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76A636A CEA8035-65 APPLICATION FOR B ILDINGP5'ERMIT
C04NTY OF LOS ANGELES BUILDING
DEPARTMENT OF COUNTY ENGINEER ADDRESS
BUILDING AND SAFETY DIVISION LOCALITY
JOHN A. LAVIBIE. COUNTY ENGINEER NEAREST '
COLEMAN W. JENKINS SUPT OF BUILDING CROSS ST.
DISTRICT NO. GROyL- TYPEP C 5EO BY
FOR APPLICANT TO FILL IN 1 1 CONST.
BUILOI NG �1.� n, -/may STATISTICAL{CC SSIFICATION SE E AP
ADDRESS �' J I[/ w? CLA55 NO.Jl—DW E L L U NI T S B< PG
LOT NO. BLOCK USE ZONE MAP
F NO.
TRACTCIAL
.KCL, SPED/0 �o J OF BLOGS.
J
SIZE OF LOT ` CONDITIONS
OW ON LOT r
USE OF
EXISTING SLUG. BLDG. SETBACK FROM
/�
TEL. r (�/^/�9 FRONT PROP. LINE OF (STREET)
OWNER 00 - NOS// OVC J TYPE.OF .EXISTING SETBACK HIGHWAY } YARD = TOTAL
ADDRESS LL/ o GG �JT OT(/ HI WAY WIDTH FROM. CC.
.L
CITY YM/ A-- �� • V +
BLDG. S!TBACK FROM
ARCHITECT OR TEL. SIDE PROP. LINE OF (STREET)
ENGINEER NO.
TYPE OF I EXISTING SETBACK I HIGHWAY } YARD = TOTAL
HIGHWAY WIDTH FROM C.L.
ADDRESS //''''�0�YL, �f77��0// /F/ p �y
CONTRACTOR IVA^' /tW L� 'NO L/T/ O OL�.F + d
ADDRE�SrS /�
NO CORNER CUTOFF YES NO F 00
nrr.Yu'J�Y �'4J't/ CLA SEE REVERSE SIDE FOR SPECIAL APPROVALS O
DESCRIPTION OF WORKG
r
/2/9%°" .v IC &7Z
NEW ADO ALTER REPAIR DEMOLISH
SQ.FT. O. OF NO. OF A'G` ^-- 'O"%lY-"�
SIZE STORIES FAMILIES
USE OF
STRUCTURE
bin oO6L rct a ^/ -
SIGNATURE OF
APPLICANT
VALUATION
APPROVALS DATE INSPECTOR'S SIGNATURE
P C PMT FOUNDATION, LOCATION
FEE r'J FEES FORMS. MATERIALS
FRAME, FIRE STOPS.
HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION BRACING BOLT
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY FURNACE: LOCATION
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING GAS VENT. DUCTS
9UILOING CONSTRUAICEY THAT. IN DOING THE.WORKAUTHORIZED HEREBMPLOY ANY PERSON IN VIOLA. LATH. INT.
TION OF THE LABORSTATE OF CALIF RELAT.INGTO WORKMEN'S INSV$/1NCE._/ LATH. E%T.
SIGNATURE OF HOUSE NUMBER COR- /PERMITTEE RECT AND POSTEDADDRESS ' /.�45 FINAL
JOHN F. LEWIS. PRINCIPAL STRUCTURAL.ENGIN�ER
PLAN CHECK VALIDATION CK. M.O. CASH _ PERMIT VALIDATION cK. M.O CASH
LAC0 7 '9 4 1 DEC g 1 D. 4.00-
4
' I
DEPARTMENT OF BUILDING AND SAFETY APPLICATION FOR PERMT
COUNTY OF LOS ANGELES ' U' l L® � Pte@ G
WM. J. FOX, CHIEF ENGINEER II"�
FOR APPLICANT TO FILL IN FOR OFFICE USE ONLYBUILDING _
a� DISTRIC(TT VO. - PLAN CK. NO. ERMITT NO.
ADDRESS 2/ 0 V ® �I _ �o ! 2 Z
p I
LOCALITY ` P II RE IVED By, DATE OF APPL. DATE IBSU ED
NEAREST. 'N �,. A r r �S BUILDINo '7 �WI� y
o ADDRESS 7 77�"`'' 4F�2 d�
MAILOWN � G"1� / ISI .- v/ L'.
MAIL I LOCALITY
ADDRESS rJ _ 19 1'0 a'CI G V NEAREST EFiy�iN.� T-Jq�f
TCROSS ST.
CITY .rfR/1 ♦ ,�O I•1 (s NO,L. r FIRE NO. OFI TYi I GROUP
ARCHITECT Ogf TEL ZONE PLANS
ENGINEER NO, BLDG. A ell NO.
SETBACKLINE /-
r ADDRESS APPROVED
TEL. BY DATE
CONTRACTOR l NO. USE II / APPROVED'
ZONE �T BY DATE
ADDRESS r LEGALHOUS NUMBERING
DESCRIPTION I LOTNO. P--7q I BLOCK MAP NUMBE • CCW FIELD CHECK BY
TRACT /� 1 O ' 1 C P NO. ASSIGNED BY ^ATE
No. of BLDGS. - CORRECTIONS .-
NE OF LOT ) I NOW ON LOT
O
USE FFS NO. OF /
EXISTING BLDG. 1 FAMwss _
DES RIPTION OF WORK -
' NEW ALTERATION I ADDITION
0
REPAIR I DEMOLITION I - 9
60. FT. 11 NO. OF 0
SIZE l/ ROOMS STORIES Z
EXT. WALL ,�
ROOFww �A r
COVERING .�/J I COVERING A4
USE OF STRUCTURE
y s Gobi
APPROVAES
INSPECTOR'S SIGNATURE DATE
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS AP- FOUNDATION: LOCATION
PLICATION AND STATE THAT THE INFORMATION GIVEN IS FORMS, MATERIALS
CORRECT.
I AGREE TO COMPLY WITH THE CORR CTIONS LISTED FRAME: FIRE STOPS,
HEREON AND WIT ALL Co' TY ORDINAN ES AND STATE BRACING, BOLTS
LAWS REGULATI UILDIN CONSTRUCT N. FURNACE: LOCATION,
SIGNATURE OF n GAS VENT, DUCTS
PERMI-gE
1 J. 4 Ir.� (Y( _.- //iI.JTIZ� LATH, INT.
ADDRRSS�
J Y; LATH, EXT.
AUTHORIZED AGT. 1 r'
PLASTER. INT. �.
7aA00A- DBO 10-60 S PEE
B -
FEE PLASTER, EXT. /
VALUATION FEE 8 I? FINAL i8 ✓ A
DEPARTMENT OF BUILDING AND SAFETY APPLICATION FOR PERMIT Cal
COUNTY OF LOS ANGELES �j
WM. J. FOX. CHIEF ENGINEER (O _ L
FOR APPLICANT TO FILL IN FOR OFFICE USE ONLY
,1 DISTRICT`N9: /�PLAN/yC�IK.\NO. 7 P�ERMITINOO.y�
BUI WINO /0jV Com. YG OQ Ddu l� C/ � 1�i7
ADDRESS
�p eye
LOCALITY �77f�/� G�-! ( Y RECEIVED, Y DATE OF APPL/y� /DATE ISSUED
NEAREST / — /'� lJ W/
CRO99 BT. ..
BUILDING
ADORES-
MAI L
DDRESSMAIL � LOCALITY
ADDRESS
'F— /{ A`_ NEAREST
CITY NE[ / FIRE BHT. NO.Or TYPE GROUP /
ARCHITECTORTEL. ZONE PLANS L/
ENGINEER NO. \ 1 ORD.ND.
SEGO. �.
ADDRESS SETBACK LINE\� /Il ! .�� �T 40L'/l�
.( Tr APPROVED I
CONTRACTOIi �Qj//J6J�j� �Ip.r� D.ZV�/ BY t� \ DATE.
USE �/// APPROVED
ADDRESS e ZONE /r/� BY V* DATE
LEGAL ✓! / . V U CORRECTIONS
DESCRIPTION LOT
'N/O.H� /' BLOCK/j y�
TRACT )Y � 1 �F1N 7) NO.OF
, V'/ ' /-1-/ �� No f r > �G �•
SIZE OF LOT 70 41.4V I NOW ON LOTS V:`
UBE Or NO
.OF ND.pr
EXISTING BLDG. FaNIL.EB ROOMS
DESCRIPTION OF WORK
NEW ALTERATION I ADDITION O
lA
REPAIR MOVING DEMOLISH G
SG.rT. NO.OP Z
SIZE ROOMS STORIES I D
r
WALL .. ROOF
COVERING I COVERING
USE or NEW _
BUILDING
1 HEREBY ACKNOWLEDGE THAT 1 HAVE-READ THIS APPROVALS
APPLICATION AND STATE THAT THE ABOVE I9 CORRECT FOUNDATION: LOCATION ,NBP CTOR DATE
L7�-3
E TO COMPLY WITH ALL COUNTY ORDINANCES. FORMS.MATERIALS ��
LAWS REGULATING BUILDING CONSTRUCTION.
FRAME: FIRE BTOPB. V e
OF I BRACING,BOLTS
"� LATH. INT.
AST_
LATIN, EXT.
sG 8 P.C.8 PLASTER.INT.
FEE PLASTER.EXT.
/ JYOO '— FEE ^a�i a FINAL f1/� 'Ald
76AO38A CE"03 9.67
APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING
DEPARTMENT OF COUNTY ENGINEER ADDREss
BUILDING AND SAFETY DIVISION LOCALITY
JOHN A. LAMBIE, COUNTY ENGINEER
COLEMAN W. JENKINS, SVP'T of BUILDING NEAREST
Cft 055 ST.
FOR APPLICANT TO FILL IN DISTRICT NO. 11 GROUP TYPE PROCESSED BY
(Print or type .DIY) 6 Q� CONST.
BUILDING ,E p ./ STATISTICAL CLASSIFICATION -SEWER MAP
ADDRESS — /_CLASS NO,_-_ -<g BK PGIII O
LOT NO. BLOCK USE ZONE MAPGam'
NO. -1-d G ES
TRACT �/ SPECIAL
NO.OF BLOGS. CONDITIONS
SIZE OF LOT 70 7 S NOW ON LOT ,
USE OF 1 /� _ '
EXISTING BLDG. / E(,/ `W BLDG.SETBACK FROM
•:. / Jr, I TOL FRON T PROP.LINE OF I"C" '-V'L'L' (STREET)
OWNER Lam/ C AV TYPE OF EXISTING SETBACK HIGHWAY + YARD = TOTAL
ADDRESS
,! HIGHWAY WIDTH FROM G.L.
{p
CITY `E / BLDG.SETBACK FROM
ARCHITECT OR TESIDE PROP.LINEOF (STREET)
ENGINEER G, L.NO. _
TYPE IA EXISTING SETBACK HIGHWAY + YARD - TOTAL
ADDRESS HIGHWAY WIDTH FROM C.L.
TEO. - SZ�d + d
CONTRA CTOR �'�
'7 ' Np/ CJ
ADDRESS (6 NO. iib CORNER CUTOFF YES ❑ NO k;�_ V
LIC.
CITY CLASS h / SEE REVERSE SIDE FOR SPECIAL APPROVALS
DESCRIPTION OF WORK d
h
z_
NEW ADD ALTER REPAIR DEMOLISH
Sq. FT. NO. OF NO. OF
SIZE STONES FAMILIES
USE OF �BB
STRUCTURE // w v
SIGNATURE OF
APPLICANT I
VALUATION S
APPROVALS DATE INSPECTOR'S SIGNATURE
P.C, p O PMT. O O FOUNDATION: LOCATION
FEE 5 FEES I Z= FORMS, MATERIALS
FRAME: FIRE STOPS,
1 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 COUNTY ORDINANCES AND STATE LAWS REGULATING GAS VENT, DUCTS
BUILDING CONSTRUCTION. I CERTIFY THAT IN DOING THE WORK
AUTHORIZED HEREBY 1 WILL NOT EMPLOY ANY PERSON IN VIOLA-
TION OF TME LABOR CODE OF TH STATE OF CALIFORNIA RELAT. LATH, INT.
M
ING TO WORNEN'S CO MPENS TION NSVRANI CE.
\\IL fEAA�I�IA_LL_}_1"` IATH, EXT.
SIGNATURE OF HOUSE NUMBER COR-
PERMITTEE' RECT AND POSTED
ADDRESS FINAL
JOHN F. LEWIS. PRINCIPAL STRUCTURAL ENGINEER
PLAN M.O.�LAUD M.O. CCASH 6
•00N
1u_i0 4 7 8 3 MAP 23 1 D. 1 2.0 0
`� -
76A638A CE #803 3-69
i. APPLICATION FOR BUILD NG PER IT uI
COUNTY OF LOS ANGELES aaWILDIss O -C
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION
LOCALITY
JOHN A. LAMBIE, COUNTY ENGINEER
COLEMAN W. JENKINS, SUP'T OF BUILDING NEAREST
CROSS ST.
FOR APPLICANT TO FILL IN oISTR c�N0,�' Gaou TYPE CONS PR C
(PRINT/,OR TYPE ONLY) _ (/
BUILDING TATISTICAL CLASSIFICATION SEWER MAP;
ADDRESS �Y/L� �.�J�'/�i'f'�7'/ /c-1�/'�E C./
CLASS NO. DWELL.UNITS BK_ - PG
LOT NO. Q BLOCK USE ZONEMN0.AP Q-V/1 I:
/(I
TRACT (I / SPECIAL '
N0. OF BID GS. / f CONDITIONS. -
SIZE OF LOT NOW ON LOT
USE OF —/`���GL
EXISTING SLOG. i BLDG. SETBACK FROM
TELV `L / FRONT PROP. LINE-OF '- - - -1STREETI
OWNER .�/c �C�nN N0 c TYPE OF EXISTING SETBACK HIGHWAY - + YARD - TOTAL
ADDRESS Y/� � pi_�LIIT HIGHWAY WIDTH FROM C.L.
CITY
ARCHITECT OR TEL. SIDE PROP. LINE OM (STREET)
ENGINEER NO.
TYPE OF EXISTWG SETBACK HIGH YARD = TOTAL
ADDRESS " HIGHWAY WIDTH FROM Ql.
CONTRACTOR F�,III//ec fy/T NOLL��Q
AODRESSMN. S SII/ ✓�• ®fiC'7/ CORNER CUTOFF- YES *❑ NO ❑, L
Lp
CITYCLASS SEE REVERSE SIDE FOR SPECIAL APPROVALS
CONSTRUCTION LENDER A A t
NAME AND BRANCH V
p
ADDRESS
L
SFT. N0. OF NO. OF
SIZE
E STORIES FAMILIES NEW
USE OF ADO ❑
STRUCTURE
�� A ALTER ❑
It'I.'��+T/J/f� ^ y�f/y F�CLi REPAIR ❑
SIGNATURE OF OEMOL ❑
APPLICANT �f
VALUATION $ 21 c' APPROVALS DATE INSPECTOR'S SIGNATURE
P.C. PMT. FOUNDATION: LOCATION
FEE $ FEE S A FORMS MATERIALS
I HEREBY ACKNOWLEDGE THAT I HAVE HEAD THIS APPLICATION FRAME: FIRE STOPS,
BRACING BOLTS
ANO STATE THAT THE ABOVE IS HAVE
AND AGREE TO COMPLY FURNACE: LOCATION,
WITH ALL CERTIFY
ORDINANCES AND LAWS REGULATING BUILDING HEREBY
GAS VENT DUCTS
TION. CERTIFY THAT IN GOING THE WORK AUTHORIZED HEflEBY
WILL NOT EMPLOY ANY PER$IA ;WEI TING OF THE LABOR CODE LATH, INT.
OF THE STATE OF CA LISP NIA (ARE EATING TO WORKMENS CDM-
PEN5ATION IN SURA NCE. LATH, EXT.
SIGNATURE OF, HOUSE NUMBER CORRECT
PERMITTEE L.-�X� _L q!D POSTED
ADORES y C• �� L" FINAL 0
JOHN F. LEWIS, PRI CIPAL STRUCTURAL ENGINE
PLAN CHECK VALIDATION CK. M.a. CASH - PERMIT VALIDATION CK. M.O. CAS.
I r9.p_. 4 3 5 8= APR 6 1 D 6.0 01'
a
76A639A CECB035-� APPLICATION OR BUILDING ^PERMIT
COUNTY OF LOS ANGELES BUILDING 1
DEPARTMENT OF COUNTY ENGINEER ADORE" 4 C
BUILDING AND.SAFETY DIVISION LOCALITY
JOHN A. LAMBIE. COUNTY ENGINEER NEAREST /
COLEMAN W. JENKINS.SDP'T DF BUILDING CROSS ST.
DISTRR�T NO. GR¢i.)P TYPE P/ SSED BY
FOR APPLICANT TO FILL IN CONST.
ADDRe SG STATISTICAL ASSI FICATION
t /
/ u CLASS NO. DWELL UNITS BK PG
LOT NO. /� '� BLOCK USE ZONE MAPall r/
TRACT IFIfl /Y//C O //`// TI�C SPECIAL a
SIZE OF LOT �OA /` NO. OF BLOCS. /]' CONDITIONS
NOW ON LOT
USE OF
EXISTING lis/ /l x/f. BLOC. SETBACK `
TEL FRONT POOP. LIREE OF OF ��'L (�iflE ET)
OWNER %(/ Y NO.
t y� TT;E 01 E%(STI NG I SETBACK I HIGHWAY } YARjV - TOTAL
ADDRESS
} � !�/�/- ��• 44,1 =WIDTH WIDTH FROMC.L. of SIT
CITY / !/79 -;�I \ /� zad I, ow }
BLDG. SETBACK FROM
ARCHITECT OR TEL.
ENGINEER NO. SIDE PROP. LINE OF (STREET)
TYPEOi E%I STING SETBACK HIGHWAY } TAgO = TOTAL
ADDRESS HIOXWAT WIDTH FROM C.L.
TE
CONTRACTOR en u !/'S NOL +
_10'h -
LIC
O
ADDRESS 9ySy//Frs%s� NO CORNER CUTOFF YES NO Ll U.
// LIC old
C L A SEE REVERSE SIDE FOR SPECIAL APPROVALS O'
DESCRIPTION OF WORK
NEW ADO 3 ALTER REPAIR DEMOLISH '��� // Q /� ✓ / Z
S
SO
QZET .3
STORIES
I FAMIOF Is IFS/ F I iCiy/I'
SIGNATUREUSE OF
STRUCTURE ?3e C/�
OF
APPLICANT / C fQ�,/"
VALUATION$ III7A /l/,/1, AM
/ APPROVALS D)�TE INSPECTORI8:9f�A�UHE
P.C. PMT. /(Jd FOUNDATION, LOCATION
FEES FEESFORMS, MATERIALS
`J FRAME,
I HEREBY ACM NOWLEOGE THAT I HAVE READ THIS APPLICATION BRACING BOLT
ANO STATE THAT TIME 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. ( ) OJ
TION OF THE LABOR CODC OF TVE STATE OF CALIFORNIA REI-AT.
ING TO WORKMENS COMP;NS)TION IN �E. l/ LATH. EXT. ( �� �J�� ~l•
SIGNATURE OF � OUSE NUMBER COR- '
PERMITTEE RECT AND POSTED
ADDRESS r`s / ..5' FINAL
JOHN F. LEWIS. PRINCIPAL STReCTVRAL ENGINE/R
PLAN CHECK VALIDATION OK. M.D. CASH _ PERMIT VALIDATION cM.o <ASH
jjj
7AAa39ACExaos.,o.SA'APPLICATION FOR BUILDING PERMIT
BUILDING
BUILDING AND SAFETY DIVISION ADDRESS771
Department of County Engineer
County of Los Angeles LOCALITY
JOHN A. LAMBIE. COUNTY ENGINEER NEAREST
LASS_ATT D. GRIFFIN, SUPT OF BUILDING CROSS ST. GC/
DISTRICT NO. GROUP. TYPE (SEWER MAP
FOR APPLICANT TO FILL IN CONST. BK PG
144.
BUILDING / 2
ADDRESS STATISTICAL CLASSIFICATION
/ / ASS. NO. DWELL. UNITS
.F LOT NO. S K CLASS.
�'/ STATE
C NUMBER yid d HWY YES
TRACT USE ZONE SPECIAL
NO.OF SLOGS. 7 CONDITIONS
SIZE OF LOT ZZ" NOW ON LOT n
' USE OF �� w
EXISTING DG. BUILDINGEXIST.
[ ' SETBACK YARD HWY STREET NAME WIDTH
OWNE FRONT �5
MAIL P. L.
/
ESS y
ADDRat SIDE
P. L.
CITv NO — r INSPECTION RECORD -
ARCHITEC OR TEL.
ENGINEE NO. `
�o-1 rt-tc:
ADDRESS
TEL.
CONTRACTOR NO. �l-.�•� A
ADDRESS
DESCRIPTION OF WORK —Y
A.J 7�9�
NEW AD j ALTER REPAIR DEMOLISH
SQ. FT. o NO. OF NO. OF G� - ��
SIZE STORIES FAMILIES
USE OF STR I f
� 1
APPROVALS
SIGNATURE
APPLICANT DATE INSPECTOR'S SIGNATURE
ADDRESS FOUNDATION: LOCATION
FORMS. MATERIALS
$ {'/�{ /t P. C. 34 - FRAME: FIRE STOPS, -
.0 7 e 0 FEE BRACING. BOLTS _
1 FURNACE: LOCATION.
VALUATION GAS VENT. DUCTS
FEE -
-1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS AP- LATH. INT.
PLICATION AND STATE THAT THE ABOVE IS CAORRECT AND "
AGREE TO COMPLY !{�JPLL COUNT ORD ANCES AND BATH, EXT.
STATE LAWS REGU G B DI C STRUGTION.
SIGNATURE OF HOUSE NUMBER COR- ,
PERMITTEE RECT AND POSTED'
ADDRESS iQ FINAL -
JOHN A. LAMBIE. COUNTY ENGINE CLYDE N. DIRLAM. PRINCIPAL.STRUCTURAL ENGINEER
PLAN CHECK VALIDATION cK N.C. CASH PERMIT VALIDATION CK. N.C. CASH
0 3 6 9' 6.r�; OCT 2 4 1 1 '6.0 0 M
WORKERS COMPENSATION DECLARATION �• - - J'j
I hereby affirm that I hove a certificate of consent.lo.selE
insure, or a certificate of Workers'Compensation Insurance, AP1I?LO V//3\M0 FR ROOLDU V V PERMO '-IIL,II
or o certified copy thereof (Sec. 3800, Lab. C.)
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
D Certified copy is hereby furnished. ., FOR APPLICANT TO FILL IN BuuDING
ADD �l 2��-�(.✓
RESS
- Certified copy is Tiled with the county building inspec- BUILDING � -
tion eport ent. /y �/ r ADDRESS 2 �� If—)A -
Date 3a '� Applicant L. 'l6 ,ZL1 /nN57- ctl_ CITY / T3 ZIP LOCALITY
CERTI CATE OF EXEMPTION FROM WORKERS' , - NO.OF BLDGS. 780 NEAREST �..
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CRO55 ST.
(This section need not be completed if the permit is for one TRACTA 8 lip-1
6 L07 NO.'—(.l, ASSESSOR
Mqp BOOK
hundred dollars (§100)or less.) BLOCK PAGE PARCEL
TEL USE ONE MAP
• OWNER OO,0 - IN D
'certify that in'tha�parformance of the work for which this NO.
permit is issued, I shall not employ any person in any manner
ADDRESS _( SPECIAL O
so as to become subject to the Workers'Compensation Laws. CONDITIONS
CITY ZIP 9
Dd10 Applicant ARCHITECT OR TEL.
NOTICE TO'APPLICANT: If, after making this Certificate of - DISTRICT GROUP TYPE FIRE ESSED BY
ENGINEER NO. CONST. ZONE. H
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth. ADDRESS r UO W
with comply with such provisions dr this permit shall be - . . TEL q� - D_'
deemed revoked. CONTRACTOR L•D. T NO.35�5^'090/7 STATISTICAL CLASSIFICATION APT. CONDO. N
LICENSED CONTRACTORS DECLARATION DU CLASS NO. DWELL. UNIT$_ Z
-�s..z LIC.
I hereby affirm that I am licensed under provisions of Chapter 9 _ gDDRE55� 2/}N/ '"P""^'� NO.
(commencing with Section 7000)of Division 3 of the Business and f - - LIC SEWER MAP -
Professio1.ns Code, and my license is in full force and effect. CITY > t �R CLASS BK. FG. 33 VALIDATION
(�.-. SQ. FT. NO. OF NO.OF CHECK
License Number�� (�Z � Lic.Class 'J ' SIZE STORIES-- FAMILIES ONE
1 VALUATION
Contractor 41-7Date DESCRIPTION OF WORK 24^'t^-F-sGtXNEW ❑❑ $
ADD ILO
(% P
D
Q I am x mpt under5ec. •�-s'v'L•— F,W,
-
Z, r ALTER
•
B.BP.C. for this reason REPAIR ❑ $ ( `A
USE OF
Date: EXISTING BLDG. - DEMOL ❑ -�� '•J!',
Signature APPLICANT TEL. r FINAL
OWNER-BUILDER DECLARATION PRINT NO. DAT`:?/
I hereby affirm that I am exempt from.the Contractor's License
ADDRESS 1
Law for the following reason (Section 7031.5, Business and FINAL
Professions Code): PREONT - By
UILDIN
I, as,owner of the property, or my employees with ADDRESS
wages as their sole compensation;will do the work and
•„-!F } I �3
the LOCALITY
re is not intended or offered for (Section n
7044,-Business and Professions Coda). MOVING TEL. rt , -��•. _t,e
I, as owner of the property, am exclusively contracting CONTRACTOR NO'
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code). _ -
CONSTRUCTION LENDING AGENCY REQUIRED YARD HWY TOTAL SETBACK ;2737.8A
SET BACK PROPANE WIDTH
hereby affirm That there is a-construction landing agency for FRONT - - y# .4 e s
the performance of the work.for which this permit is issued P.I.
-
(Sec. 3097, Civ. C.). SIDE e 2 0.9.2 5
P.L.
Lender's Name -^.e 2 0 9,.2 J.c's.
LDM
• L� A Ref. #
Lender's Address P.C. fee$- Permit fee ✓ D 0630—,87
3 3L
I certify that I have read this application and state that the Issuance Fee ��' �y LDMA P/C If _
above information is correct. I.agree to comply with all County, Investigation Fee - -
ordinances and State laws relating to building construction, Total Fee -
and hereby authorize representatives of this County to enter / LDMA Perm. #
upon the above-mentioned,properly for inspection purpos s.
C� Q SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicam or Agent Dot - _
WORKERS' COMPENSATION DECLARATION - -
hereby off
certificate
L have r cert Cote ofmpensation
tion Insurance,
=elf_ - APPUCAMN 0f Q. 13UR O[� G -PER T
insure, or a certificate of Workers' Compensation Insurance, .•
or a certified copy thereof (Sec. 3800, Lab. C. - COUNTY OF LOS ANGELES . . .BUILDING.AND SAFETY
Policy No✓�r�.S�T.G0--6Pp�7_1i ix_ l�'�
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS
❑r. Certified copy is filed with the county building inspec- BUILDING �r .
,tion department. ADDRESS'
'DateI-le Applicant T ` . " - CITY ZIP LOCALITY
PP NO. OF BLDGS. NEAREST
CERTIFICATE OF EXEMPTION FROM WO KE S' SIZE OF LOT NOW ON LOT CROSS ST. '-
COMPENSATION INSURANCE ASSESSOR
(This section need not be-completed if-the permit is for one TRACT - BLOCK I LOT NO' MAP BOOKPAGE PARCEL
hundred dollars ($100)or less.) _ TEL' USE ZONE MAP'
OWNER NO. - NO.
I certify that in the performance of the work for which this - _
permit is issued, I shall not employ any person in any manner - ADDRESS SPECIAL
CONDITIONS
so as to become subject to the Workers'Compensation Laws. 0
_ CITY. t 1 - ZIP '
Date Applicant ARCHITECT OR I TEL. DISTRICT GROUP TYPE, FIRE PROCESSED BY O
NOTICE TO APPLICANT: If, after makingthis Certificate of - ENGINEER NO. r
- CONST: ZONE > (.1
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- ADDRESS !A
with comply with such provisions.or this permit sholl be - TEL. STATISTICAL CLASSIFICATION - APT. CONDO.
CONTRACTOR7 - NO. 2-41-403' Z
deemed revoked / -
LICENSED CONTRACTORS DECLARATION ,,. q UC. n 11 NO. �� DWELL. UNIT$_
I hereby affirm that am licensed under provisions of Chapter ADDRESS r T N0.3 p rS -
(commencing with Section 7000)of Division 3 of the Business T/ LIC. SEWER MAP
and Professions.Code,and my license is in full force and effect. OTY- q_ CL's C -' gg PG VALIDATION
' �J c SQ. FT. NO. OF NO. OF 'CHECK _
License Number .}7(S DS� Lia Classe'3/ SIZE STORIES FAMILIES ONE -
• EVAL,�UATION
Coniractor� `z - Date l DESCRIPTION OF WORK yytpU NEW ❑ c
. / 0 3 .,o6a D
"ADD ❑
❑I am exempt under Sec
_ ALTER ❑
B.BP.C. for this reason REPAIR ❑ $ "
Date: USE OF _ - - -
EXISTING BLDG. DEMOL ❑
Signature APPLICANT - f L, TEL - FINAL -
OWNER-BUILDER DECLARATION "(PRINT) - NO.
I hereby affirm that am exempt from the Contractor's License , • DATE A,_ .
Law for the following reason (Section 7031.5, Business and ADDRESS FINAL _
Professions Code): PRESENT _ By -
- - t ('..E
❑ I, as owner of the property, or my.employees BUILDING
with ADDRESS _ _/ rl i
wages os their sole compensation,will do the work and
the structure is not intended or offered for sole(Section LOCALITY -
•❑ 7044, Business and Professions Code.) MOVING TEL. V t r (' y,:
I,as owner of the property,am exclusively contracting CONTRACTOR NO. _t 6_
. with licensed contractors to construct the project (Sec- - - - - TOTAL
- S• C—`
tion 7044, Business and Professions Code.) ADDRESS _ I , is ,
REQUIRED.• TOTAL SETBACK FROM EXIST. - La �,l (:, _-
CONSTRUCTION LENDING AGENCY SET BACK YARD Hwv' PROP..LINE I WIDTH -
I hereby affirm that there is a construction lending agency for FRONT - r'k;
the performance.of the work for which this permit is issued - P.L. -' - 'HAHl E •tl `
(Sec. 3097, Civ. C.), .. SIDE-
P1. . +.
Lender's Name •" f 400111- fla3 1 y;t 10
LDMA Ref. q -
P.C.Fee$ Permit Fee
Lender's Address _ �J .5'
p I certify that I have read this application and state that the Issuance Fee '-/ �o•` LDMA Pic 8 D
8 above information is correct. I agree to comply with all County Investigation Fee' oo _ �•
ordinances and State laws relating to building construction, Total Fee O' 4 LD"Perm. fl
and hepeq goThorize fepresentatives of this County to enter
A upon o e- en oned'praperty'for inspection purposes.
a q
SEE REVERSE FOR EXPLANATORY LANGUAGE
SignatureA Oplicant or Agent Date _