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HomeMy Public PortalAbout9400 BROADWAY_Building__ 7GA998A CE#809.10.50 APPLICATION FOR BUILDING PERMIT BUILDING AND SAFETY DIVISION BUILDING 6 • Department of County Engineer ADDRESS / County of Los Angeles LOCALITY .JOHN A. LAMBIE. COUNTY ENGINEER NEAREST CASSATT D.GRIFFIN, SUPT OF BUILDING CROSS ST. DISTRICT NO. .GROUP TYPE WER MAP FOR APPLICANT TO FILL IN BK Pc cONST1 BUILDING G�� L �J 'ADDRESS /NOO F /J RARD(tlA� STATISTICAL CLASSIFICATION YJ6 / T— N�O;/ CLASS. NO. DWELL. UNITS LOT NO. BLOCK MAP �% I NUMBER Q 6 STATE , YES TRACT//SS/OA/ lIJP_e.. /I�RQS US_E.ZONE SPECIAL ... / NO.OF SLOGS. CONDITIONS s SIZE OF LOT .3- cI NOW ON LOT USE OF I C R6S G10 CI -. •. EXISTING BLDG. BUILDINGEXIST.. YARD HWY 'STREET NAME .{ SETBACK WIDTii OWNER ) OF .\q' FRONT MAIL P. L. N ADDRESS 9+nn L ��Q�}��✓/�7 /T SIDE - - 'TEL /b �/.3� P. L. _ CITY T/ /,JOS/ Ci r NO. INSPECTION RECORD ' ARCHITECT OR TEL. ENGINEER NO. 1 l '$ =ITS a T' `it•X- ADDRESS .� TEL. _�� 1 Q�. �✓i f.A_ I . ,.�a CONTRACTOR NO. •-�-.� ADDRESS DESCRIPTION OF WOR% ?-LO'u'e�i� •�.L "" - NEW ADD ALTER REPAIR DEMOLISH - SO. FT. ''77 �( NO. OF NO. OF ,1 SIZE wa� 7 STORIES FAMILIES �wA-W TnT, /✓ f USE OF St; (, APPROVALS SIGNATURE OF APPLICANT DATE INSPECTORS SIGNATURE ADDRESS / D 0 _ FOUNDATION:LOCATION FORMS. MATERIALS r $ / r7e! -0 C. Y FRAME: FIRE STOPS. FEE � BRACING. BOLTS 1 FURNACE: LOCATION. - VALUATION GAS VENT. DUCTS FEE I 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 ORDINANCES AND LATH. EXT. STATE LAWS REGU BUILDING N TION. SIGNATURE O HOUSE NUMBER COR- PERMITTEE' RECT AND POSTED ADDRESS – FINAL ' JOHN A. LAMBIE, COUNTY ENGINEER, CLYDE N. DIRLAM, PRINCIPAL STRUCTURAL ENGINEER PLAN CHECK VALIDATION CK. M.O. CASH - PERMIT VALIDATION CK. M.O. ASH 1��03 9 2 9� gc131 1 . 8.50 • COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS BUILDING ADDRESS I hereby affirm that I have a certificate of consent to self insure, 94400 Of a certificate Of Workers'Compensation Insurance,ora certified W copy Hereof(Sec.3800.Lab.C.) PASSESSOA G/ i ZIP �.0 LOCALITY-y�L p L C l Polity NO. Company. N .OF BL GS.NOW ON LOT I ❑ Certified copy is hereby furnished. NEAREST CROSS ST. ❑ Certified Copy is filed With the County building inspection LOCK LOT NO. department.' USEZONE MAP NO. Date Applicant P BOOK PAGE PARCEL SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' TE .NO. COMPENSATION INSURANCE _ g WITHIN 1000 FT OF SCHOOL? vas No ADDRE (This section need not be completed if the permit is for one hundred i DISTRICT ' GROUP TYPE CONST.' FIRE ZONE Q(iOCESB BY I Certif(,that)or less.) - D� �-3 3 v/1nV\ cm .ZIP I certify that in the performance of the work for which this permit � /'7 is issued, I shall not employ any person in any manner s0 as l0 ARCHITECT OR ENGINEER TEL NO, become subject to the Workers'Compensation Laws. STATISTICAL CLASSIFICATION I APT NDO Data Applicant ADDRESS CLASS NO. DWELL UNITS NOTICE TO APPLICANT., If, after making this Certificate of REOUIREO TOTAL SETBACK FROM EXIST Exemption, you should become subject t0 the Workers' CONTRACTOR TEL NO. SETBACK YARD HM 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. PL LICENSED CONTRACTORS DECLARATION CITY LIC.CLASS FIDE I hereby affirm that I am licensed under provisions Of Chapter 9 SEWER MAP (Commencing with Section 7000)of Division 3 Of the Business and S NO.OF STORES NO.OF FAMILIES C Professions Code,and my license is in full force and effect. NEW ❑ BK 6G o DESCRIPTION OF WORK o V 0 TI! 1, O0 D N License Number Lia Class ADD i ./J{ OV Contractor Date ALTER ❑ z ❑ I am exempt under SEC. REPAIR ❑ $ B.&P.C.for this reasonDate: USE OF EXISTING BLD G. DEMOL URM ❑[ILOMA PIC N . Signature APPLICANT(PRIN TEL.NO. / LDMA Pam It ❑ I, as Owner of the Property, Or my employees with wages Be / _ their sole compensation,will do the work and the structure is ADD SS O a not intended or offered for sale (Section 7044, Business and 4 eA QFFALD C At_CT. Professions Code.) ..3.( .i��7 151.95 El WILLTHEAPPLIOAFfl OR RE BUILDINOOCCU HANOLEAHAZAR U9MATEPIAL `_ .. OR A MIXTURE CONTAINING A HAZARDOUS MAT IAL EQUAL TO OR GREATER THAN 1, a9 Owner tr the property, ru exclusively contracting 0with44, THE AMOUNTS SP IFIEDONTHEHAZARDOUSMATERIALSINFORMATIONGUIDO FINAL BY � 1 1 I ' I ITEMS licensed contractors to construct the project-(Section 7044, YES❑ No ` a,, `V Business and Professions Code.) TtITAL 151 e 95 WILL THE INTENDED USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING + _ 'K 151.95 ,.... OCCUPANTREOUIREA PERMIT FOR CONSTRUCTION OR MODIFICATION FROMTHE SOUTH ` t.HEt CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SGAOMD)SEE PERMITTING-0 ECKUST C.FOR GUIDELINES 1 hereby affirm that there is a construction lending agency for YES❑ NO CHANGE .01 the performance of the work for which this (Sec. :....... . 1 •- .. PB permit 191A4Ued I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD v 3097,Civ.(i.,. PERMITTING CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES F Lenders Name COUN DE TIEREZ CHAPTER ZMSECTIIONS2X WTHRO GIT FROM CONCERNINGCAOMD: ,, 013013-130131 'G/r),r}PZlll Lenders Address I4`b _ I AN 7:41 o' I certify that I have reed this application and state that the above P.C.FEE PERMIT FEE , I� �I; information is correct. I agree to comply with all county _ ordinances and State laws relating to building construction,and - hereby authorize reprettentatives of this County to enter upon ISSUANCE FEE3, 00 — O /�T thtj above-m ioned pro for ffor inspecli purposes. V l C 0 g0 INVESTIGATION FEE TOTAL FEE G ay.0 aro AT.. aN 31„ t9 S ca, /f Sl+GA4 SEE REVERSE FOR EXPLANATORY LANGUAGE tiJ y ;ORKERS' COMPENS/�TION DECLARATION - _- - ".^ .1 Ili• - '�• -` -� - - - - -"- - - •--- - -• - -.__ -� '.. .ipsure�`b. ,<c"if" ent to o�e�eorkers�tCompensationificate of s Insurance, - _A_ PP_LICAT_ I.ON FOR -BUIL'DING FERMI_ T ; or a certified copy thereof (Sec: 3800, Lab. C.)' - COUNTY OF LOS ANGELES BUILDING AND SAFETY - Policy No. Company I I- -- - a Certified copy is,herebyfurnished. FOR APPLICANT TO FILL IN BUILDING G P Certified copy is filed with the county building inspec- BUILDING ADDRESS - 'lion department. ADDRESS (/ ,Date• Applicant CITY -ZIP .. LOCALITY -- --- - -- - CERTIFICATE OF EXEMPTION FROM WORKERS' NO, OF BLDGS. - COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS ST. I •(This section need not be completed if the permit is for one - -- — -- ASSESSOR - --- •-' ' •hundred do0ars-($100)-to leas.) TRACT BLOCK LOT NQ MAF'BOOK`A r PAGEI PARCEL J J) -a p L TEL. .. USE NE MAP. I certify that in the,perfformance of the work for which this OWNER' 91-kA, NO. 'f NO. ----permit is.issued'f shall not employ any person in any manner e-� _ SPECIAL -so.as fo become subject,to the Worker 'Compensation Laws. ADDRESS -/•. CONDITIONS Date Appl,canr Y ZIP _ -,� NOTICE TO APPLICANT If after ENGINEERR NO. -- king-this-Ce ate of ITEOR TEL _DISTRICT GROUP TYPE _ FIRE RO ESSED.BYO E Exemption,-you, should become subject to the Workers' CONST. ZONE Compensation provisions of the Labor Code, you must forth- / p 'W with comply with such, provisions or this permit shall -be ADDRESS _ J�U .. .i y TEL. STATISTICAL CLASSIFICATION APT. CON deemed revoked. � �a^ CONTR R NO. _ LICENSED CONTRACTORS DECLARATION - _ _ _ .LIC - - .- CLASS NO. DWELL UNITS_ I hereby affirm that I am licensed under provisions of Chapter 9D NC;. NO. (commencing with Section 7000)of Division 3 of the Business and SEWER MAP - ' t Professions Code, and my license is in full force and effect. CITY CLASS E -- - VALIDATION SO. FT. NO. OF _ __ _ NO.OF _ _ CHECK - License'Number Lic.Class SIZE STORIES FAMILIES ONE ' ❑ _VALUATIONN.. DESCRIPTION OF WOR Contractor Date r - NEW - $ '' - _ ADD ❑ O� , __ _ _ _ am exempt under Sec - ALTER ❑ f B.BP.C. for this reason .REPAIR ❑ $ Date: USE OF DEMOL EXISTING BLDG. ❑ - _ .. _ _ Signature - - - - APPLICANT TEL - FINAL _ OWNER-BUILDER DECLARATION PRINT) NO. _ _DATE. --)-�Z I hereby off Irm.thot I.am.exempt from.the Contractor's.License - - v Law for the following reason (Section 7031.5, Business and ADDRESS FINA r - Professions Code):" " - - - PRE ENT - - - '' By -�I _ - - -- /�t�L\ I, as owner of the property, or my employees with BUILDING _ 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.-- - - - - - - - El1, as owner of the property, am exclusively contracting CONTRACTOR NO. i •i with licensed contractors to construct the project (Sec- ADDRESS-- -- - ' '- �- - -- - - - - - -- - - - - - J tion 7044, Business and Professions Code). ;2 6 0 7.8 A L CONSTRUCTION LENDING AGENCY SETT BACK - YARD HWY TOTA PROP.L NEFROM- -WIDTH s - I hereby affirm that there is a construction lending agency for FRONT s `# P the performance of the work for which this permit is-issued -- PL.- - _ -- - -- - - - - - - .( s - 49.,88- (Sec. 3097, Civ- C.). SIDE s P,L. -Lender's Name - .. -. ... _ _ _ _ t.a s 4 9.8 8 6„ , 3 ' DMA Ref. It, ` m Lender's Address -- _ P.C. Fee$ - PermirFee -- O ' 2 0 8--8`6- a1 certify that 1-have read this application and state that the _ - Issuance Fee­/ `PK N---- - - i' a above information is correct. I agree to comply with all County Investigation fee Q;p� ' ordinances and State laws relating to building construction, Total Fee LDMA•Perm. A' - - - - - - - -- i, and.hereby authorize representatives of this County to enter - m upon t eabove-mentioned property for inspection purposes. ' SEE REVERSE FOR EXPLANATORY LANGUAGE - ,9nawre o Applic nt or g r , o WORKERS ,CO,MPEN9ATION'DECLARATION - ~ /�� r�-I>��IL /+� /+�'•.m_� Irl-�p� �^L�}- �r��(�- � - �•x• �FTI������s, , 1��}�F��y��//�'7� �I {•�su affirm that Lriav`e a certificate of consent to self /O� IJ IJ II �E( /Ok ��-O U•V--II ,O U�1 �.�.��D�U V'`/-`PIS O�lI1Vl1�� C.7 nsu re o7-a certificate of Workers' Compensation Insurance, _ lrgll UU LLSS `V/rU or'a certified copy iheieoP(Sec. 3800,-Lob, C.)- - - - - - - '--"'- - - - r'�`••' 'rt - - COUNTY OF LOS ANGELES BUILDING,AND SAFETY- Policy No Company. - F Certified',copy Whereby.furnished. FOR APPLICANT TO FILL IN r BUILDING ❑ ounADDRESS �V V •t Cerllfled'C OPY is filed with the cty building inspec- BUILDING j "tion depaftment, " t - - ADDRESS ! Date •• -I.-<vu Appl¢antT CITY l ZIP eo LOCALITY - CERTIRCATE OF EXEMPTION FROM WORKERS' • `- - -- --- NO.OF BLDGS. n NEAREST � d '-T COMPENSATION-INSURANCE SIZE OF LOT NOW ON LOT rK CROSS ST. (This section need.not.be'mmpleted if the permitris for one - - - - - /• - - _ ASSESSOR„ -- - -- — «i•-; hundred dollars ($100)or less ) TR^cT BLOCK LOT NO, MAP BOOK •c'. PAGE; PARCEL . DI ' - - OWNER - _LA, _ TEL, lA g USE ZONE MAP. - I certify that in the performance of the work for which this ` NO. 8i NO. I } 'permit is issued, shall not employ any person In anymanner ! CLF1.QFr .2/3 / �� SPECIAL d So as to become subject to the Workers Compensation Laws. 'ADDRESS - - - �- - CONDITIONSI 1 V " Dose •�q�I� A ' licant It k�sAi f Q9 CITY. _ - ZIP pp ARCHITECT OR TEL. O NOTICE TO APPLICANT: If, 'after making Certificate of . I DISTRICT GR UP 'TYPE FIRE P O ESSED,BY_ ENGINEER NO. R - Exempmlon, 'yau' should become.subject to the 'Workers' � //{J,'�2�)T CONST'/ ZONE Compensation.provisions of the Labor Code .you must forth- ADDRESS �L�VY '-11 Y J 6 with comply-wilh;,such,provisions or this permit shall be _ - - - -' - -- - N deemed revoked... - _ _ 'TEL. " STATISTICAL CLASSIFICATION '1 APT. W Z s\ CONTRACTOR NO. 2 -' t; LICENSED CONTRACTORS DECLARATION.., _ - ._ _LIC - CLASS NO. - DWELL.•UNITS__ I hereby affirm that am licensed under provisions of Chapter 9 - ADDRESSfiM - NO. (dommenring with Section 7000)of Division 3 of the Business and ,_ _ LIC. SEWER MAP ` Professions Code, and my license•is'in full force ond'effect. CITY CLASS. - - - - - -I - -r t - BK� PG. VALIDATION" - I�. SQ. FT. - NO. OF _ NO. OF _ CHECK - License Nilmbei Lic.Class SIZE STORIES - ' FAMILIES ONE "' " i. - ,' - VALUATION ! Contractor Date DESCRIPTION OF WORK - - - NEW- ❑ $ � � -" ADD Ulf F-11 am exempt under Sec. 1 - - - - ./T•O-p-7fLf_ . . .r❑ r'I n 6 - 9q ALTER .1 B.BP.C. for this reason - CIC Q S REPAIR ❑ $: -' .. - - - - _ _ ___Date: . . -.: USE OF _ . EXISTING BLDG. - DEMOL ❑ . $Ignature.• _ ._ _ .. _ ....- __ APPLICANT.. . . - - __ .-_ . TEL: FINA OWNER-BUILDER DECLARATION (PRINT) NO. DATE �fs�- _ _ -_ 4 2(�.5.A -- I hereby affirm that 1 am exempt from.the.Contractor's License - -- -� - -- Law for the following7reoson'(Section 7031.5, Bustiness.and ADDRESS - _ F L - .!et1 - a: 'Professions Code)-" - - -• - PRESENT - - - - ' -- - - --- - BUILDING - I, as owner of the property, or my employees'with ADDRESS_ / // 1 • 2 4.18 81 wages as their sole compensation,will dolhe work rind - - "' the structure is notintended or offered for sale(Section LOCALITY. U s \ _ T L • • ' 7044, Business-andProfessions Code). -- - - MOVING -- - - TEL - 12Q885 - /�� j;, I,.as owner of the 'property, property, am exclusively contracting CONTRACTOR NO. n� ('0320-86 r'with licensed contractors to construct the project (Sec- tion Seo- ADDRESS - « ��`Y tion 7044, Business and Professions Code). „ REQUIRED - TOTAUSETBACK M CONSTRUCT is a co NDING AGENCY' _' r - SETBACK - YARD HWY- PROP. LINE WIDTH \ - hereby affirm that there is a construction lending agency for FRONT - the-performance•of-the work for which this permit is issued - - P.L.- �:.z_ (Sec. 3097, Civ. C.). SIDE P.L. . _ .. - . c_J 1��1,`• ._ _ .. Lender's Name `�Q' $ .. - ! ✓ U - LDMA Ref. # -'- - •- - - -- - - - P.C. Fee$- - PermiFFee - - , Lender's Address - I certifyi formal have read t. I agreli to co and state that,the _ Issuance-Fee Q..,�.Qj -.LDMA P/C R a above information is correct. agree to comply with all County Investigrfrn Fee _ a - S ordinances and State laws relating to building construction, -__ _ _ Total Fee - LZ LDMA Perm. IF - - - a and hereby authorize representatives of this County to enter a upon the above-mentioned property for inspection Purpo es. _ , 0 • �lA I�(T� I /1T SEE REVERSE FOR EXPLANATORY LANGUAGE I ) I �- _ ..SlgnaNrerf Applicant of Agen, .. - .Date . - '.. '•s.,, - _ _ . .. _. ._ -. . . __ _ _ _ . L_. _.__ _ _._ .cOO � WORKERS'CQMPENSATION DECLARATION • I'herebyoff,m that L have a.cenificate of consent to self 'APPn OC /n� 700H IF0R OO I) O DONG PER lT I h -in sure, or a certificate of Workers' Compensation Insurance, LL [/� u� v LL uV' u�u u LJ or o certified copy thereof"(Sec. 3800, Lob. C.) - ` - COUNTY OF LOS ANGELES . BUILDING AND SAFETY Policy No. Company Certified copy is hereby furnished. FOR'APPLICANT TO FILL IN BUILDING O . Certified copy ii filed with fhecounfy building inspec- ADDRESS BUILDING tion department. ADDRESS Dote�Applicant CITY ! IP 9Z LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NOW ONLOTNEARESST. COMPENSATION INSURANCECROSS (This section need not be completed if the permit is for one ASSESSOR hundred dollars($100)or less.) TRACT BLOCK LOT NO, MAP BOOK PAGE PARCEL TEL USE ZONE MAp I certify that rin the performance of the work for,which this OWNER NO. NO. permit is issued, I shall not employ any person in any mannerSPECIAL • so as to atom subject to the Wor eri Corrpensot1 n La S. ADDRESS CONDITIONS 0 r U Data Applicant • CITY ZIP Q ARCHITECT OR TEL. Exemption, OAP LI ANT: If, offer 'subject to Cartificaf of DISTRICT G UP TYPE FIRE PROCESSED BY O Ezempfion, you should become) sub'ect fo the Workers' ENGINEER NO. ��s /�/1�'(/ CONST'/ ZO E h Compensation provisions of the labor Coda, you must forth- ADDRESS ✓�v U Y 0 with comply with such provisions or this:permit shall be n.' deemed revoked.' LLI TEL STATISTICAL CIP.SSIFICgTION APT. ONDO. Ln CONTRACTOR NO. A / Z LICENSED CONTRACTORS DECLARATION LIC CLASS NO. ice. DWELL. UNITS_ I hereby off irm that I am licensed under provisions of Chapter 9 ADDRESS NO. (commencing with Section 7000)of Division 3 of the Business and LIC SEWER MAP Professions Code, and my license is in full force and effect. CITY CLASS BK PG VALIDATION SO.FT. NO.OF ' NO.OF CHECK License Number Lic.Class SIZE STORIES FAMILIES ONE ❑ VAL�,� DESCRIPTION OF WORK NEW Contractor Date ADD ❑ $ D X798.1 A I am exempt under Sec. ALTER ❑ / / #'e'e • e •i1 8.8P.C. for this reason REPAIR ❑ $USE V D Date: EXISTING BLDG. DEMOL ❑ `.I e i1 81. 13 Signature APPLICANT TEL.(PRINT) NO. FINAL e• ° 181..13U OWNER-BUILDER DECLARATION DATE. I hereby off irm that am exempt from the Contractor's License 09.23,!87 Low for the following reason (Section 7031.5, Business and ADDRESS FIN Professions Code): _ - PRESENTB I!'N' I, as owner of the property, or my employees with BUILDING ADDRESS _ wages as their sole compensation,will do the work and 1 the structure is not intended or offered for sole (Section LOCALITY 7044, Business and Professions Code). MOVING TEL. ❑ I . , as owner of the property, am exclusively contracting CONTRACTOR NOJ� with licensed contractors to construct the project (Sec- ADDRESS ,tion 7044, Business and Professions Code). REQUIREDTOTAL SETBACK _ CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH • . hereby affirm that there is a construction lending agency for FRONT - the performance of the work for which this permit is issued P. (Sec. 3097, Civ. C.). SIDE ` •'' �1� 1. P.L. .t •\ Lender's Name •� } .� LDMA�Ref. If " m Lender's Address P.C. Fee E Permit Fee - . •� D ' I certify that l have read this application and state that the Issuance Fee LDMA PiCR 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 Parm. q S up the above fioned property for inspection urpoyees. - a IdSEE REVERSE FOR EXPLANATORY LANGUAGE Signature pplicu r Agent Date r - ' WORKERS'COMPENSATION DECLARATION rte. I�pM FOR - .. �N��(/.��.r gyp}R�p/L7� yl�� fl I he`eb'y waffler That have'a-ceriCome of consent to self Ply�ll � /OY Ir0OU V U •O LL Y� BV RDOU V`�/ PISU�IUTA 0 �jLlll +•insurer pry certifimte of'Workers' Compensation Insurance, - /rpll U LS `V- 4'U '. .. or o'cer:died copy thereof,(Sec. 3800, rob. C.) COUNTY OF LOS ANGELES BUILDING AND SA ETY "Policy No. Company BUILDING ADDRESS �� Certified copy Is hereby furnished. ,FOR APPLICANT TO FILL IN (/(f ❑ Certified copy is filed with the county building inspeADORE55 n BUILDING /�.� tion department. ADDRESS' Lr(J --� Date Applicant CITYfR J J ZIP ro LOCALITY c� CERTIFICATE OF EXE4MPTION FROM WORKERS' - O. OF BLDG . _ NEAREST COMPENSA ION'.INSURANCE SIZE OF LOT NOW ON LOT CROSS Si. /t (This section need not-be completed if the permit is for one TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL TEL.hundred dollars ($100)or less.) NO. USEy$ONE MAP 41 OWNER I(/(\/,j I certify that in the performance of the work for which this O' NO. pe"a"l is issued, I Noll not employ any parson in any manner �-'� !I SPECIAL sa as to come ubject to the Workers'Com ensation Lows. ADDRESS a CONDITIONS O FtT Date Applicant CITY Yzr T ZIP / NOTICE TO PL CANT: If,'ofter making/this this rti icote of ARCHITECT OR TEL, DISTRICT GROUP TYPE FIRE PRO SSED BY O Exemption, you should become subject to the Workers' ENGINEER NO. �. CONST, - ZONE U Compensation provisions of the Labor Code, you must forth- ADDRESS O �� _ LLI with comply with such provisions or this permit shall be TEL STATISTICAL CLASSIFICATION 'APT. CO W. N deemed revoked. - CONTRACTOR ryp. . LICENSED CONTRACTORS DECLARATION - LIC CLASS NO. DWELL. UNITS_ Z I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. (commencing with Section 7000)of Division 3 of the Business and LIC SEWER MAP Professions Code, and my license is in full force and effect. CIN CLASS VALIDATION ! SO. FT. NO.OF NO. OF CHECK BK. PG, , License Number - Lia Class SIZE STORIES FAMILIES. ONE DESCRIPTION OF WORK NEW ❑ VALUATION Contractor Dote ADD $ D I am exempt under Sec. ALTER S.&P.C. for this reason - —/ AIR $ USE OF /� Dote: EXISTING BLDG. 1-/)"J f "rD r DEMOL C3 Signature APPLICANT ctoe r. TEL. FINA OWNER-BUILDER DECLARATION . PRIM NO. DAT _ 7 6 3.0 A -1 hereby affirm that.I am exempt from the Contractor's License Law for the following.reason (Section 7031.5, Business and ADDRESS FINA JZ Code): ING y JZ 1, as owner of the properly, or my employees with ADDRESS 49, 88 wages as their sole compensation,will do the work and D (•• • the structure is not intended or offered for sole(Section LOCALITY e • 0 4 9.8 8.5 7044, Business and Professions Code). MOVING TEL. - MI, as owner of the property, am exclusively contracting CONTRACTOR NO. Q a,a 0 8 7 With licensed contractors to construct the project (Sec-. ADDRESS ' tion 7044, Business and Professions Code). o REQUIRED TOTAL SETBACK ' CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP, LINE WIDTH Y I hereby affirm that there is o construction lending agency for FRONT the performance of the work for which permit is issued P1. (Sec. 3097, C.N. C.). SIDE P.L. Lendei s Name 7 LDMA Ref. # m Lender's Address P.C. Fee$ Permit Fee J , I certify that I have read thisapplicationand state that the Issuance Fea ,J,Q LDMA PLC.p D above information is correct. I agree to comply with all County Invevigmion Fee q 'ordinances and State laws relating to building construction, "oral Fee LDMA Perm, fl ` •} - . and hereby authorize representatives of this County to enter upon the abovep-mentioned property for inspection purposes. ."A SEE'REVERSE FOR EXPLANATORY LANGUAGE LC6ignatu a of A,FFSricont or Agent Date ry COMPENSATION DECLARATION //p�� �(/�p/J�� l�I���� gyp} FLIp�p c�F.ryelap�d�.(/��-. FFpw �r��y�F�Tq/�LL� nt to self Insure, or afcertifcatte ofoWorkers' Comve a tpensation e of eInsurance, APPd0C��ION FOR L/U��©��NG U EU�lN"T LJ or a certified copy thereof (Sec. 3800, Lab. C. COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. _ Company „ El Certified copy is hereby furnished. FOR APPLICANT TO FILL IN G ADDRESS OV Certified copy is filed with the county building inspec- BUILDING tion d part ent. ADDRESS 1.Date Applicant XY" CITY CL ` ZIP LOCALITY CC IF EXEMPTION FROM ORKER NO. OF BLDGS. NEAREST COMPENSATION INSURANCE SIZE Of LOT NOW ON LOT CROSS ST. (This section need not be completed if the permit is for one ASSESSOR hundred dol lots (§100)or less.) .TRACT BLOCK LOT NO. , MAPBOOK PAGE PARCEL TEL. USE ZONE NO, — Z 1 certify that in the performance of the work for which this OWNER NO. — 6S permit is issued, 1 shall net employ any person in any manner Q—I SPEC AL so as to Jbbeccro`mmeeD�ubbject to the Workers'Compensation L ws. ADDRESS � �. CONDITIONS C' Dote( Applicant CITY C� ZIP N;TI O APPLICANT: If, of eking this Certificate of ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY C) Exemption, you should be< subject t0 the Workers' ENGINEER NO. CONST.) ZO E' �. Compensation provisions of the Labor Code, you must forth- ADDRESS with comply with such provisions or .this permit shall be TEL. STATISTICAL CLASSIFICATION APT. CO to deemed revoked: CONTRACTOR NO.. - - Z LICENSED CONTRACTORS DECLARATION LIC, - CLASS NO. DWELL UNITS_ - I hereby affirm that I'am licensed under provisions of Chapter 9 ADDRESS NO. SEWER MAP (commencing with Section 7000)of Division 3 of the Business and LIC Professions Code, and my license is in full force and effect. CITY CLASS BK. PG. VALIDATION SQ. FT. NO.OF NO. Of CHECK License Number lie Class SIZE � NO I FAMILIES ONE VALUATION Contractor Date DESCRIPTION OF WORK f NEW ADD � $ /' D I am exempt under Sec. kqOg . ALTER B.BP.C. for this reason k REPAIR ❑ Date'. USE OF EXISTING BLDG.' DEMOL ppp , Signature APPLICANT TEL. FINAL OWNER-BUILDER DECLARATION PRMi NO. DATE I hereby affirm that I am exempt from the Contractor's LicenseC Low for the following reason (Section 7031.5, Business and ADDRESS O E FINA Professions Code): - - PRESENT By rn BUILDING �W\ 1, as owner of the property, or my employees with ADDRESS t wages as their sole compensation,will do the work and P 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. with licensed contractors to construct the project (Sec- - ADDRESS tion 7044, Business and Professions Code). O'6 rJ A CONSTRUCTION LENDING AGENCY SETQBAED YARD HWY TOTAL OTP LINE WIDTH f I hereby affirm that there is a construction lending agency for FRONT # e•s •.e s,�- the performance of the work for which this permit is issued A ' (Sec 3097,Civ. C.). FSIDE I •'1S 3,O O P.L. Lender's Name a e 53 0'0 5 LDMA Ref. N. m e P.C. Fee E Permit Fee V D .O 9, 6-8 8 J-DI certify that I have read this application and state that the Issuance Fee MP/C qLender's Address a above information is correct. I agree to comply with all County Investigation Fee q ordinances and State laws relating to building construction, _ Total FeeI LDMA Perm. N and hereby authorize representatives of this County to enter - m upon he ab ve-mentioned property for inspection urposes. \ T _!�� m � _ y SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of AP licant or Agent - Date -. (�,.(r• s , WORKERS' COMPENSATION DECLARATION - '' : - I hereby affirm that I have r certificate of consent to Insurance, - QPpD��C ATMN F'OR WRONG PERM? insure, or o certificate of Workers' Compensation Insurance, or o certified copy thereof (Sec. 3800, Lob. C.) LL� -- COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company Certified copy is hereby furnished. FOR APPLICANT TO FILL 1N ADDR SG / ADDRESS �ka Certified copy is filed with the county building inspac- - -- BUILDING tion deportment. ADDRESS QUO A, Data Applicant CITY - AW ZIP LOCALITY �rs � CERTIFICATE OF EXEMPTION FROM WORKERS' NO. OF SIZE OF LOT NOW ON LOTS COMPENSATION INSURANCE C OSSSST. (This section need not be completed if the permit.is for one -- ASSESSOR hundred dollars ($100)or less.) TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL TEL SE ONE P certify thot'in the performance of the work for which this OWNER L NO. — U1 NO. permit is Issued, I sholl not employ any person in any manner ADDRESS • b 1 SPECIAL - so as tto^o'beco�mee�subject to the Workers'Compensoti mLaws. 111 CONDITIONS DateY�Applicaty CITY ~ ZIP y 0 NOT"TOA If,�' er maks ng't is Certificate of ENGINEARCHITER TOR TEL. DISTRICT UP TYPE FIRE RO EDB ENGINEER NO. Exemption, you should be a subject to the Workers CONST. . Z U Compensation provisions of the Labor Code, you must forth- ADDRESS � pyLEJ W with comply with such .provisions or this permit shall be - E zv -O J D1 deemed revoked. - CONTRACTOR STATISTICAL CLASSIfICA ON APT. C W Z LICENSED CONTRACTORS DECLARATION tic. - .. CLAS$NO. DWELL. UNITS_ I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. (commencing with Section 7000)of Division 3 of the Business and - .LIC SEWER MAP ' Professions Code, and my license is in full force and effect. CITY CLASSBK VALIDATION SQ. FT. NO. OF NO. OF CHECK PG License Number Lia Class SIZE STORIES FAMILIES ONE VON SALtI�O Contractor Date DESCRIPTION OF WORK 1 NEW ❑ Q ADD DI am exempt under Sec. E]ALTER B.BP.C. for this reason REPAIR ❑ $ - Date: USE OF EXISTING BLDG. DEMOL ❑ Signature ' - APPLICANT - TEL. FINAL Q OWNER-BUILDER DECLARATION PRINT NO. DATE O /� I hereby affirm that I am exempt from the Contractor's License I Low for the following reason (Section 7031.5, Business and ADDRESS 6) FIN Professions Code): PRESENT RE EN BUILDING 6y es I ­,4G50 (�5 Q U 'e I, as owner of the property, or my employees with ADDRESS wages their sole compensation,will clothe work and LOCALITY D ; 'o9. 1 9-8 8 the structure for is not intended or offered for sale(Section 7044, Business and Professions Code). MOVING TEL. - ElI, as owner of the properly, am exclusively contracting CONTRACTOR NO. with licensed contractors to construct the project (Sec- ADDRESS, tion 7044, Business and Professions Code). 8 CONSTRUCTION LENDING AGENCY YARD MWY .REQUIRED TOTAL SETBACK FROM EXIST. SET ACK PROP. LINE WIDTH B I hereby affirm That there is a construction lending agency for FRONT the performance of A work for which this permit is issued P.I. - (Sec. 3097, Civ. C.) SIDE SID Lender's Name /(/1 LDMA Ref. R m lender's Address P.C. Fee$ Permit Fee W..�o I certify that I haread.this application and stat that thee. _ Issuance.Fea pV� LDMA P/C R d D _ above information is correct. I agree to comply with all County Investigation Fee - - ordinances and Stale lows relating to building construction, Total Fee L - and eby authorize representatives of this County to enter [ LOMA Perm. R up n the above-mentionedpro arty for inspection purposes. - SEE REVERSE FOR EXPLANATORY LANGUAGE C ' igna ure of Applicant or Ag nt Date t -