Loading...
HomeMy Public PortalAbout10108 DAINES DR_Building__ DEPARTMENT OF BUILDING AND SAFETY. APPLICATION FOR PERMIT CQWTY OF-LO.RNGELES1 Vomt-J. FOX. CHIEF ENGINEER U ' L FOR APPLICANT TO FILL IN FOR OFFICE USE ONLY DISTRICT NO. I PLAN CK.NO. PERMIT NO. BUILDING 10108 E. Daines Drive ;'' 399 1 60 r/ LOCALITY Ten-.1e City RECEIVED BY DAT OF APPL. DATE ISSUED NEAREST N R. sand CRAB BT. J BUILDING P" OWNER Rex Flaharty � ADDRESS y MAIL ADDRESS 118 E. Huntington Dr. LOCALITY NEAREST � n TEL. CROSS ST. CITY Arc NO. Do 7-35 ' FIRE NO.OF TYPE GROUP / ._ ARCHITECT OR TEL. ZONE PLANS ENGINEER NO. BLDG. OR,Q NO. ADDRESS SETBACK LINE 7 f APPROVED S CONTRACTORT hn Douglas i el ..No. DO 7- 121 UDATE APPROVED ADDRESS ZONE , BY DATE LEGALCORRECTIONS DESCRIPTION I LOT NO. BLOCK TRACT See Other side NO.OF BLDOH. SIZE OF LOT 68 x 108 ( NOW ON LOT i"O'D s �. v �1I 0 USE OF NO.OFNO.DF EXISTING BLDG. I FAMILIES I ROOMS DESCRIPTION OF WORK NEWy ALTERATION ADDITION O REPAIR MOVING DEMOLISH+_ p Sq.FT. 1 NO.OF Z _ SIZE 1144 ROOMS 6 STORIES 1 � WALL ROOF OQ _COVERING Stucco I COVERING Shinle USE OF NEW �w BUILDING Residence and detached arae f t, �^t ' `�C` '�✓ R` Design No. 100 "" X T, ,� <�ej ► ' {" 1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS C��,e•, wJgpe' APPROVALS APPLICATION AND STATE THAT THE ABOVE IS CORRECT FOUNDATION., LOCATION INSPECTOR DATE AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES FORMS,MATERIALS AND STATE LAWB R GULATING BUILDING CONSTRUCTION. - - ,,,�+/////��, FRAME: FIRE STOPS, SIGNATURE O • -/� --KT"""' BRACING.BOLTS 7 PERMITTEE - LATH, INT. AUTHORIZED AOT LATH, EXT. 76A636A-3 2-60 $1 9 Z�jp,c_O P C $ Y PLASTER,INT. p tro i FEE ' PLASTER.EXT. VALUATION - lt, •arc FEE > FINAL 1-j "' -Y •l� " f L/ 76A 638A CE 0803 12/69 CITY OF a , APPLICATION FOR BUILDING PERMIT COUNTY OF LOS ANGELES ASSESSOR DEPARTMENT OF COUNTY ENGINEER MAP BOOK PAGE PARCEL BUILDING AND SAFETY DIVISION BUILDING JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS COLEMAN W. JENKINS, SUPT OF BUILDING LOCALITY FOR APPLICANT TO FILL IN NEAREST Print ort a onl CROSS ST, _>Q DISTRICT NO. GROUP TYPE CESSED BY ADD EBUILCISS � �� 8 .L CONST,1/ LOT NO. BLOCK STATISTICAL CLASSIFICATION SEWER MAP _ t CLASS NO.zI DWELL.UNITS— BK PG TRACT �. USE ZONEI MAP NO.OF BLDGS. NO. ' SIZE OF LOT NOW*ON LOT I SPECIAL USE OF l�• CONDITIONS EXISTING LDG. TEL. OWN �^ NO. BLDG.SETBACK FROM —PROtLADDRESS) �3D' T PROP,LINE OF (STREET) TYPE OF EX SETBACK HIGHWAY + YARD = TOTAL CITY HIGHWAY WIDTH M C.L. ARCHITECT CHR TEL. + _ ENGINEER NO. BLDG.SETBACK FROM ADDRESS SIDE PROP.LINE OF (STREET) v TEL. G TYPE OF EXISTING SETBACK HIGHWAY + ARD = TOTAL CONTRACTO O. �3�5L q�a HIGHWAY WIDTH FROM C.L. ADDRES 2, NOIc iS97/ + _ �- �j LIC. U CIT '�(/ 4 O Z L CLASS CORNER CUTOFF YES ❑ NO CONSTRUCTION LENDER CD NAME AND BRANCH SEE REVERSE SIDE FOR SPECIAL APPROVALS c_') W a ADDRESS � SQ. FT. NO. OF NO. OF ❑ Z NEW SIZE STORIES FAMILIES USE OF ADD ❑ STRUCTURE - lfLTER ❑ SIGNATURE OF EPAIR APPLICANT DEMOL ❑ VALUATION $ ®G O APPROVALS DATE IN5PECTOR'S SIGNATURE P.C. PMT, �{ O Q FOUNDATION: LOCATION FEE S FEE $ �+! _ FORMS, MATERIALS FRAME: FISTOPS, I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION BRACIRE NG BOLTS AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY FURNACE: LOCATION, WITH ALL ORDINANCES AND LAWS REGULATING BUILDING CON- GAS VENT, DUCTS STRUCTION. I CERTIFY THAT IN DOING THE WORK AUTHORIZED HEREBY I WILL NOT EMPLOY ANY PERSON IN VIOLATION OF THE LATH, INT. LABOR CODE OF THE STATE OF CALIFORNIA IN RELATING TO WORKMEN'S COMPE TION INSU NC/7 ATH, EXT. SIGNATURE O OUSE NUMBER COR- PERMITTEE RECT AND POSTED ADDRESS FINAL JOHN F. LEWIS. PRINCIPAL STRUCTURAL ENGINEER PLAN CHECK VALIDATION CK. M.O. CASH _ PERMIT VALIDATION CK. M.O. CASH o o 1-- JuN 2 2 1 D 1 2.00-7 7 V APPLICATION FOR BUILD�.NG PERMIT �=wCOUNTY OF LOS ANGELES ' BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION BUILDING ADDRESS FOR APPLICANT TO FILL IN,, r. 1 uILOfIUG DREss hereby affirm.that I have a certificate of consent to self insure, ./ Q or a certificate of Workers' Compensation Insurance,or a certified 4�J LAND copy thereof (Sec.3800,Lab.C.) CITYPLE CAT ZIP ^I--I sO LOCALITY Policy No. Company el SIZE OF LOT NO.OF BLDGS.NOW ON LOT ❑ Certified copy is hereby furnished. 52 'X )00' S MNEAREST CROSS S . ❑ Certified copy is.filed with the county building inspection TRACT BLOCK L T N0. department .3 USE ZONE MAP NO. Date Applicant ASSESSOR MAP PAGE2 PAR61E •V11 z SPECIAL CONDITIONS rJ / CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER �L, f TEL NO. r COMPENSATION INSURANCE S Intl i+Q-34PU WITHIN 1000 FT.OF SCHOOL? YES NO (This section need not be completed if the permit is for one hundred ADDRESS DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY dollars ($100)or less.) 5-go KrLAgp ZIP ) I certify that in the performance of the work for which this permit G I $O , CITYr is issued, I shall not employ any person in any manner so as to /1<7 –3 `� �t L,�"r✓ become subject to the Workers'Compensation Laws. ARCHITECT OR ENGINEER TEL NO, VA I L I g � $ STATISTICAL CLA IFIQATION APT CONDO Data Applicant ADDRESS G CLASS.— DWELL UNITS NOTICE TO APPLICANT.' If, after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST Exemption, you Should become Subject 'to the Workers' CONTRACTOR - TEL NO. -SET BACK YARD HWY 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 SIDE 0 CITY LIC.CLASS PL U 1 hereby affirm that I am licensed underprovisions Of Chapter 9 SEWER MAP (commencing with Section 7000)of Division 3 of the Business and S NO.OF STORIES NO.OF FAMILIES Professions Code,and my license is in full force and effect. NEW ❑ BK PG O License Number Lic.Class DESCRIPTION OF WORK ADD VALUATION , (� T EN LU $ Z Contractor bate ALTER ❑ V CL ❑ I am exempt under Sec. E n0 Ih s• REPAIR ❑ $ z BAP.C.for this reason DEMOL ❑ LDMA P/C# Date: USE OF EXISTING BLDG. URM ❑ 23 T Signature APPLI NT(PRINT) TEL NO.p LDMA Perm# ACC t ag ❑ I, as owner of the property, or my employees with wages as Q"0 IAW g 243` z <i c� their sole compensation, will do the work and the structure is ADDRESS Ho /+ G1 �� O 3303 `10.5 not intended or offered for sale (Section 7044, Business and �1 M�1 S l_LIQldodi 12* FINAL DATE ////,//�� a Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL �*7/ ACCT 8 OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE VV T g 1, as Owner of the property, am exclusively contracting with AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY 5: C ". licensed contractors to construct the project (Section 7044, YES 11 NO 0 303 654.47 Business and Professions Code.) WILL THE INTENDED USE OF THE BUIBY THE APPLICANT OR FUTURE BUILDING _ 2 ITEMS T t-M OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH R C[ +J CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FOR GUIDELINES. TOTAL I_17AL 704 - 9 vi 1 hereby affirm that there is a construction lending agency for YES 13 NO El1 n n the performance of the work for which this permit is issued(Sec. CHECK 704.97 I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING 3097,CIV.C.) CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE;. e, , (''�'} N TITLE 2,CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING HAZARDOUS C 1••t e CIO >r Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD. Lender's Address OWNER OR AGENT 1 certify that I have read this application and state under penalty (][;013-0001 3/27/96 p of perjury that the above information is correct.I agree to comply P.C.FEET... PERMIT FEE / �'f r�•-,. 1n with all county ordinances and State laws relating to building !� • J 6� /' / ��6 1 PM 6-' 1 M cons ruction, and hereby authorize representatives of this County ISSUANCE FEE �} to ter o tioned properly for inspection purposes. pC 3 oaJaAv— 32V INVESTIGATION FEE TOTAL FEE N nature of gpplicanl or Agent Date - SEE REVERSE FOR EXPLANATORY LANGUAGE APPLICATION FOR BUILDING PERMIT COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS / BUIL IN A�QRESS �.J I herebyaffirm that I have a certificate of. consent to self insure, `LJ�U �or a certificate of Workers' Compensation Insurance,or a certified �tLA-N � IIaa� /vim copy thereof (Sec.3800,Lab.C.) "Tel" I "IOLE- � �l� Z!i I�8 �,f-\ __ll ! (j LOCALITY Policy No. Company SIZEF�107 i �( NO,OF BLDG NOW O I mcf-C.� ❑ Certified copy is hereby furnished. "L )` 10 3 I :5; D "N try NEAREST CROSS ST. ❑ Certified copy is filed with the county building inspection TRACT BLOCK LOT Nq department. USE ZONE MAP NO. Date Applicant ASSESSOR A�t_AP_$OOK PAC PAR0 SPECIAL CONDITIONS �f (u1 5 CCJ (J CERTIFICATE OF EXEMPTION FROM WORKERS' NER' L O.•_ COMPENSATION INSURANCE D�-1 D UL �ttb!`lY5Sf �i8 `FS3-3 G4 3 WITHIN 1000 FT.OF SCHOOL? VES No (This section need not be completed if the permit is for one hundred s �(/�L� `� / /u DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY dollars($100)or less.) J I� 1v Vc-/`r / . I certify that in the performance of the work for which this permit (t� ZIPS 1780 780 T/ is issued, I shall not employ any person in any manner so as to ARCHITECT OR•ENGINEER J'\ TEL become subject to the Workers'Compensation Laws. ��8t 6 .�A l ( n -Q $18 �}:3 STATISTICAL CLASSIFICATION APT CONDO Date Applicant ADDRESS/-��/ 'v �.r� CLASS NO. DWELL UNITS 13 NOTICE TO APPLICANT If, after making this Certificate of REQUIRED TOTAL SETERA�,V FROM EXIST Exemption, you should become' subject to the Workers' CONTRACTOR,...gip TEL NO, SET BACK YARD HWY PROP �LIF) •I `'l WIDTH Compensation provisions of the Labor Code, you must forthwith LdNc� FRONT 66IJ15 iiz comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC.NO, P L i _ ``} LICENSED CONTRACTORS DECLARATION CITY LIC.CLASS PL T?•s SIDE A=• - 0 {� I hereby affirm that,I am licensed underprovisions Of Chapter 9 SEWER MAP - --` a''-t� (commencing with Section 7000)of Division 3 of the Business and SQ.FT.SIZE NO.OF STORIES NO.OF FAMILIES CHECK !12 f.+40 D- Professions Code,and my license is in full force and effect. �}- 1` NEW El BK PG L€ t_ License Number Lic.Class DESCRIPTION OF WORK ADD VALUATION , CHANGE I i� BED�o�r� S1 a rJ $ ,� , Contractor Date 60 ALTER ❑ ❑ I am exempt under Sec. M EXIA - i)IJ REPAIR ❑ $ 00-0-0001 5j.may f�` BAP.C.for this reason OF j r DEMOL ❑ $651 PM5:10 LOMA P/C# Date: USE OF EXISTING BLDG. URM El Signature LICANT(PRINT) --••���,'' EL NO. LDMA Perm# .'t. ❑ I, as owner of the property, or my employees with wages as I-e5LI e r t61-( E'EN ��6 Z r a.` '•r their sole compensation, will do the work and the structure is ADDRESS- 0 3-303 448.91 not intended or offered for sale (Section 7044, Business and L� L /fib � & l 9I TBC FINAL DATE Q Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZAR OUS MATERIAL , C 1 IT E S OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE ��** �r I, as owner Of the property, am exclusively contracting 44, AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY 0 T�t IAL •=•g-•�p 7 c 9 1 • icensed contractors to construct the project !Section 7044, YES❑ No❑ Business and Professions Code.) CHECK 4 .91 WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH t CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT ISCAOMDI SEE PERMITTING CHECKLIST FOR CHANGE .00 GUIDELINES. I hereby affirm that there is a construction lending agency for YES❑ NO Elthe performance Of the work for which this permit Is Issued(Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING 'l±e��y-''t'� � !{ /='� 3097,Civ.C.) CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, 01 3 (.+l j i��1 18 :tf 6 TITLE 2,CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING HAZARDOUS j q —0 Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD. 6.971 f YAM Fr u Al•9 m Lender's Address OWNER OR AGENT I certify that I have read this application and state under penalty P.C.FEE ^ f�./_ PERMIT FEE p of perjury that the above information is correct.I agree to comply - rn with all county ordinances and State laws relating to building M construgfpn, and hereby authorize representatives of this County ISSUANCE FEE ^ I en r po the m ed property for inspection purposes. 11 o `�,y2 INVESTIGATION FEE TOTAL FEE N turbof gpplicanl or Agen Oate SEE REVERSE FOR EXPLANATORY LANGUAGE APPLICATION FOR BUILDING PERMIT � w s°s• .nom' COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS I hereby affirm that I have a certificate of consent to self insure, BUILDING ADDRESS or a certificate of Workers' Compensation Insurance,or a certified copy thereof(Sec.3800,Lab. C.) CITY ZIP LOCALITY Policy No. Company SIZE OF LCT NO.OF BLDGS.NOW ON LOT ❑ Certified copy is hereby furnished. I INEAREST CROSS ST BLOCK LOT NO. El Certified copy is filed with the county building inspection TRACT department. USE ZONE MAP NO. Date Applicant ASSESSOR MAP BOOK PAGE PARCEL SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER TEL NO COMPENSATION INSURANCE WITHIN 1000 FT.OF SCHOOL?(This No (This section need not be completed if the permit is for one hundred ADDRESS DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY dollars($100)or less.) CITY ZIP I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to ARCHITECT OR ENGINEER TEL NO become subject to the Workers' Compensation Laws. STATISTICAL CLASSIFICATION APT CONDO Date Applicant ADDRESS CLASS NO. DWELL UNITS NOTICE TO APPLICANT: If, after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST Exemption, you should become subject t0 the Workers' CONTRACTOR TEL NO. SET BACK YARD HWY PROP LINE WIDTH } Compensation provisions of the Labor Code, you must forthwith FRONT OL comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC NO P L O SIDE U LICENSED CONTRACTORS DECLARATION CITY LIC CLASS P L J I hereby affirm that I am licensed underprovisions of Chapter 9 ? (commencing with Section 7000)of Division 3 of the Business and SQ.FT.SIZE NO.OF STORS NO.OF FAMILIES SEWER MAP IE Professions Code,and my license is in full force and effect. I i NEW ❑ BK PG >- License Number Lic. Class DESCRIPTION OF WORK ADD ❑ VALUATION t� < Contractor Date ALTER ❑ $ O I ❑ 1 am exempt under Sec. REPAIR ❑ $ 2 LU BAP.C. for this reason DEMOL ❑ LDMA P/C# (— Date. USE OF EXISTING BLDG. URM ❑ Signature APPLICANT(PRINT) TEL NO. LDMA Perm# ❑ I, as owner of the property, or my employees with wages as Z their sole compensation, will do the work and the structure is ADDRESS 0 not intended or offered for sale (Section 7044, Business and FINAL DATE Q Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL O OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE J ❑ 1, as owner of the property, am exclusively contracting with AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY 5 licensed contractors to construct the project !Section 7044, YES❑ NO❑ Business and Professions Code.) WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FOR GUIDELINES. I hereby affirm that there is a construction lending agency for YES❑ NO❑ the performance Of the work for which this permit IS issued(Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING 3097,Civ.C.) CHECKLIST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, TITLE 2.CHAPTER 2.20 SECTIONS 2.20 100 THROUGH 2.20 140 CONCERNING HAZARDOUS m Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD. � I Lender's Address OWNER OR AGENT 3 I certify that I have read this application and state under penalty 0 of perjury that the above information is correct. I agree to comply PC FEE PERMIT FEE m with all county ordinances and State laws relating to building m construction, and hereby authorize representatives of this County ISSUANCE FEE to enter upon the above-mentioned property for inspection purposes. 0 INVESTIGATION FEE TOTAL FEE N 1g-­of Apphl.nt o,Agent oa SEE REVERSE FOR EXPLANATORY LANGUAGE WORKERS' COMPENSATION DECLARATION hereby affirm that I have certificate of consent to self APPLICATION FOR BUILDING PERMIT . insure, or a certificate of Workers' Compensation Insurance, or a certified copy thereof (Sec. 38 Lab. C.) R�9k-2-Company COUNTY OF LOS ANGELES BUILDING AND AFETY PolityNo. f�Y« �c"♦l�i� V�1' rtified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDINGADDRESSrtified copy is filed with the county building inspec- BUILDING 'on department. ADDRESS Date%(_—!!,—M! 1` 04pplican If2 E CITY ZIP LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' F BLDGS. NEAREST 1 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 TE MAP I certify that in the performance of the work for which this OWNE E NO. permit is issued, I shall not employ any person in any manner �I SPECIAL ADDRESS ' so as to become subject to the Workers'Compensation Laws. CONDITIONS O Date Applicant CIT ZIP NOTICE TO APPLICANT: If, after making.this Certificateof ARCHITECT OR TEL. DISTRICT G OUP TYPE FIRE PROCESSED BY O Exemption, you should become subject to the Workers' ENGINEER NO. A _7 CONST. ZONE /� U Compensation provisions of the Labor Code, you must forth- ADDRESS with comply with such provisions or this permit shall be f.L deemed revoked. TEL STATISTICAL CLASSIFI ATION APT. ONDO. U)CONTRACTOR NU `, Z LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. DWELL. UNITS — I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS (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 .► C/t' VALIDATION 7 cw--� SQ. FT. NO. OF CHECK BK. PG. f License Number �SN��Lic.Class SIZE STORIES FAMILIES ONE VALUATION Contractor Contractor Date 0'��tr i DESCRIPTION OF WORK 1 NEW $ '0, �- ADD ❑ ❑ I am exempt under Sec. ❑ ALTER B.BP.C. for this reasonREPAIR ❑ $ a USE OF EXISTING BL G. DEMOL ❑ Signature MW APPLICAN TEL. FINAL O NER-BUILDER DECLARATIO PRINT t NO. DATE I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and ADDRESS Professions Code): PRESENT B 98210 A ❑ BUILDING I, as owner of the property, or my employees with ADDRESS # 0 0 o e o wages as their sole compensation,will do the work and , o e 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. 0 0 0 7 a-0.0 with licensed contractors to construct the project (Sec- ADDRESS (130-87 tion 7044, Business and Professions Code). REQUIRED TOTAL SETBACK FROM CONSTRUCTION LENDING AGENCY SET BACK YARD HWY 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. (Sec. 3097, Civ. C.). SIDE P.L. Lender's Name LDMA Ref. # Lender's Address P.C. Fee$ Permit Fee ((JJ 3 /1 '_ i? I certify that I have read this application and state that the Issuance Fee V"� © LDMA P/C# o above information is correct. I agree to comply with all County Investigation Fee �( 0 ordinances and State laws relating to building construction, Toral Fee _ U �� LDMA Perm. # R and hereby authorize representatives of this County to enter n the ab -ment' roperty for inspection purposes. �®_71C) 8� SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or gent Date APPLICATION FOR BUILDING PERMIT s• .TM�3 COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS I hereby affirm that I have a certificate of consent to self insure, BUILDING ADDRESS or a certificate of Workers' Compensation Insurance, or a certified copy thereof (Sec. 3800,Lab.C.) CITY ZIP LOCALITY Policy No. Company SIZE OF LCT NO OF BLDGS.NOW ON LOT ❑ Certified copy is hereby furnished. NEAREST CROSS ST El Certified copy is filed with the county building inspection TRACT BLOCK LOT NO. department. USE ZONE MAP NO. Date Applicant ASSESSOR MAP BOOK PAGE PARCEL SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER TEL NO. COMPENSATION INSURANCE WITHIN 1000 FT OF SCHOOL? YES No (This section need not be completed if the permit is for one hundred ADDRESS DISTRICT GROUP TYPE CONST FIRE ZONE PROCESSED BY dollars ($100)or less.) CITY ZIP I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to ARCHITECT OR ENGINEER TEL NO become subject to the Workers'Compensation Laws, STATISTICAL CLASSIFICATION A 7 CONDO Date Applicant ADDRESS CLASS NO. DWELL UNITS NOTICE TO APPLICANT If, after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST Exemption, you should become subject to the Workers' CONTRACTOR TEL NO. SET BACK YARD HWY PROP LINE WIDTH >_Compensation provisions of the Labor Code, you must forthwith FRONT CL complywith such provisions or this permit shall be deemed revoked. ADDRESS LIC NO P L SIDE U LICENSED CONTRACTORS DECLARATION CITY LIC CLASS P L J I hereby affirm that I am licensed underprovisions of Chapter 9 SEWER MAP (commencing with Section 7000)of Division 3 of the Business and SQ.FT.SIZE NO,OF STORIES NO.OF FAMILIES Lt' Professions Code,and my license is in full force and effect. NEW ❑ BK PG , License Number Lic.Class DESCRIPTION OF WORK ADD ❑ VALUATION Q Contractor Date 0 ALTER ❑ $ O CL ❑ I am exempt under Sec. REPAIR ❑ $ :2 W BAP.C. for this reason DEMOL ❑ LDMA P/C# ~ Date: USE OF EXISTING BLDG. URM ❑ Signature APPLICANT(PRINT) TEL NO. LDMA Perm# El 1, as owner of the property, or my employees with wages as Z their sole compensation, will do the work and the structure is ADDRESS O not intended or offered for sale (Section 7044, Business and FINAL DATE Q Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL J OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE ❑ I, as owner of the property, am exclusively c contracting 44,ith AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY 5 licensed contractors to construct the project !Section 7044, YES El No 1:1Business and Professions Code.) WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR GUIDELINES I hereby affirm that there is a construction lending agency for YES❑ No❑ the Of the WOfk for which this permit IS ISSUed(Seo, I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING 30977,,Civ. IV..C.)C.) CHECKLIST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, TITLE 2.CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20 140 CONCERNING HAZARDOUS rn Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD m Lender's Address OWNER OR AGENT 3 I certify that I have read this application and state underpenalty 0 of perjury that the above information is correct. I agree to comply P.C.FEE PERMIT FEE Uw with all county ordinances and State laws relating to building m construction, and hereby authorize representatives of this County ISSUANCE FEE 0 to enter upon the above-mentioned property for inspection purposes. O INVESTIGATION FEE TOTAL FEE 0 N �ignalure of ApVlicanl or Agent Dale SEE REVERSE FOR EXPLANATORY LANGUAGE J