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Home My Public Portal About6033 CLOVERLY AVE_Building__ TI N FOR BUILDING PERMIT 0/6A833A CE#803 8 63 APPLICATION \ COUNTY OF LOS ANGELES BUILDING DEPARTMENT OF COUNTY ENGINEER ADDRESS 60 N. Cloverl Temple Cit BUILDING AND SAFETY DIVISION LOCALITY 7yoq,45 c�/ JOHN A. LAMBIE, COUNTY ENGINEER NEAREST /////✓/��/ -/'. WILLIAM A. JENSEN, SUPT OF BUILDING CROSS ST. DISTRICT O.. GROUP_ TYPE PPS�SED BY FOR APPLICANT TO FILL IN 1p -(;r CONST. BUILDING STATISTICAL CLASSIFICATION SEWER MAP ADDRESS6033 Cloverly. Temple Cl BKPG Y CLASS. NO. DWELL. UNITS LOT NO. �J. '' BLOCK WATER CERTIFICATE: NOT REQUIRED ❑ RECEIVED ❑ TRACT MAP NO. (CIRCLE)AY NOOF BLDGS. E) STATE MAJOR SECOND, LOCAL . SIZE OF LOT NOW ON LOT USE ZnON� SPECIAL USE OF 1� /Z CONDITIONS EXISTING BLDG. TEL F, OWNER Wm• Miller NO BUILDING EXIST. 6033 N. Cloverl Tem le Cit SETBACK YARD HWY STREET NAME WIDTH ADDRESS y7 P y FRONT ARCHITECT OR TEL. P. L. ENGINEER NO. SIDE P. L. ADDRESS >TEL ° _ d CONTRACTOR Virgin Roof Co. NO 287-05_0 V ADDRESS 600 .So. San Gabriel Blvd., San a[ DESCRIPTION OF WORK° O W NEW ADD ALTER REPAIR rOCIfEMOLISH Z SQ. FT. NO. OF NO. OF ' SIZE STORIES FAMILIES STROUCTURE Reroof rear flat roof of ho SIGNATURE OF APPLICANT VALUATION $ APPROVALS DATE INSPECTOR'S SIGNATURE P C PMT FOUNDATION: LOCATION - FEE $ FEE $ 4.00 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 COUNTY ORDINANCES AND STATE LAWS REGULATING GAS VENT. DUCTS BUILDING CONSTRUCTION. I CERTIFY THAT IN DOING THE WORK AUTHORIZED HEREB(i' I WILL NOT EMPLOY ANY PERSON IN VIOLA- LATH. INT. TION OF THE LABOR CODE OF THE STATE OF CALIFORNIA RELAT- ING TO WORKMEN'S MPENSSAATION LNSURANCE. VIRGIN OOF COO LATH. EXT. SIGNATURE HOUSE NUMBER COR- PERMITTEE RECT AND POSTED ADDRESS ff) Marcia adden Sect'y. FINALJOHN F.F. LEWIS. PRINCIPAL STRU.CTURAL ENGINEER PLAN CHECK VALIDATION CK. M.D. CASH PERMIT VALIDATION CK. M.O. CASH L5 1 0 41 OCT 4 1 0 4.00 WORKERSO COMPENSATION DECLARATION hereby affirm that I have,a certificate of consent to self A p p L I C AT I O N FOR BUILDING PERMIT 0, r,.ficate of Workers' Compensation Insurance, o x�,S.'p'y thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company ❑ Certified copy is hereby furnished. FOR APPLICANT'TO FILL IN ADDRESS VJ 3 Certified copy is filed with the county building inspec- BUILDING tion department. ADDRESSCY ` 'J /� Date Applicant.' CITY ZIP I$ll LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' NO. OF BCDGS. NEAREST ( COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT t CROSS ST. O (This section.need not be completed if the permit is for one — ASSESSOR �' hundred dollars ($100)or less.) TRACT BLOCK LOT NO. MAP BOOK GE PARCEL < TEL. �/ USE Z NE MAP I certify that in the performance of the work for which this OWNER NOE. 4O' permit is issued, I shall not employ any person in any manner ADDRESS CONDITIONS O so as to become subject to the Workers'Compensation'Lows. \ (ry� (L CITY ZIP C 1 I ! V Date-`� Applicant— :2A�' ARCHITECT OR TEL., NOTICE TO'APPLICANT: If, after makin this Certificate of DISTRICT GROUP TYPE,. FIRE PRO SSED BY !0 g ENGINEER NO. CONST. ZONE Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- ADDRESS with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION APT: DO. deemed revoked.. CONTRACTOR NO. LICENSED CONTRACTORS DECLARATION - LIC. CLASS NO. 2/) 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 CLASS BK 2--PG ISS VALIDATION SQ.FT. NO. OF NO.OF CHECK License Number Lic.Class SIZE STORIES FAMILIES ONE VALUATION DESCRIPTION OF WORK 'V0 NEW ❑ Contractor Date ADD $ ❑ I am exempt under Sec. CLL-, SCID ALTER ❑ , B.&P.C. for this reason REPAIR ❑ $ Date: " USE OF DEMOL ❑ EXISTING BLDG. APPLICANT TEL. �1 yy� Signature PRINT) NO} FINAL g OWNER-BUILDER DECLARATION DATE-�`�� I hereby p affirm that I am exempt from the Contractor's License ' Law for the following reason'(Section 7031.5, Business and ADDRESS FI Profe ons Code): PRESENT //zl9w BUILDING 2 6 8 7.5'A as owner of the property, or myemployees with ADDRESS „ wages as their sole compensation,will do the work and ' # 0 0 0 0 0 1 the structure is not intended or offered for sale(Section LOCALITY 7044,Business and Professions'Code). MOVING TEL. r1 I, as owner of the property, am exclusively contracting CONTRACTOR NO. ° ° 4 9.8 8 with licensed contractors to'construct the project (Sec- -o 0 0 4 Q 8 8= ADDRESS v. tion 7044, Business and Professions Code). 4 1 7 8 7 CONSTRUCTION LENDING'AGENCY SETT BACK YARD HWY TOTAL SETBACK LINEF.ROM WIDTH O 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 m P.L. Lender's Name 1 1 .SLS( LDMA Ref. # P.C. Fee$' Permit Fee —✓CJ ' Lender's Address > I certify that I have read this.application and state that.the Issuance Fee �� U LDMA P/C# a above information is correct. I agree to comply with all County Investigation Fee ordinances and State laws relating to building construction, Total Fee LDMA Perm. # u and hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Inc--A 42 Signatueof Applicant or Agent - Date OO WORKERS' trOMPENSATION DECLARATION i Vti�here Y a certificate that I have,r certificate of consent to self APPLICATION FOR BUILDING PERMIT Ca or a certificate of Workers' Compensation Insurance,j or certified copy thereof(Sec.`3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY � cy No. Company BUILDING / Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS / Certified copy is filed with the county building inspec- BUILDING. tion department. • ADDRESSSS Date ApplicantCITY ZIP 11 LOCALITY J CERTIFICATE OF EXEMPTION FROM WORKERS' NO. OF BLDGS. NEAREST 1 COMPENSATION INSURANCE SIZE OF LOT s �C Q NOW ON LOT CROSS ST. (This section need not be completed if the permit is for oneASSESSOR' hundred dollars ($100)or less.) TRACT BLOCK LOT NO. MAP BOOK tlj�A PARCEL TEL. USE ZONE MAP J�y�CONDITIONS /- I certify that in the performance of the work for which this OWNER n' NO 70 NO. permit is issued, I shall not employ any person in any manner •3 ✓r U C.f - / SPECIAL so as to become subject to the Workers.•Co pensa`ion Laws. ADDRESS Date ' Applic6n CITY .� ZIP 0. 09 NOTICE TO APPLICANT: If, after•making his Certificate of ARCHITECT OR TEL. DISTRICT GROUP TYPE. FIRE PROD•ESSED BY ENGINEER NO.r- I CONST. ZONE (/92 Exemption; you should become subject To the Workers' f Compensation provisions of the Labor IA ?e,-you must forth- ADDRESS � t11Lwith comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION� Ru APT. deemed revoked. CONTRACTOR NO. LICENSED CONTRACTORS DECLARATION LIC CLASS NO. Vii' 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 CLASS BK L-__ PG �s�l VALIDATION SQ. FT.Ov� NO.OF NO. OF CHECK License Number Lic.Class SIZE STORIES FAMILIES ONE VALUATI N _ Contractor Date DESCRIPTION OF WORK (hL H1 NEW 0 $ .� /)/l DADD p ) (J(� , I am exempt under Sec. El B.BP.C. for this reason REPAIR s Date: USE OF DEMOL EXISTING BLDG. i Signature APPLICANT TEL. ^^ FINAL OWNER-BUILDER DECLARATION (PRINT) NO.pC S`IDATE - .I hereby affirm that I am exempt from the Contractor's License Law for the following reason'(Section 7031.5, Business and ADDRESS 33 G FINAL- ' Professions Code): PRESENT BY n BUILDING 3 vet L E z 6 6 5 3 A I, as owner of the property, or my employees with ADDRESS wages as their sole compensati #on,will do the work and o e:o 0 0;1 the structure is not intended or offered for sale(Section LOCALITY e n n U 7044, Business and Professions Code). MOVING TEL. ' j o ��R uX}V( I, as owner of The property, am exclusively contracting CONTRACTOR NO. with licensed contractors to construct the project (Sec- 3, 12-87 tion 7044, Business and Professions Code). ADDRESS REQUIREDTOTAL SETBACK FROMEXIST. -CONSTRUCTION LENDING AGENCY SET BACK YARD HWY• PROP. LINE WIDTH hereby affirm that there is a construction lending agency forFRONT the performance of the work for which this permit is issued P:L. (Sec. 3097, Civ. C.). SIDE \ P.L. Lender's Name m I < LDMA Ref. # Lender's Address P.C. Fee$ Permit Fee I certifythat I have read this application and state that the q) C PP Issuance Fee I/(/ t Jo LDMA P/C# above information is correct. I agree to comply with all County Investigation Fee 0 ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter Total Fee LDMA Perm. # upon the above- tioned property for inspection purposes. n SEE REVERSE FOR EXPLANATORY LANGUAGE gnature-of Ap licant or Agent Date -• - WORKERS' COMPENSATION DECLARATION •..I hereby affirm that I have a certificate of consent to self in Nurt,or a certificate of Workers' Compensation Insurance, APPLICATION FOR BUILDING. PERMIT or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING ADDRESS !/ O-33 s �� ❑ Certified copy is filed with the county building inspec- BUILDING �� / 0� J L tion department. ADDRESS (_ II Date Applicant CITY' 1•V-I ZIP I �C C5 LOCALITY pp CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NO. OF BLDGS. NEAREST_ qr) NOW ON LOT CROSS ST. COMPENSATION INSURANCEASSESSOR �� (This section need not be completed if the permit is for one TRACT (O ` BLOCK LOT NO. MAP BOOK ✓ Fs PAGE DD PARCEL VL/ hundred dollars ($100) or less.) TEL. l• --, OWNER S,-I p M tCC t C�l2 NO.6��vZ�S ILI(IrS USE ZONE MAP I certify that in the performance of the work for which this t SPECIAL permit is issued, I shall not employ any person in any manner ADDRESS UUr. D_ .( CONDITIONS O so as to become subject to the Workers' Compensation Laws. -y1 / _l U CITY d!f: (y_ 41t 14 ZIP Date Applicant ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY 0 NOTICE TO APPLICANT: If, after makin this Certificate of ENGINEER ��'y�� NO. g �p, CONST. NE v Exemption, you should become subject to the Workers' OV w Compensation provisions of the Labor Code, you must forth- ADDRESS '�� a- with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION CONDO. Z deemed revoked. CONTRACTOR 1`( P NO. i,:,J_APT. :�' A — LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. DWELL. UNITS ADDRESS NO 1 hereby affirm that I am licensed under provisions of Chapter 9 ' SEWER MAP (commencing with Section 7000)of Division 3 of the BusinessCITY CLASS �-—�`- and Professions Code,and my license is in full force and effect. �IBK. . PG. VALIDAt�07J SQ. FTv/ NO. OF NO. OF' CHECK License Number Lic. Class SIZE(� STORIES FAMILIES ONE LITAI_ ?' =� VALUATION ', DESCRIPTION OF WORK. r!'t,_V Contractor Date NEW d0 -•HE • ' C 'ADD ❑ $ / S� �• pp � _❑ am exempt under Sec. r ALTER ❑ Pit 8.8P.C. for this reason i +n F5=, C_.— REPAIR ❑ $ USE OF _1 i) I i-1'I l.:i Date: EXISTING BLDG. DEMOL ❑ APPLICANTG- TEL. CFINAL/j� ^ �! 3 1e.L1�. Signature (PRINT) M f CC i � -e NO. a)�CoZ Q� OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License (�53 Cr'011 �— y Law for the following reason (Section 7031.5, Business and ADDRESS'" ACL (ffFU C\ —1 FINAL Professions Code): PRESENT BY ,lj QBUILDING a.' `•�.,,I i 1 �.' !:.:;S °a I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and •'� LOCALITY r >I. + -'° the structure is not intended or offered for sale(Section ; ^1 r`, �y 7044, Business and Professions Code.) MOVING TEL. L� I, as owner of the property, am exclusively contracting CONTRACTOR NO. t w with licensed contractors to construct the project (Sec- ADDRESS !I n= -146 _ 4?4 tion 7044, Business and Professions Code.) _ REQUIRED.- YARD HWY TOTAL SETBACK FROM EXIST. .•.j�'!. 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. 'r•�`ti•it GE (Sec. 3097, Civ. C.). SIDE. P.L. Lender's Name / LDMA Ref. # t Il?! —I`l!IJ P. Fee$ / (9• Permit Fee t --,a , _ �, :•,°; Lender's Addresspool. :!,:.•5O ! !I=� °14. I certify that I have read this application and state that the Issuance Fee / LDMA P/C# above information is correct. I agree to comply with all County Investigation Fee 8 ordinances and State laws relating to building construction, Total Fee 'r LDMA Perm. # a and hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. Q`1lJl."4? `�a r -r-'L'A 4 �—I•��I SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date ' �,.• WORKERS' COMPENSATION DECLARATION hereby�a certificate that I have r certificate of consent to self i APPLICATION FOR BUILDING P E RM I T i.nsu�q,.`2t a certificate of Workers' Compensation Insurance, r a certified copy thereof (Sec. 3800, lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company BUILDING i ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS �i��- ✓ ❑ Certified copy is filed with the county building inspec- BUILDING j o�� 7 LSU�f . tion department. ADDRESS k� 1� l_ /� Date Applicant CITY y ��ELE C t ZIP 91-?9 v LOCALITY C J�✓J N . OF BLDGS. NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT U�. U NOW ON LOT CROSS.ST. dr COMPENSATION INSURANCE ) ASSESSOR (This section need not be completed if The permit is for one TRACT '� BLOCK LOT NO. /Q MAP BOOK PAGE PARCEL hundred dollars ($100) or less.) hh/�s TEL. �!(� N OWNERS'r�� 1'L+CC t Gl,� NO.��`78 USE ZONE OP I certify that in the performance of the work for which this SPECIAL } permit is issued, I shall not employ any person in any manner 1 ADDRESS t 013 CLo U zrL- CONDITIONS so as to become subject to the Workers'Compensation Laws. ^� nn (( �/ 0 ITL` `� -W ZIP l f? 0 0 Y� 1" Date Applicant CHITECT OR TEL. / DISTRICT GROUP TYPE FIRE PROCESSED BY NOTICE TO APPLICANT: If, after making this Certificate of E GINEER CLJ.-�,er NO. CONST. Z NE �G� U Exemption, you should become subject to the Workers' y G Compensatin provisions of the Labor Code, you must.forth- ADDRESS - ov 'e-3 with comply with such provisions or this permit shall be TEL STATISTICAL CLASS�ON APT. CONDO. N deemed revoked. CONTRACTOR Q r NO. Z LICENSED CONTRACTORS DECLARATION LIC. CLASS NO.a 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 LIC. and Professions Code,and my license is in full force and effect. CITY, CLASS BK PG VALIDATION - SQ. FT. NO. OF NO. OF CHECK License NumberLic. Class • SIZE,. STORIES FAMILIES ONE s , VALUATION Contractor Date DESCRIPTION OF WORK NEW ❑ $ I - ADD ❑ ❑I am exempt under Sec. Pir,/\d ct e ALTER ❑ B.&P.C. for this reason REPAIR ❑ $ Date: USE OF EXISTING BLDG. DEMOL Signature APPLICANT TEL.. p FINAL OWNER-BUILDER.DECLARATION DATE (PRINT)' IJP lti=G 1 �1 NO. y tl 13 I hereby affirm that I am exempt from the Contractors.License S (�� FINA� Law for The following reason (Section 7031.5, Business and I ADDRESS 1)�✓L� F Pro essions Code): V PRESENT By I, as owner of the property, or m employees with BUILDING P P Y. YADDRESS wages as their sole compensation,will do the work and LOCALITY the structure is not intended or offered for sale(Section 7044, Business and Professions Code.) MOVING TEL. CONTRACTOR NO. '• r""' I, as owner of the property, am exclusively contracting } =T11 I-D with licensed contractors to construct the project (Sec- T_I ) r,-. tion 7044, Business and Professions Code.) ADDRESS '_ tea. b REQUIREDTOTAL SETBACK FROM EXIST. i'I"1sr-CK CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH t G t I herebyaffirm that There is a construction lending agency for FRONT xs^- 9 9 Y <14s,�1» j jt the performance of the work for which this permit is issued P.L. .. (Sec. 3097, Civ. C.). SIDE. P.L. Lender's Name, LDMA•Ref. # { t �': P.C. Fee$ Permit Fee Lender's Address , -' s i y i a 1 certify that I have read this application and state that the Issuance Fee J LDMA.P/C# 8 above information is correct. I agree to comply with all County Investigation Fee R ordinances and State laws relating to building construction, Total Fee O LDMA Perm. # a and hereby authorize representatives of this County to enter upon the above-mentioned property for inspection.purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signoture'of Applicant or Agent Date i - WORKERS' COMPENSATION DECLARATION hereby affirm that I havecertificate of consent to self APPLICATION FOR BUILDING PERMIT � 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. Company I ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING ADDRESS ❑ Certified copy is filed with the county building inspec- BUILDING tion department. ADDRESS Date Applicant CITY cA,1ZIP LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' O. 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 dollars ($.100)or less.) TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL TEL.OWNER US1ZO E MAP I -cerfify that in the performance of the work for which this T � NO. � \ NO. 10 o A permit is issued, I shall not employ any person in any manner 1 /• SPECIAL CL so as to become subject to the Workers'Compensati6nCaws. ADDRESS 1 CONDITIONS � `�(� (� CITY /�✓ ZIP %Date Applicant S' . rcA 14 NI1�_ ARCHITECT OR TEL. O NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. DISTRICT GROUP TYPE FIRE PROC SED BY. Exemption,' you should become subject to the, Workers' �J �j CONST., / ZONE 01 Compensation provisions of the Labor Code, you must forth- ADDRESS J c" ��J 1� with comply with such provisions or this permit shall be TEL. Z deemed revoked., STATISTICAL CLASSIFICATION + APT. CO DO. Z CONTRACTOR X NO. LICENSED CONTRACTORS DECLARATION LIC. - CLASS NO. DWELL. UNITS 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 CLASS BK. PG VALIDATION SQ. FT. NO. OF NO. OF CHECK License Number Lic.Class SIZE STORIES FAMILIES ONE VALUATION Contractor Date DESCRIPTION OF WORK -NEW - $ a s ADD , ❑ I am exempt under Sec. f' ❑ ALTER B.&P.C. for this reason REPAIR ❑ $ Date: USE OF DEMOL EXISTING BLDG. E] 2'0 9 0 A Signature APPLICANT TEL. FINAL OWNER-BUILDER DECLARATION (PRINT) NO. DATE` # ® 0 0 0 0 hereby affirm that I.am exempt from the Contractor's License Law for the following'reasbn (Section 7031.5, Business and ADDRESS FIN Professions Code): PRESENT B ) o - 49.88 BUILDING S_ I, as owner of the property, or my employees with ADDRESS o o oA q 8 8- 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. ' Q S22-85. ❑ 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 SETT EQBACKK YARD HWY TOTAPROP .LINESETBCKFR M _WI I hereby affirm that there is a construction lending agency Tor FRONT the performance of-the work for which this permit is issued -P.L. -- (Sec. 3097, Civ. C.). SIDE m .. P.L. .. - - a• - Lender's Name P.C. Fee$ Permit Fee LDMA Ref. # - Lender's Address w I.certif that I have read this application and state that theoil, /'Y PP Issuance Fee ULSLDA P/C# ••above information is correct. I agree to corriply with all County Investigation Fee ordinances and State laws relating to building constructionand hereby authorize representatives of this County to enterTotal-Fee QLDMA Perm. # m upon the above-mentioned property for inspection purposes./ a !4 ��✓� SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicani orAgent — Date /I ---i_— WORKERS' COMPENSATION DECLARATION bor a certificate of Worke s' Compensat on e insureInsuto selft, ran e, APPLICATION FOR BUILDING PERMIT pr'a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company d BUILDING ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS ❑ Certified copy is filed with the county building inspec- BUILDING 1 .z . tion department. ADDRESS L!X� rr,, I ' [ 1 Q0 LOCALITY Date Applicant ZIP _ PP NO. OF BLDGS. NEAREST- CERTIFICATE OF EXEMPTION FROM.WORKERS' SIZE OF LOT sc lGC NOW ON LOT CROSS ST. COMPENSATION INSURANCEASSESSOR /l' � /7 (This section need not be completed if the permit is for one TRACT 10 BLOCK LOT NO. MAP BOOK 1JZ 4PAGE �r6 PARCEL LSD hundred dollars ($100) or less.) r , USE ZONE TEL.�( G MAP y� OWNER JT'-C.,�• ICS l C �.SZ NO. o�RS�O�rI NO. ��D � p( 1 certify that in the performance of the work for which this SPECIAL >- perrnit is issued, I shall not employ any person in any manner ADDRESS LOSS( f nV,QrL_—{ �r CONDITIONS I- so as to become subject to the Workers' Compensation Laws. O CITY Iprj\�Np, ( 1��I ZIP l r7 d Date Applicant ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY O NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. CONST. ZONE V Exemption, you should become subject to the Workers' f� t/ Compensation provisions of the Labor Code, you must forth- ADDRESS �Or/ �`� V -L,c.� ii with comply with such provisions or this permit shall be r ` TEL. STATISTICAL CLASSIFICATION APT. CONDO. N deemed revoked. CONTRACTOR Z LICENSED CONTRACTORS DECLARATION nn LIC. CLASS NO. DWELL. UNITS — I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS tis ✓ NO. (commencing with Section 7000)of Division 3 of the Business LIC. SEWER MAP and Professions Code,and my license is in full force and effect. CITY CLASS BK./- PG /�/�J`- VALIDATION SQ. FT. NO. OF NO. OF: CHECK License Number " Lic: Class SIZE"—j yr( STORIES FAMILIES ONE VALUATION Contractor Date DESCRIPTION OF WORK i NEW ❑ --E 11 5 {" fin, _ t�LIU �Si�I,LGl rC�G�-+ ADD 1 S S .J ► _ ;�} ❑I am exempt under Sec. - -. i P f ALTER ❑ // OO� �� jFF' `;;. ;� .. o B.&P.C. for this reason -1-1UcA �G.`�� P REPAIR ❑ $ (p - Date: USE OF q � DEMOL ❑ EXISTING BLDG. SLS;dl�_L�Cs APPLICANT M j TEL.Yjj, ' Signature OWNER-BUILDER DECLARATION (PRINT) 7(�� Ric- C ' O. Q S'�(j� FINAL DATE � �`- I hereby affirm that I am exempt from the Contractor's Licensee Ct'r v�2�`' -t;`C ADDRESS " '•_ '='' Law for.The following reason (Section 7031.5, Business and FINAL ,� r•.I�_'''-_.___ is•�_`:` r:: Professions Code): PRESENT BY L'A - _^ i ` IL�J/ I, as owner, of theproperty, or m em to employees with BUILDING `s.+ 3" Y P Y ADDRESS wages as their sole compensation,will do the work and the structure is not intended or offered for sale(Section LOCALITY I�y/7044, Business and Professions Code.) MOVING TEL. L� I, as owner of the property, am exclusively contracting CONTRACTOR NO. with licensed contractors to construct the project (Sec- EADDR ` tion 7044, Business and Professions Code.) _ } D - TOTAL SETBACK FROM ]EX '- ` CONSTRUCTION LENDING AGENCY K YARD HWY PROP.'.LINE -•:• I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued P. „• Su .:- IT- (Sec. wg (Sec. 3097, Civ. C.). Lender's Name I m / `/ I^•:,%:. :moi: G! 7 7- Permit FeeLDMA Ref. #Lender's AddressI certify that I have read this application and state that the ��✓ Issuance Fee aLDMA P/C# above information is correct. I agree to comply with all County n Fee 0 ordinances and State laws relating to building construction, Total Fee V / �• LDMA Perm. # a and hereby authorize representatives of this County to enter upon the above-mention d property for inspection purposes. � �� t y C SEE REVERSE FOR EXPLANATORY LANGUAGE. Signature of Applicant or Agent Date