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79A686A CE#803- 1-61 APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING
OZ
DEPARTMENT OF COUNTY ENGINEER ADDRESS
BUILDING AND SAFETY DIVISION LOCALITY
JOHN A. LAMBIE, COUNTY ENGINEER NEAREST
WILLIAM A. JENSEN SUPT OF BUILDING CROSS ST. Z
DISTRICT NO GROUP -�ypE _ P OCES BY
FOR APPLICANT TO FILL IN j �_ CONST.
BUILDING / STATISTICAL7EDWELL.
IFICATION SEWER MAP
ADDREPG
SS
CLASS.NO. B UNITS
LOT NO. BLOCK WATER NOT REQUIRED RECEIVED
t7 CERTIFICATE: 14 0
TRACT ,C� y MAP oI6HIGHWAY STATE MAJOR SECOND, OCAL
SIZE OF LOT `/� �bI�NO.OF BLDGS. N0. (CIRCLE)
{NOW ON LOT USE ZONE SPECIAL
USE OF 4 ` CONDITIONS
EXISTING BLDG. I/es
6,4 2p
TEL.
OWNER Y NO. BUILDING YARD HWY STREET NAME EXIST.
r` a SETBACK WIDTH
ADDRESS` �� �✓.l.�I�IJ'. FRONT F
ARCHITECT OR TEL. P. L.
ENGINEER NO. SIDE
P.L.
ADDRESS TEL. / INSPECTION RECORD O
CONTRAC NO. 6 V
ADDRESS G^ f d'
DESCRIPTION OF WORK
W
O_
NEW ADD ALTER REPAIR DEMOLISH N
SQ.FT. NO.OF NO.OF ?
IZE STOR S FA LIES
USE OF
STRUCTURE r.r
1�
SIGNATURE OF
APPLICANT
VALUATION$ I
APPROVALS DATE INSPECTOR'S SIGNATURE
P.C. PMT. C ,SZ'} FOUNDATION: LOCATION
FEE, FEE $ , FORMS.MATERIALS
FRAME: FIRE STOPS,
IHEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION BRACING, BOLTS
AND STATE THA E ABOVE IS CORRECT AND AGREE TO COMPLY FURNACE: LOCATION,
WITH ALL CO T ORDINANCES AND STATE LAWS REGULATING GAS VENT DUCTS
BUILDING CO ST UCTION. I CERTIFY THAT IN DOING THE WORK
AUTHORIZED E EBY I ILL NOT EMPL NY PERSON IN VIOLA- LATH, INT.
TION OF THE L BOR C DE OF T EST F CA IFORNIA ELAT-
ING TO WOR N'S M S yQN S LATH,EXT.
SIGNATURE — HOUSE NUMBER COR-
PERMIT T RECT AND POSTED
i
ADDRESS
FINAL ,•
CLYDE N. DIRLAM, PRINCIPAL STRtUC'TURAL ENGINEER
PLAN CHECK t'i,GeLIi.LSL({i�lir M CASH PERMIT VALIDATION
_>) M.o. CASH
0982'%2 FEB 5 1 D 25.50-
. ����
• WJORKEJRS' COMPENSATION DECI.ARAnoN
+•. I her af#irm that I have a certificate of consent to self : A P P L I CA
a certificate of W.arkers Oompensctlon insurance' '
T I O N � F O R: BUILDING , P E:RM I�'
or tl ter+�Fled copy t},ereo# (sec 3800," Lab, �) COLfNTY OF LOS ANGELES ' BUILDING AND SAFETY'-
Policy No.• Company'
'Certified copy b hereby.fumisl,ed. FOR APPLICANT TO FILL IN BUILDING
ADDS
❑ Certified copy.Is filed'with the oc ulitybulldlnQ Irapec- BUILDING
ADDRESS
• tion.department.- -
Date ApplicantZIP LOGLIIy
.. '. . NO. OF
CTIFlCi4TE OFfXEMPTION Fi2dN1 WOR}�RS' SIZE OF LOT - NQW ON LOT CROSS
Si.
-COMPENSATION INSURANCE,
ASSESSOR
(ThU seciIon.ne•1d not be com I•ted if. the permit Wfor orre u TRACT BLOCK LOT NQ MAP FlQOiC PAGE J PARCELhundred dolltrn (�100)or I•ssL)SEZCXE
OVYt�R { NO.
I certtfy.that In•the petforMance of the work-for which this .
permlt Is Issued']shall rust employppny_perso�n In any manner ADDRESS
so,as to becbmp sublett to.the Worken>' Comperuatlon Laws :.
cny TIP'
Date Applloont. ARCHITECT OR TEL. D GROUP TYPE FIRE PROCESSI�BY O
NOTICE ,TO APPWCANT::_If, after makln this CWtlficate of ENGIf�t• NO.
Q CONST. ZONE
Ex•mptloR, yqu shou(d become rubl•d to. The.-Workers' _
Compeniatlon provisions of the Labor Code, yoy most forth- ADDRESS — •o V15
with comply with such •prgvlsIons ar this permit shall be T� STATMK4.CLASSIFICA,T10N_ APT. COtDO..
deemed-revok6d. NO.
LICENSED.CONT ACTORS DECLARATION tiC CLASS Na. UNITS
I hereby affirm that I am Licensed under provlOons of,Chapter 9 ADDRESS NO.
SEWER MAP
,(commencing with Settlon7000}of Dlvlslon.3.of the Business_ M i ,
and Profe"lorn Code,and-my License Is In fu(I force and effect. . , - Crry- CLASS BK PG. VALIDATION
SCS. FT. NO. OF NO. OF CHECK .
Ucenso Nurrlbeir LIC, pass SIZE STORIES FAMILIES ONE
VALUATION
Contrbdor pgtq DESCRIMON•OF-WORK NEW, El
El am'exempt under'Sea i 4 _
ADD
-ALTER
'..❑ .
B.$P.C_ forthI4 rea►on, REPAIR ;
Dete: USE OF _n
- EXISTING BU)G. DEAADL
Slgnature_ ANT TEL. r FINAL --
OWNER-BUILD�R DECLARATION, -DAT6
I}hereby off lrm that I am exempt from the Contrg�t License
Law for the following re4on"(Sectl 'n 7031.5, Buslne"-and ADDT 55 IR1AL -3 � it T
_ Pr lona Codq)`. � .: - - .. .. . _ - - - - By �- -
W u
BUILDING
I'- as owner of the property, drmy employees with i;ITE�CS
,wages as their sole compensation,wllhdo`thework and. I TTA _ 1
the structure Is not Intended off•red)fdr sale Section LOCALITY Poo.
V
.7044, Buslhess and Professlons Code. HOMING TEL
❑ I, as owner pf the,property, am exclUslvely contradlrV CONTRACtCP NO.
...with Ilcensed contradors to constructjh4 project (Sec-
tion 7044, Biuslden and Profs"I.ons Code.) ADS i, - — •"�'i
CONSTRUCTION LENDING AGENCY YARD HWY
1-hereby gffirm that there,ls a constructlon lending ogency#or FRONT _ _ Ib'H� �i 3/25/91
the performance of-the work for which thjs�rmlt is'Jssued 'l : P.L W h
- (Sec. 3097, Civ. C. - ,Sly •, _
R Lenders Name
P.0 Far Perm It Fee LDMA Ref. I
Lenders Addreas
I certify-thgt I.have riod this application and state that the - lawance Fee � LDMA P/C♦ pop „
. above Information Is correct A agree to compply with all Coyung7 Invs�tlpatlon _
I drdlnances and State laws relating IQ bullding constructton, Total Fee LDMA PWTM
I and hereby authorize representatives of his County to enter
upon the above-m Ibh•d Inspection:purposes.
w_ ti MUM FOR.DPLAN�ITORY L 4.NGUAG4
� .
APPLICATION F,,ORfiyILDING PERMIT
COUNTY OF LOS ANGELES.. BUILDtNQ.A►Nb SAFETY
` WOR1�COI 49MT10M DECD AF�ATM" troll APPLICANT To,PILL N - =
I wcaby affirm that I ham a certtfloife of oorW17t to astf kuure,
or 0 ceclkfe of Workers Comperridoh lee rens,or a cwtfW c�
bopy ftrreof(Rapp aeon.LA&a)" / /t ti tv �
Loc,Aurr
Po"No: dna Um of um Na OF WWW ON LOT
❑ Certlfled oopy Is hereby hrnhtwd: T
❑ carmw Copy w flea with the.60 my bulking krprtotbn TFUIcr BLOCK Lor Na uw zcw YAP NO,
Deft Applicant Boort i1 EPEC AL CONUTIONS
eo
T'E OF E030MM RWV wO UWW TEL Na
COMPEPMTION Q OURANCB G WHIN 1000 FT.of sct400L7 YEa NO
(chis secrion need not be cornpleled n the pwTnit In for one hundred rE BY
dDlan AV 00)or bee-) a rY 2pP
I owtffy that h the pwbm "of the.work for whloh thw pemrlt
)s hsued, I sha not employ arty Person h arty mardw so w to ARCWTBCT.OR ENGR*E t Na
tb the V"k" LeaAt
Dai ,PMM CLASS NO. Dwyat UK":�L
TO APPLW,"T: H• after nuidng thle Caftl1losts/4P rteQUUVM TOv1.6ETBACK FRED ocin
Exampbon, you should become subject to the Worker' CONT ACTH Tri NM BET BACK VIM FWY PROP UNE WIDTH
Cornperraflon prwisiorr of the Lebd Code, you must forthwkh FRONT
oompty wfth suoh prwbfons or this pwn*shFal be deemed Taroksd. ADDR13SB LC;,NO. P L
SIDE
OCENW,CONTRACTORB DECLARATION C" V 7 Lr—CLASS P L 8
I herby sffinn that I sm Iloeneed under provla >!of C4WW 0 Na of aro+ Na of FA1L® mkn�
( �g withSeotfon 7000)of DMalon 3 of the Bmbvm and NEW BK Po
Profaeelorr Code,and rpy.Dow*@ Y In fu forotl and I ,
Lioww Number Lb.Daae WORK ADD ❑ V
Contractor opt. ALTEReA
❑ ' �f�IJ
ElI pm e�ae, raider Seo. V RFPAIR El # —
B.6P.a for thy neon Ci,
DEaAOL ❑ LDYA P/Ci
Dam USE QF PXDBTrro BaLD - URM, 1111 � 1
Bf�YtLIEAPKX Nfr( RVM Ta-NO. LDYA-Perms i -
1..4 noirrw of the property, with Won
or my errgioye wWoM as ACCT,
their apple cdmperstatlor arllU do the'work and the strUctm is A
not 1.6. d or offered for sale (Section 7W4, Buekiew and rR S FVWL DATE 17122
Profe.ei«r Code) wLLTFrApRjwN ronmiTU mA�,o•, 000mx-"ff vitLEArwWo«nMOMEMt �*ZC—¢? 1 ITEM I
❑ "WER THAN
I, w owner of the peri am-��y �f�G �
OR AMC i�ePec earn i-wNooue�r�Li rNao%wCioniQUIDO PL16L By
Vcwwmd contrap" to corsbuct the pt (Ba* 704►, rb.11No'❑ TOTAL 140 -22
&xkmee and Profeolmr Cibde.) .
waL TFC INTENDED USE OF TGE BUILDING W TFE APRXANr OR RM"INAMINS CHECK 140.K
ACCL*%MT FIICLA A PUIRM T FOR COls'T}iJCT10M Onwx319R�1 M eOUTH .
. LQ' Q A `Y COAST Aar OUALRY...N,I' farT oamecr PpAOD)a P6aiTTlre OF QtT ��{{��}},,yyyy�� - (�j
_ Epp[r IDU�� NNE .00
I hweby.aMmn that then Is a conabuodon bndtng agopf for rm❑ No❑
the pwformarwaof the work for III dd thb permit Is leer»d(Sec. F FwE FI'AD ll3 FIAZArA M-ORWQFOM GUIDE AND Trw eOACAM
POFNATTM CFO3007,"Ctk a).
COUNTY CODE, F iia. wornFora CONOr,M"M
Lender.Norm HAZArmoue mpaw% -s Arm EOE pevaaaa A F7ffT TF!saC11111JNC@R THE LOS AMBLES O-0001 10/31/90
. 3590 1 AM 9:13
. LelnKere Address ORS aR Air 1
¢ I car"that I hwa read d*appfk m and strts tfist the sbove RC.FEE Pt3a;t FEE
krformebon le correoL I agree m comply with all oounty 9_
ordtrnnoes and 8td@ Iowa relaA to builldit oorwMicdcoN end /• as`�
authorme rapraeerstativee of thls County to artier taeUANOE FEE a
ProPertY
PIVESMAGtON FEE TOTAL FMva
O, 1
/ WE FF>l VEFM POR waw AMATORY LANQUAW,
WORKERS'COMPENSATION DECLARATION
} I hereby affirm that I have a carifficateof consent to ..If A P P L I CAT I OV &TUIL PERMIT'
Insure, or a certificate of Workers'Compempenstlon Insurance, or
a certlflad copy thereof (Sec. 3800, Lab. C.)
2 COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No.QC Company SH�'E�
Certifled copy Is hereby furnished. BUILDI
FOR APPLICANT TO FILL IN
❑ Certified copy Is filed with the county building Inspec- BUILDING
Ilandepartment. ADDRESS5 2- L
NEAREST—
Dote Applicant CITY zip D CROSS'ST.
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. OF BLDGS.
COMPENSATION-INSURANCI SLZE OF LOT X Z 0 NOW ON LOT MAP BOOK PAGE PARCEL
(This section need not be comP leted If the permit Is for one US
hurid.red dollars (;100)or less.I TRACT BLOCK kay ^ LOT NO. NO. CL
CL
I certify that In the performance of the work for which this. OWNER cr r ' /�� ;��/
DC MONS O
permit Is Issued, I shall not employ any person In any manner A14 rZ DISTRICT GROUP TYPE FIRE D BY U
to as.ta become subject to the Workers'Compensation Laws. ADDRESS 2 4C .i1 '� � ` �
Dare Applicant CITY L F C / ZIP / 7� STATISTFCAL CIASSIF TK)N CONDO
NOTICE' If, after making this Certificate of Et4GNER W
Exemption, you ,should become subject to the Worker' G1NffR �' CLASS tJO. DWE1L UNITS y
Compensation provisions of the Labor Code, you must forth- ADDRESS SEWER MAP Z
with comply with such provisions or this permit shall be
deemed revoked. CONTRACTOR BK. FIG, VAUDATIQN
LICFNSED CONTRACTORS DECLARATION UC
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. VALUATION
(commencing with Section 700D)of Division 3 of the Bushes and LIC
Professions Code, and my license Is In full force and effect. CITYCLA55 f Q t� , G7
SQ. Fr. NO. OF NO. OF CHECK
License Numbsser LIc.ClaSIZE STORIES FAMILfES ONE
f .
Contractor Date DESCRIPTION OF WORK' .D iJE1M ❑
❑ I am exempt front,the.-licensing requlrements as I am a W) X31 / ", _r Gc� ADD ❑
licensed arch•Itect or a registered prpfesslonal engineer ���// ALTER FINAL
acting In my professional capacity (Section 7051, 1410 09"" �1v, REPAIR ❑ DATE
Business and Professions Code). USE OF ❑ FINAL
EXISTING BLDG.
LIc.orRbg. No. Date APPLICANT /y TEL. B
OWNER-BUILDER DECLARATION 1� /� No' " S'�s
I hereby affirm that I am exempt from the Contractor's License ADDRESS C
Law for the following reason (Sectlon 7031.5, Business and
Professions Code):
y employees BUILDING
as owner of the
property, or M em to ees with ADDRESS
wages as their sole comperlsatlon,will do the work and
the structure Is not Intenddd or offered for sale(Sectlon kDR
7044, Business and Professlons Code). - TEL.
I, as owner of the property, am exclusively contracting NO. 9 7,$ A
with licensed contractors to construct the project (Sec-
tion 7044, Business and Professions Code). # 0 0 0 0 0
CONSTRUCTION LENDING AGENCY ID
YARD HWY TOTAL FROM WIDTH
I hereby affirm that there Is a construction lending agency for 2,0 0 2 []
the performance of the work for which this permit Is Issued
(Sec. 3D97, Clv. C.). ' 22. 006,
Lender's Name O'R 0 3-8 0
Lender's Address Permit FN
I certify that I have read this application and state that the issuance Fee
above Information Is correct. I ogres to comply with all County Investlgatlon Fee
ordlnances and State laws relating to building construction,
and hereby authorize representatives of th s County to enter Total F«
upon the a -ment ed o I pectlon purpose*.
SEE R!VEtSE FOR PXPLANATORY L.ANGLIArA
Signature of Appllca t or Agent Dote �s