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? Q '1 licensed contractors to construct the project (Section 7044, YES❑ No❑ Business and Professions Code.) -,1.5' WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING "1-,r - OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR z rr. GUIDELINES. _ I hereby affirm that there is a construction lending agency for t y�i — 85 VES❑ NO❑ .lTt"-i 7 �., the performance of the work for which this permit is issued(Sec. � � rn IHAVE REA AZA SMA MATERIALS INFORMATI NG AND THE SCAOMO PERMITTING t 3097,CIV.C.) CHEC UNDE AND MV REQUIREMENTS U E LOS ANGELES COUNTY CODE, 3?4t^ TIT 2,CeHAPTE IONS 2.20.100 T 2.20.140 CONCERNING HAZARDOUS �y Lender's Name ERIALGAN FOR 0. 01) IT F AQMD. i".L? iL��o Lender's Address ftO OWNER 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 P.C.FEE �. PERMIT FEE D3. YII f�f r i r 310 with all ty ordinances and State laws relating to building m const,. , and hereb autho ze representatives oft 's County ISSUANCE FEE // j_j i i�3 u ) to enter nth abov d property for inspect pur oses. ' OU2 /AA2' INVESTIGATION FEE TOTAL FEE D. 3 7gnatp, of Applicant of gent � Dale . V SEE REVERSE FOR EXPLANATORY LANGUAGE APPLICATION FOR BUILDING PERMIT ` COUNTY OF LOS ANGELES ���✓ ~`1�BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRE I hereby affirm that I have a certificate of consent to self insure, BUILDING ADDRESS . _ or a'certificate of Workers' Compensation Insurance,or a certified c T copy thereof(Sec.3800, Lab.C.) CITY ZIP LOCALITY Policy No. Company SIZE OF LCT NO.OF BLDGS. OW ON LOT ❑ Certified copy is hereby.furnished. XO NEAREST CROSS ST ❑ Certified copy is filed with the county building inspection TRACT BLOCK LOT NO. d UG- USE ZONE MAP NO. 49 department. Date Applicant ASSESSOR MAP BOO PAGE PARCEL 0 SPECIAL CONDITIONS q (9 CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER TEL N COMPENSATION INSURANCE 14alellq — -/ 7 WITHIN 1000 FT.OF SCHOOL? YES No (This section need not be completed if the permit is for one hundred ADDRESS 6 j DISTRICT GROUP TYPE CONST FIRE ZONE PROCESSED BY CITY dollars ($100)or less.) � v � I certify that in the performance of the work for which this permit ZI Ys is issued, I shall not employ any person in any manner so as t0 ARCHITECT OR ENGINEER "TELN1 become subject to the Workers'Compensation Laws. STATISTICAL Cl­] SS`IFICATION APT CONDO Date Applicant ADDRESS CLASS NO. -Z-(--i-- DWELL UNITS 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 (114 Z)13 comply with such provisions or this permit shall be deemed revoked. FRONT ADDRESS LIC.NO. P L LICENSED CONTRACTORS DECLARATION SIDE QQ CITY LIC.CLASS P L hereby affirm that I am licensed underprovisions of Chapte 930 SEWER MAP } (commencing with Section 7000)of Division 3 of the Business d SQ.FT.SIZED NO.OF STORIES NO.OF FAMILIES O Professions Code,and my license is in full force and effect. -el NEW ❑ BK PG , U DE CRIPTON-OF WORK VALUATION License Number Lic.Class � ADD Contractor Date 0 ALTER ❑ ` 0 REPAIR ❑ ~ ❑ I_am exempt under Sec. $ 1*X `' NN t� U B.SP.C. for this reason DEMOL ❑ LU LDMA P/C# �- Date: USE OF EXISTING BLDG. URM ❑ - N Z Signature APPLICANT(PRINT) TEL NO. LDMA Perm# ❑ I, 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 i Professions,Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL M ,•+ J I, as owner of the OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE property, am exclusively contracting with AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? j''`'' a FIN �icensed contractors to construct the project (Section 7044, AT YES❑ NO❑ Business and Professions Code.) -f_ - ° - WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING -- i' ' OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH CONSTRUCTION LENDING AGENCY COAST AIR QUAUTY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST GUIDELINES. - - I hereby affirm that there is a construction lending agency for YES❑ No❑ " _ er N the performance Of the Work for which this permit IS ISSUed(Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING " `- ° 3097, Civ.C. . t"•Li" a ) CHECKLIST.I UNDERSTAND MV REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, "�•T t 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 SCAQMD. a! )J o Lender's Address OWNER OR AGENT O o I certify that I have read this application and state underpenalty O of perjury that the above information is correct.I agree to comply P.C.FEE �"'/� PERMIT FEE 1// ,�•� C. •i, N with all county ordinances and State laws relating to building �;�J L/ �J /�� �.J t=f`^F''-}'")L ,I,A4y, ..,_ construction, and hereby authorize representatives of this County ISSUANCE FEE ��D '_?-r = lil=, CIDto enter upo the abov ment ed property for inspection purposes. ` ' +- l' i}� INVESTIGATION FEE TOTAL FEE i— r Awns V VV SEE REVERSE FOR EXPLANATORY LANGUAGE