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7GA638A C8#BOBC 39 APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING
DEPARTMENT OF COUNTY ENGINEER ADDRESS
BUILDING AND SAFETY DMSION LOCALITY
JOHN A LAMBIE COUNTY ENGINEER NEAREST
CASSATT D GRIFFIN SUP T OF BUILDING CROSS ST
DISTRICT NO GROUP TypE P ESSED Y
FOR APPLICANT TO FILL IN 6 - CONST I
BUILDING
ADDRESS - ��� STATISTICAL CLASSIFICATION I S ER MAP
BK PG
CLASS NO DWELL UNITS
LOT NO t ,77/- 1� BLOCK MAP STATE
C\ NUMBER r HWY YES NO
TRACT a Fig zl S�Z/ USE ZONE SPECIAL
NO OF BLDGS CONDITION
.i f SIZE OF LOT S NOW ON LOT ///
USE OF ��
EXISTING B DG BUILDING EXIST
SETBACK YARD HWY STREET NAME WIDTH
OWNER - G7 FRONTMAIL I
ADDRESS '�~ p�61L''f ` ' P L
SIDE
CITY" TEL P L INSPECTION RECORD
ARCHITECT OR TEL
ENGINEER NO
S l -'YO(0 3
DDR S ! TEL
CONTRACTOR
�j 11,E- G�f N`O 'jQ
DESCRIPTION OF WORK
NEW ADD ALTER REPAIR DEMOLISH U
SO FT NO OF NO OF �j
SIZE STORIES FAMILIES
USE OF STRUC URE
o�-
SIGNATURE OF APPROVALS
� APPLICANT s v"L�
RATEI INSPE RSSIGNATURE
ADDRESS ^ �!I Gj ? r FOUNDATION LOCATION
FORMS MATERIALS !
�XmV r� P C $
FRAME FIRE STOPS
00 FEE �n BRACING BOLTS
VALUATION " /
V FURNACE LOCATION B
FEE y GAS VENT DUCTS ,
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS AP LATH INT
PLICATION AND STATE THAT THE ABOVE IS CORRECT AND
AGREE TO COMPLY WITH ALL COUNTY ORD NANCES AND LATH EXT
STATE LAWS RE INv�UI IN NSTRUCTION
SIGNATURE OF [/��_'/ HOUSE NUMBER COR
+"' PERMIT" ' 10 RECT AND POSTED l^
ADDRESS � r� ��u 6Zj/_ FINAL
CLYDE N DIRLAM PRINCIPAL STRU URAL ENGINEER
PLAN CHECK VALIDATION mo CASH PERMIT VALIDATION cK m o CASH
r
�I` M 0112 13 a`pit
ty,7 -o,2,24 to �flfiY h'1f G .J (1
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APPLICATION FOR BUILDING PERMIT
• COUNTY OF LOS ANGELES } BUILDING AND SAFETY
~ WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL INaUiL �.5RF$S �'
I hereby affirm that 1 have a certificate of consent to self insure, BUILDING ADDRESS �' r.
or a certificate of Workers' Compensation Insurance,or a certified AI `•
w^ F�
copy thereof (Sec.3800,Lab.C.) CITY '-/ LOCA ITE
ZIP
Policy No. Company SIZE OF LOT Y NO.OF BLD S.NOW ON LOT
❑ Certified copy is hereby furnished. I oX NEAREST CROSS St.
❑ Certified copy is filed with the county building inspection TRACT BLOCK LOT NO.
department. - USE ZONE MAP N�.yy <� `
Date Applicant ASSESSOR MAP BOOK p589 PAGE z., PARCELO�,A / �v
f0 e., i SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER IVI TEL NO. J
COMPENSATION INSURANCE M WITHIN 1000 FT.OF SCHOOL? YES NO
s section neenot completed permit is for one hundred ADDRESS
(Thiineed bltd if thP p DISTRICT _ GROUP TYPE CONST. FIRE ZONE PROCESSED BY
dollars($100) or less.)
I certify that CITY IP the performance of the work for which this permit a C/ Z0041e4� a
is issued, I shall not employ any person in any manner so as to ,
A 160
become subject to the Workers'Co ensation Laws. ARCHITECT OR NGINEER T NO.
f P STATISTICAL CLASSIFICATION APT CONDO
Date � 'K�plit;�(nt ADDRESS CLASS NO. 2 DWELL UNITS
NOTICE TO APPLICANT.' If, Wer maki this • ertificate cO REQUIRED •.TOTAL SETBACK FROM EXIST
Exemption, you should become Subject t0 the Workers' CONTRACTOR TEL O.- SET BACK YARD HWY PROP LINE WIDTH
Compensation provisions of the Labor Code, you must forthwith 7-
/< /�/�`] - el s '�%&_P40 FRONT
comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC.NO. PL
165� ft
.LICENSED CONTRACTORS DECLARATION O �� 6�� SIDE
CITY ,{` e LIC.CLASS PL
V(�
I hereby affirm that I am licensed underprovisions of Chapter 9 , e/ SEWER MAP
(commencing with Section 7000)of Division 3 Of the Business and SO.FT.SIZE NO.OF STORIES NO.OF FAMILIES
Professions Code,and my license is in full force and effect. 5n '" NEW 13 BK PG �-
DESCRIPTIO OF WORD ADD E] VALUATIO4/ XN
a
License Number Lic. Class_� APO
1
Contractor r Date o+r- 2 CLf/�J 2 1 gEAa� /v ALTER ❑ $ S U
fG REPAIR ❑ $ O
El0
I am exempt under Sec.
BAP.C. for this reason DEMOL ❑ - U
LDMA P/C#
Date: ` USE OF EXISTING BLDG.�f ,` URM .❑
Signature C�
APPLICANT(PRINT) •.--, % TEL NO. LDMA Perm# i•ii Z
❑ I, as own the ro ert or to ees wit wa es as rr '
P P Y Y P Y 9 r� �_ >�!_',.•T o 8
their sole compensation, wil o the work and the structure is ADDRESS c /
�I b/ &n e /lam FINAL DATE ~ - _'
not intended or offered for sale (Section 7044, Business and ! / . QQ I } I,.s1 I
Professions Code.) f_ _
WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL _ "'
OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN'THE
❑ 1, as owner of the property, am exclusively contracting with AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY _
licensed contractors to construct the project (Section 7044, 'YES❑ NO❑
Business and Professions Code.)
INTENDEDWILL THE USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING i
r OCCUPANT REQUIIREA PERMIT CONSTRUCTION OR MODIFICATION FROM THE SOUTH T ' ' 'per •u�'
CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR t I-i T HL I-� a-�
GUIDELINES. f, t. Nv
1 hereby affirm that there is a construction lending agency for YES 1:1 No El CHECK 1`"',_`
N the performance Of the Work for Wt11Ch this permit IS ISSUed(Sec. (HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING t G
3097,Civ.C.) CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE,
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 SCAOMD.
EL Lender's Address /?`
O
OWNER OR AGENT _100111-010101 ':f 2. /-r
o I certify that I have read this application and state under penaltyi iev
0 of perjury that the above information is correct. I agree t0 comply P.C.FEE ,�0 PERMIT FEE •791 M
with all county ordinances and State laws relating to building
< construction, and hereby authorize representatives of this County ISSUANCE FEEco
to r upon the above-mentioned prop t inspection purposes. L�J
2 ��Z•ui- INVESTIGATION FEE TOTAL FEE
ID
r
SIC;e OI Applicant Or Aqe Date
SEE REVERSE FOR EXPLANATORY eANGLIAGE