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HomeMy Public PortalAbout9629 CRAIGLEE ST_Building__ APPLICATION( FOR BUILDING PERMIT F R.A 4:rCANT TO FILL IN '(Print or type only) COUNTY OF LOS ANGELES ADDRESS 94. DEPARTMENT OF COUNTY ENGINEER CITY ZIP ] BUILDING AND SAFETY DIVISION / NO.OF BLDGS. BUILDING SIZE OF LOT (�a-- NOW ON LOT ADDRESS .TRACT (p� BLOCK — LO Cid LOCALITY OWNER. .. TEL. 57� CROSS ST, ASSESSOR- ADDRESS SSESSOR ADDRESS (ppc© p� MAP BOOK PAG PARCEL DISTRICT CITY c ._ ZIP 9� �p"` GROUP TYPE FIRE kR ESSE BY CONS ARCHITECT OR TEL. J U ✓ J ENGINEER NO. STATISTICAL CLASSIFICATION SEWE ;MAP ADDRESS CLASS NO. —DWELLAJNITSPG r, TEL �y CONTRACT R (.� N nn 3�ba USE ZONE MAP ©G ADDRESS' WNO. O� y�v• SPECIAL LIC. � _/ CONDITIONS . CITY CLASS ROAD DEPARTMENT APPROVAL REQUIRED YES ❑ NO ❑ CONSTRUCTION LENDER NAME AND BRANCHBLDG.SETBACK FROM FRONT PROP.LINE OF (STREET) A 5 CIT TOTAL SETBACK FROM TYPE OF EXISTING SQ.FT. NO.OF NO.OF CHECK HIGHWAY + YARD = FRONT PROP.LINE HIGHWAY WIDTH SIZE STORIES FAMILIES ONE > DESCRIPn OF WORK NEW ❑ +. O. BLDG.SETBACK FROM ADD (❑ SIDE PROP.LINE OF (STREET) O T ~ ALTER = TOTAL SETBACK FROM H TYPEOF EXISTING w HIGHWAY + YARD SIDE PROP.LINE HIGHWAY WIDTH N. USE OF . REPAIR ❑ Z EXISTING BLD DE M-05 +. APPLICANT TEL CORNER CUTOFF YES C] NO 1:1(PRINT) NO. IN OPEN SPACE YES_❑ NO ❑ BY(SIGNATURE( IN COASTAL PERMIT ZONE YES ❑ NO ❑ VALUATION IHEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL ORDINANCES ' AND LAWS REGULATING BUILDING CONSTRUCTION.I CERTIFY THAT IN DOING THE WORK AUTHORIZED HEREBY I WILL NOT EMPLOY ANY PERSON IN VIOLATION OF THE LABOR CODE OF THE STATE EC/+LIFORNIA IN RELATING TO WORKMEN'S COM- PENSATION INSURANCE. // - SIGNATURE OF PERMITTEE' ADDRESS FINAL CITY NO. DATE !l, ! 076 MC. AKE CHECKS PAYABLE TO: F E $ �! FET HARVEY T.BRANDT,COUNTY ENGINEER PLAN CHECK VALIDATION CK. M.O. CASH- o PERMIT VALIDATION. cK.`; M.O. CASH . 7 6 cNIAR, 17 1 0 6.0 0 &u8 ®s 76A638A CE#803 3-75 ' m FOR A,°�'"i.`ICANT TO"FILL'IN (Print or type only). ,. .BUILDLNG - (S .. - a.'COUNTY OF LOS'`ANGELES ADDRESS. 9629 CrAi lee-_ EPARTMENT OF COUNTY ,ENGINE,ER CITY Temple- Cit_ Y •: zi P•. '1 BUILDING` AND SAFETY DIVISION x 4 2 r .NO.OF,BLDGS: BUILDING y/ SIZE OF-`LOT ..5.3X 1 ; 'NOW-.ON L ADDRESS C.,..•` ''- •� TRACT' Vi/ .' BLOCK .�..�:. LOT NO` LOCA LIT ' NEAREST !� •1 NO. -2.O C 5,76. CROSS:ST.,•.. "! OWNER.MZ.d_hael 'Gillmore :,. NO. - ASSESSOR ieADDRESS, ..,9V29:- C.L"a.L LeB ':. `. MAP BOOK -G; . .PAGE ^.•. .... •' PARCEL.,.. - ,. �7•+ pleCDISTRICTGROUP .- .',.TYP - _ SSED BY T,Y e'm " Zty: ..ZIP1 T. CONSE ' FIRE ♦ e 'ARCHITECT OR CI .:ENGINEER .• e; ,NO. . - STA-TIST.ICAL'CLASSIFIC'ATION - SEWER AP..: .. ADDRESS - - .:CLASS NO �- , / _'DWELL.UNITS BKN PG' L��.. TE�/� CONTRACTOR,p.r6f 'Dev-:�R..CO NO't4•5--3560 USE ZONE NOP •���; - " l2' 'S o Santa .Anita rLio 279486'• ,'{ SPECIAL ADDRESSt LIC. D CONDITIONS Aada" CITY rdz , _ �CCASS U� - ROAD-DEPARTMENT APPROVAL REQUIRED YES[ NO CONSTRUCTION LENDERS -`' NAME'AND BRANCH ' Jed.' ^ paCifIC` BLDG SETBACK,FROM - _ FRO T PROP.LINE OF ' - (STREET)' ADDRESSA:t'lantld BlVdzY, Man'terey. .P.•� HIGH AY } YARD 'TOTAL SETBACK FROM TYPE OF EXISTING SQ.'FT NO.-OF NO:;OF G_I.E CK FRON T.p R,OP,.." LINE HIGHWAY WIDTH. ,5 ` -r ,SI.ZE• `O STORIES . FAMILIES„ •ONE - _ - DES'CRIPT.I'ON OF'WORK ~; NEW O- - - BLDG;SET,BACK�FROM• - O •p ADD Tcao s't6r addition- ,B/'.L\ BIDEGPSET 'LINE OF (STREET). Batl1 Fam/'i11E1 .CJG."Se ALTER Q HIGHWAY. } YARD TOTAL SETBACK,,FR9MY E OF EXISTi NG U- ,. W/li1Ll.. A.L. L'.o - HSG AY :.WIDTH REPAIR .SIDE PROP. LINE` -'-. ..W CIL Cis E, EXIST^ING._BLDG. -ReS d,ence .� ;,.,:. DEMOL',Q -�Z `APPLICANT `." : ''• :TEL CORNER.CUTOFF_. YES ❑ NO BY (SIGNATURE) IN-OPEN.SPACE Y - N ES..O O'0, ' IN COASTAL PERMIT;ZONE, YE'S112 ,,; Nb'11 VAL'UATION,$. 20` 000. 00 '.- ,q,�y.��} �,r - /yJ, .may e.rf A , . 7 HEREBY ACK NOW LEDGE•.'THAT Io:HA VE READ-THIS APPLICATION /w n o ."ellen 1+'t ""0L f fwV^-� -AN D STATE-THAT THE ABOVE `I'S:CORRECT ANDrAGREE,TO COMPLY' �✓^ i m�. R- -�wit I. WITH ALL ORDINANCES AND'.LAWS. REGULATING BUILDING CON- STRUCTION:. I ,CERT!FY THAT .IN -DOFNG THE WORK AUTHORIZED �. HEREBY I•WILL NOT ,EMPLOY. ANY-PERSON JN 'VIOLA.TION OF'THE. a .LABOR CODE- OF T-jE, -s--r7oT,E; OF 'CALIFORNIA. IN RELATING TO �iv��'y`_•J'�., 5� - 1' 'WORKMEN'S COMP ,NSATIONpINSURA NC SIGNATURE. .._. as , ...� h;a ! '-L�: lcxS F�,23 G3.'�{ ~.. s' ? : PERMITTEE - ,,�• ,••� - - ADDRESS q,7*a�o% `- "?'O ;4e 664,k.=.{r"'.P.a '!`.iC.�2w w'-•y:.:'. - .F-IN.AL BY. TEL. CITY N O. DATE . 111KE CHECKS.PATABLE 70; FEE"✓"' FEE ' HARVEY T.'BRANDT, COUNTY ENGINEER ,-PLAN'CHECK VALIDATION CK..• M.o. _ CASH m PERMI ALIDATION cif: `)M.o. ...'CASH .6 6 'A1A,p :9 Jc ' 76A638ACE803 5/74 ,4' '. -L C�QR. ^(J 1 U� 1 - - 3.25A LJ v DEPARTM M' OF COUNTY MGIIIT= DIVISION OF WELDING ARID SAFETY COUNTY OF LOS ANGELES IOU � k D-H NO WILLIAM J. FOX, COUNTY ENGINEER ?(j� APPLICATION L� CASSATT D. GRIFFIN, SUPT OF,BUILDING FOR APPLICANT TO FILL IN FOR OFFICE USE.-ONLY BUILDING DISTRICT NO. P �c6R REc,NO, j3 IT NO. ADDRESS Q"�1 1 LOCALITY '2 A. t� !dn'� ( e�eT RECE ED BY DATELPF A PL. DATE ISSUED NEAREST CROSS ST .,.s �Frp BUILDI OWNER , r� . ! JP F! � P?,:a�.�� l�i'L' .. ADDRESS ADDMAILRESS [ ._. d�/1,Il` /7, �.�"" LOCALITY 1 �¢ x',< ° Sq NEAREST P P. 1I f TEL. s'� eta ! 4! CROSS ST. CITY ♦ !1 '1 6,:.. O 'v✓ - ARCHITECT OR TEL. ' FIRE NO. OF TY GROUP ENGINEER NO. ZONE I PLANS I• ADDRESS , BLDG- ,O f, � ✓✓✓- O SETBACK LINE ' �''� t /J "TEL.! ./ dF USE APPROVEDCONTRACTOR '•l a c?9;' 01 11A h 1.1 A_Z.R. .L�� ZONE / /BY ♦ �,�w DATE o HOUSE NUMBERING ADDRESS ` _._R7 dQtA AA LEGAL i MAPNUMBER NO. ASSIGNED BYDESCRIPTION T� , I BLOCKTRACTCORRECTIONS NO. OF BLDGS. SIZE OF LOT .NOW ON LOT USE OF NIfEXISTING BLDG. FADESCRIPTION OF WORK NEW ALTERATION ADDITIOG) REPAIR DEMOLITION Y SO. FT. NO. OF �� �I Y3l_�tGt ivy 1?AN1 a-t�1 r SIZE.. , r ROOMS STORIES EXT. WALL `�, ROOF ' ` d - ," C T—A16 - COVERING yct,Plr; f Y.'I I,�COVERING' �[5 q' � R - P C) ���o�-•s"3- C USE OF STRUCTURE / f APPROVALS INSPECTOR'S SIGNATURE DATE PFOUNDATION: LOCATION �lh _ Z�- FORMS, MATERIALS O�� b I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS AP-. FRAME: FIRE STOPS, q+ PLICATION AND STATE THAT THE INFORMATION GIVEN IS BRACING, BOLTS r7� s CORRECT. FURNACE: LOCATION, _ p 1 AGREE-TO COMPLY WITH ALL COUNTY ORDINANCES GAS VENT, DUCTS /1 , AND STATE LAWS REGULATING BUILDI G CONSTRUCTION. LATH, INT. pp SIGNATURE OF / 71 In PERMITTE I r .�. LATH. EXT. (Y ` Y ADDRESS r PLASTER, INT, AUTHORIZED AGT: - PLASTER, EXT.. pp y S / ®� FEE S/ HOUSE NUMBER COR- RECT AND POSTED ,/` � - VALUATION FEE O U`7`- FINAL 76AG38A 01363 9-82 • oI _ 76A638A CEd803 5-65 APPLICATION F®R BUI ®I G P R_ m0' _ 7 COUNTY OF LOS ANGELES BUILDING DEPARTMENT OF COUNTY ENGINEER aoDREsso? BUILDING AND SAFETY DIVISION LOCALE �L JOHN.A. LAMBIE. COUNTY ENGINEER NEAREST COLEMAN W. JENKINS.SUP'T�OF BUILDING CROSS ST. DISTRICT NO.-. G I T Y P E.--� _PROSED BY. FOR APPLICANT-T"0 FILL IN _� CONST<_ BUILDING ry STATISTICAL CLASSIFICATION -SEWER:MAP. ADDRESS • CLASS NO. - DWELL UNITS. - B LOT NO. - BLOCK USE ZONEMAP /l TRACT (� I- SPECIAL - - CONDITIONS NO. OF BLDGS. . SIZE OF LOT.. .NOW ON LOT USE OF f_ F __`_ -_ C. CL - ry. EXISTING DG. P" BLDG. SETBACK FROM _ >-� TE FRONT PROP. LINEOFi STREET)•- OWNER NQ TYPE OF EEXISTING SETBACK HIGHWAY' + YARD — TOTAL ADDRESS HIGHWAY FROM C,L. - CIT ARCFI` OR m BLDG: S TBACK FROM . ._- ARCSIDE PROP. LINE OF — (STREET) ENG TYPE OF EXISTING SETBACK HIGHWAY '.�- "YARD- — 'TOTAL W , ADDR SS HI AY WIDTH FROM C.L. C O TAV �•, - C O. AD S CORNER CUTOFF -Y-ES'� NO - V Iw e-..../� ' CITY , CILASS SEE REVERSE.SIDE FOR'SPECIAL APPROVALS -O DESCRIPTION OF WORK Lu L_ NEW ADD A'L TER REPAIR - DEMOLISH SQ..FT. NO. OF - -NO. OF SIZE STORIES FAMILIES_, USE OF STRUCTURE 7 - _ �8 SIGNAT RE OF Z 4 APPLICANT �i `� - //l I�_^� - • VALUATION.$ -,�'�,� �v - i �/`�` !/ - v APPROVALS' Y DATE .INSPEC)fO 'S SIGNATURE . ' FOUNDATION, LOCATION �p - FEE$ FEE$ FORMS, MATERIALS - FRAME, FIRE STOPS, I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION BRAC ING BOLTS AND STATE THAT THE ABOVE IS'CORRECT AND AGREE TO COMPLY FURNACE: LOCATION WITH ALL COUN ORDINANCES AND STATE LAWS REGULATING GAS VENT. DUCTS 9U ILD NG CON R ON. I CERT Y THAT. N DOING THE WORK AUTHORIZED �Y I W L NO MPLC J/11r� ,IN VI L��- TION OF'TH AS CO L-OF T9 u(�d I c LATH.'INT. ING TO WO ME S - LATH. EXT: _ SIGNATUR F HOUSE NUMBER COR- PERMITT RECT AND POSTED ADDRESS 7 _ FINAL ;�. ' JOHNF. LEWIS. PRINCIPALS RAC ENGINEER ' PLAN CHECK VALIDATION CK. M.D. CASH _ PERMIT VALIDATIO K. M.O. CASH Lt1O 0 7 9 9 ��'AR"2 8. 2...3 .2 5- W L,tCo0 8 ' 0;� MAR28 1 0 1 8.50-- ) " __ - - WORKERS'COMPENSATION DECLARATION M M insureboraafcertif cairm rte of Worke sP ' Compensation Insurancef LSU �L/—U�'�OLI V' 0 •O or a certified copy thereof (Sec. 3800, Lab. C.) q_ COUNTY.Off_LOS_�►ibG�LES BUILDING AND SAIF ETY . .. Policy N3`� I Company r=rJ2 F Certified copy is herebyfurnished.: FOR APPLICANT-TO'FILLIN- BUILDINGADDRESS 6 2 rA Certified copy.is filed with the count building ins ec'- BUILDING 'I tion department. , — . ADDRESS G - LOCALITY NEAREST Date �i f Applicant CITY • ZIP CROSS ST. CERTIFICATE OF EXEMPTI F FRO ORKERS' - NO.OF BLDGS. ASSESSOR COMPENSATION SURANCE, SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL (This section need not be completed if the permit is'for one USE ZONE MAP D o 2 hundred dollars ($100)or less.) TRACT BLOCK LOT NO. NO. J TEL. 1 SPECIALCL , I certify.that in the performance of'the work for which this OWNER NO: CONDITIONS permit is issued, I shall not employ an person in anymanner DISTRICT GROUP TYPE FIRE PROCESSED BY O P P Y Y P CONST.V ZONE so as to become subject to the Workers'Compensation Laws. ADDRESS v�a?r%lw-2 C ilkDate Applicant CITY ZIP STATISTICAL CLASSIFICATION APT. ICONDONOTICE TO APPLICANT:- If, after making this'Certificate'of ARCHITECT OR TEL. ENGINEER NO. CLASS NO. _DWELL. UNITS LU Exemption, you 'should become subject .to the. Workers'' Compensation provisions of the Labor Code, you must forth- ADDRESS - SEWER MAP with comply with such provisions or, this permit shall be Z deemed revoked. TEL. ' 06� BK. PG,' VALIDATION CONTRACTOR'�.2,;C�I�Lxan..ri,� .NOO'�� L / ' LICENSED CONTRACTORS DECLARATION loor LIC. I hereby affirm that'I am licensed under provisions of Chapter 9 ADDRESS /6 t NO. WTI 7 - VALUTATION(commencing with Section7000)of Division 3 of the Business and pp LICe 3 + .i Professions Code,and my license is in full force and effect. CITY r�$sd'`,- CLASS / 0� D SQ. FT. NO.OF NO. OF CHECK License Number."I Lic.Class SIZE STORIES FAMILIES ONE Contractor L��� + ""/ Date $ DESCRIPTION OF WORK NEW ❑ $ 1.2'A I am exempt under Seca — # 0,0 0 0 0 r LTER 0 FINAL � B.BP.C. for this reason REPAIR [:] DATE lj (e) 1, 0 1 O 6 1 3 Date: USE OF 1 L 1 EXISTING BLDG. DEMOL FIId 0 0 1 7J v Signature APPLICANT TEL. BY O. OWNER-BUILDER.DECLARATION • PRINT NO. 11.•2 6-B Q I hereby,affirm that I am exempt from the Contractor's License D Law for the following reason (Section 7031.5, Business and ADDRESS Profess ions,Code): PRESENT BUILDING. �. 1, .as owner of the property, or' my employees with ADDRESS ,wages as their sole compensation,will do'the work and the structure is notintended 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). -REQUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH D hereby affirm that there is a construction lending agency for FRONT . the performance of th'e'-work for which this permit is issued P.L. (Sec. 3097, Civ. C.). SIDE m 'P.L. a Lender's Name - C_ - - P.C.Fee$ Permit Fee S 1 6 3 ' Lender's Address h _ I certify that I have read this application and state that the Issuance Fee w•, D above information is correct. I agree to complywith.all County Investigation Fee A 2 gordinances and State laws relating to building construction, Total Fee U J d and hereby authorize representatives of this County to enter upon he above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE n Sign ure of Applicant or Agent Date ®S f � WORKERS' COMPEf�ISATION DECLARATION 1 y pp �' h riu`ebyaffirm that I have r ce' 126ate.of tion l n L`r self � V,�L O N � o M p i ure, or a certificate of Workers Compensation InsE.rance, L/"�1 L�1 LLII M LDLI V LI •LIVU V U ll ' or a c ifig�opy"there�f,�5�c 3800 Lab C ) + ? U t COUNTY OF LOS.ANGELES 'BUILDING AND SAFETY �o�licy �V .Company 4' ❑ Co.eritfied copy is hereby furnished. \ FOR APPLICANT TO FILLIN• _ ADDRRESS 9 dee c� .. G/ //'�� __ �2 C � ❑ Certified copy is-filed with`the count y building.mspec BUDDING / 6 ..:. .�(� tion,department. \ y ti` 1 . I-qc) ' s CITY / ' ' LOCALITY Date Applican C- NO. OF:BLDGS� NEARESTr,�. CERTIFICATE OF'EXEMPTION FROM WORKERS' SIZE OF LOT NOW ON LOT CROSS ST. G, `BL��I . COMPENSATION INSURANCE ASSESSOR (This section need.not be completed if the permit is for one TRACT BLOCK LOT NO. , MAP BOOK PAGE PARCEL hundred dollars ($100) or.less.) /` TEL` USE ZONE MAP `OWNER. L fYl t. NO.tj,5 NO. 77 I certify that in the performance of the`work-foi which this c SPECIAL permit is issued, I shall not employ any person in any manner ADDRESS CONDITIONS so as to become subject.to the Workers'Compensation Laws. /' r O CITY ' l i .j �r ZIP i U Date Applicant ARCHITECT OR TEL / DISTRICT GROUP TYPE FIRE PROCESSED BY O Exem tion, you "should become making this Certificate of ENGINEER NO.E CONST-!"T' ZONE F NOTICE TO APPLICANT:-,If, after G\�1— P Y subject'to the Workers' i J� U Compensation provisions of.-the Labor'Code, you.must forth- ADDRESS J`UJ =3 w a with-comply with-such provisions,or this permit shall be TEL. q a STATISTICAL CLASSIFICATION' APT. C N deemed revoked CONTRACTOR /�j�?/�: �. NO. !L>d"` Z • LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. DWELL. UNITS - �� I hereby affirm that I am licensed under provisions of Chapter 9" ADDRESS ,NO. L 1r (commencing with Section 7000).of Division 3 of the Busi'ne'ss LIC.. SEW MAP ER CITY CLASS' and Professions Code,and my license is in full force and effect. BK M PG `/�— VALIDATION . SQ. F— NO. OF v NO.'OF CHECK. I License Number /�SJS,J 7 Lic. Class �� f SIZE STORIES 7 FAMILIES ONE J ' ` VALUATION DESCRIPTION OF WORK NEW Contr -Date $ E]1 am exempt under Sec. +� 7 " h %<P /! �is �:, ADD D .ALTER B.BP.C. for this reason ' REPAIR ❑ $ Date: EXISTING B -;`lLDG. i'^ a(,c'i•l/f— C DENOL Signature" APPLICANT TEL. FINAL'• g 1 j!! j f (PRINT) �tJO l% NO. Z�SI R OWNER-BUILDER DECLARATION Y DATE V '' TTE m'= I hereby affirm that I am exempt from the Contractor's License G pE_E E•� Law for the followi"ng reason (Section 7031.5;-Business.and ADDRESS 21 ! LS/'.• G,� _cEci S /Ov r FINAL' >v s~ t +IIIA 1_� � 50 Professions Code):.. r PRESENT: By - �' ❑ I, as owner of the ro ert or m em to ees with ADDRESS P P Y. Y P Y ADDRESS wages as their sole compensation,will do the work and n 'HHN LOCALITY D S the structure is not intended or offered for-sale(Sectio • 7044, Business and Professions Code.) ' MOVING TEL. El1,as ownerof the property, am exclusively contracting CONTRACTOR NO. E EP E'I ti i�'7.7/Lt-y' with licensed contractors to construct the prolecis(Sec- ADDREGS" � \e _ '� '3 e�= �Ii=IIlk Ei�;i_s ,,_�, �, " tion 7044, Business and.Professions Code. REQUIREDTOTAL SETBACK'FROM EXIST CONSTRUCTION LENDING AGENCY- YARD HNVY SET BACK PROP. LINE WIDTH • Vis•' , I-hereby affirm that there is a construction lending agency for FRONT W the performance of'the work for which this permit is issued P.C. *. . (Sec. 3097„Civ. C.). SIDE. - Lender's Name P.C. Fee$ Permit Fee LDMA Ref. q Lender's Address ``� 1 certify that.lLv' have'read this application and state that the Issuance Fee • 6-U LDMA P/C# o - 8 above information,is correct. I agree to comply with all County Investigation Fee d ordinances and State laws relating to, building•construction, Total Fee I Sd LDMA Perm.'# a and hereby authorize representatives of this County to.enter upon "94e mentioned.property for inspection purposes. i,/� -/ Com '-:—. Z•Z.-y SEE-REVERSE-FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date WOdKER,S' COMPENSATION DECLARATION / I hereby affirm that I have a certificate of consent'to self v[ � ��C T��N FOR MD p U� IO�.M G F E R nn.�� . insure, or a certificate of Workers''Com pensation Insurance, LI' LSU LI,V LL LI\1LIl/LI or a certified copy thereof (Sec. 3800, Lab. G.), . \ COUNTY OF LOS ANGELES $UILDING AND SAFETY' . Policy No. Company BUILDING'' ❑y Certified copy is hereby furnished. FOR APRICANT.TO FILL IN ADDRESS Lf Certified copy is.filed-with the county,building inspec- BUILDING ^7 tion department. ADDRESS G� te- _ r CITY'. ZIP LOCALITY' Dated -Applicant NO. OF BLDGS. CERTIFICATE OF`EXEMPTION FROM WO CERS' SIZE OF LOT lS I' NOW ON LOT "' NEARESTCROSS ST. COMPENSATION INSURANCE ASSESSOR . (This section need not'be completed if the permit is for one TRACT BLOCK LOT NO. MAP.BOOK PAGE" �/PARCEL `. hundred dollEirs.($100)'br.less.,) " TEL OWNER Q' NO. � ® USE Z NE MAP- NO. I certify,that.in the performarice.of-the work;for which.this SPECIAL �. permit is issued, I•sholl not employ any person in.any manner w. ADDRESS � ..•- D CONDITIONS so as to become sub'jectto The Workers' Compensation Laws. 0 CITY ZIP _ Date Applicant. ARCHITECT OR TEL. NOTICE TO APPLICANT: If,, after making this Certificate of ENGINEER NO. DISTRICT GROUP TYPE FIRE PROCESSED BY 9 CONST. ZONE Exemption, you should become subject to'the :Workers' .Compensation provisions of,ihe Labor Code, you must forth- ADDRESS al �31 - w o_ with comply with such *provisions or.This permit shall be TEL. STATISTICAL CLAS N APT. CONDO. N deemed revoked. CONTRACTOR NO. p 0� Z LICENSED CONTRACTORS DECLARATION. LIC. ' CLASS NO. DWELL. UNIT I hereby off irm-that-I am'licensed under provisions of Chapter 9 - ADDRESS �� / NO ���j � q LIC. SEWER MAP (commencing with Section 7000)of Division 3 of the Business CITY• W,. t6_0L CLASS. and Professions.Code,and my License is in full force and effect. BK pG I VALIDATION ' $ SQ: FT. NO. OF NO..OF' CHECK License Number ✓� Lic. Class SIZE STORIES' FAMILIES ONE �^M�w VALUATION g� DESCRIPTION OF WORK NEW Contract o ❑ S 13 r— �Q e« ' .ADD ❑I am exempt under Sec. D ALTER ❑ .. BAP.C. for.this reasonREPAIR ❑ $ Date: USE OF ♦ ... - .. EXISTING BLDG. �/ DEMOL ❑ Signature APPLICANT TEL. _ .. FINAL _ _OWNER-BUILDER DECLARATION. (PRINT). NO':" DATE I hereby affirm that I am exempt.from the Contractor's License Law for the following reason (Sect jon'7031:'5, Business and [ADDRESS FINA — Professions Code): _ PRESENTBUILDING AT.-1 ❑ I, as owner of the property or my employees with ADDRESS CC wages as,theirsole'compensation;wiII'do the work and the structure is not intended or offered for sale(Section LOCALITY D 301 7044, Business and Professions Code.) MOVING TEL. ❑ CONTRACTOR NO. 1 HEMS S I,.as owner of the property, am exclusively contracting _ , with licensed contractors.to construct the project (Sec- ADDRESS I_t(fh c, ' tion 7044, Business and.Professions Code.) REQUIRED TOTAL SETBACK FROM EXIST. '�,, •� CONSTRUCTION LENDING AGENCY SET BACK YARD; MWY PROP. LINE WIDTH "'" `•: lC'.K I hereby affirm that there is a construction lending agency-for FRONT the performance of the work for which.this permitis issued P.L. SJ CHANGE r (Sec: 3097, Civ..C.). FIDE '.e ,, Lender's Name t i 4•+ ems, E_T fi ftE (t�`:{ _• ' \ LDMA Ref. # � EI-:. It/ P.C. Fee$ 0 Permit fled 3 A res D . o. t I ave read this application and state that the ►-' Iss anc2�ee ©: . LDMA PLC# 8 m ion is correct. I agree to comply with':all County Investigation Fee %d State laws relating Yo building construction, To Fee v LDMA Perm. # < authorize repo sentatives of this:County to enter bo pr perty for inspectio pur oses. ►�• ►�. O< (y� #^�� co RMERSE f rE)Z�A TORY L�ttIGUAGE Signature o pp p t or Agent. Date , [o