HomeMy Public PortalAbout10214 DAINES DR_Building__ APPLICATION FOR;BUILDING PERMIT
FOR AP_PLICANT TO FILL IN (Print or type only)
BUILDING COUNTY OF LOS ANGELES
ADDRESS DEPARTMENT OF COUNTY ENGINEER ,
CITY Z, BUILDING AND SAFETY DIVISION
Nf'�O OF BLDGJBUILDING �/�d� / /--
SIZE OF.LOT CNOW ON LODDRESS PA /' �: i
TRACT BLOCK LOT NO - OCALITYEARESTOWNER ROSSSTe,SSESSOR
ADDRESS AP BOOK PAGE- - PARCELDISTRICT GROUP TYPE FIRE PROCEED BY
CITY . CONSTZONEARCHITECT OR TEL
ENGINEER NO -
STATISTICAL CLASSIFICATION SEWER MAP
ADDRESS CLASS_NO -DWELL UNITS BK ,PG
CONTRACTOR TEL USE ZONE MA7 g
� L OP IC - -_
NO
L
ADDRESS NO y� SPECIAL
_ LIC (.+' CONDITIONS
CITY CLASS
ROAD DEPARTMENT APPROVAL REQUIRED YES❑ - NO ❑
CONSTRUCTION LENDER n}.
NAME AND BRANCH BLDG SETBACK FROM - - CL
FRONT PROP LINE OF (STREET) C7
ADDRESS CITY TOTAL SETBACK FROM TYPE OF EXISTING
}
SFT OF NO, OF CHECK HIGHWAY YARD FRONT PROP LINE HIGHWAY WIDTH
SIZE SSTTORIES FAMILIES ONE cJ �;
NEW ❑ + ./� �~ O/ ��0, CA
DESCRIPTION OF WORK, i- BLDG.SETBACK FROM
Z
ADD SIDEPROP LINEOF (STREET)
ALTER TOTAL SETBACK FROM TYPE OF EXISTING
/ HIGHWAY } YARD = SIDE PROP LINE
HIGHWAY WIDTH
✓C/
( REPAIR❑
USE OF } _
EXISTING BLDG DE AOL ❑
APPLICANT TEL CORNER CUT YES ❑� NO
(PRINT) NO
BY (SIGNATURE) 'IN OPEN SPACE Y NO
Q, - IN COASTAL IZONE YES ❑ NO El
VALUATION$ CATEGORICAL EXEMPTION YES NO ❑
I HEREBY ACKNOWLEDGE THAT IHAVE READ THIS APPLICATION ENVIRONMENTAL
AND STATE THAT THE ABOVE IS,CORRECT AND AGREE TO COMPLY ,IMPACT EXEMPTION DECLARATION SIGNED (DATE)
WITH ALL ORDINANCES AND LAWS REGULATING BUILDING CON-
STRUCTION' I CERTIFY THAT IN DOING THE WORK AUTHORIZED IMPACT REPORT PROCESSED (DATE)
HEREBY I WI>NOT,EMPLOY AHY PERSON IN VIOLATION OF THE
LABOR CODETATE OF CALIFORNIA IN RELATING TO WORKMEN'S CON INSURANCE �/'� S n DY/' /Q"L� ��SIGNATURE
PERMITTEE
1
ADDRESS Id' s -
FINAL r BY
TEL DATE
CITY NO
MAKE_ -Cf/ELKS PAYABLE TO - PEE // PEE $ D
HARVEY T. BRANDY. COUNTY ENGINEER
r
PLAN CHECK VALIDATION CK M O `CASH PERMIT-VALIDATION CK M O CASH ,
5 r -� 1
8 1 0 9.004
76A638A CE4803 7/73 ,
�• 4 4ORKERS' COMPENSATIOWDECLARATION
~` bbthat
certificate
consent nself
APPLICATION F O R,';B U I L D I NG, PERMIT
nsureoa certificate of WorkersCompensahon sun e
or,a certified'copy thereof (Sec '3800, Lab C )
'COUNTY OF LOS ANGELES K<• BUILDING-AND SAFETY
Policy No lO 46 d7 7 Company_�9 T,-- -
0Certified copy is hereby furnished. FOR APPLICANT TO FILL'IN ADDRESS 1 l7 /1
' Certified copy is filed with the county building'ms ec- ADDRESS BUILDING.1*1. + r
' tion department. p,
CIN - ZIP � : 1 p C LOCALITY
Date 'Y Applicant lo CITY
, ( NO OF BLDGS NEAREST •
CERTIF TE OF EXEMPTIO OM'WORKER SIZE OF LOT + �; NOW'ON LOT CROSS ST,
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed'-if tFie permit is for one - TRACT 8 ?L- BLOCK`` LOT'NO' - MAP BOOK PAGE PARCEL
hundred dollars ($100) or'less ) EL 1Q
OWNER• M l7A 'b!D USE ZONE MAP a 3
NO /,Y7 �"!
I certify That in the performance of the 'work for which this c_�1 r SPECIAL r- >-
•permiT•is issued,`I shall,not employ.any person'm any manner •ADDRESS. Q-7 3 OUT VJ 5:LV r CONDITIONS - ' CL
O
so as to become subject to the Workers' Compensation'Ldws
b. CITY. CI IP 41[7
S - U
Date Applicant. ARCHITECT OR ITEL// DISTRICT R_�
OUP, TYPE FIRE CESSED'BY
NOTICE TO,APPLICANT 'if;•after,making this Certificate of ENGINEER N01�� 4?
O CONST ZONE
Exemption, you" should become ,subject, to the- Workers' - ``/ �� W
Compensation provisions of the,Labor Code,'you must forth- ADDRESS 4 V-" i—�' n.
` with comply with such provisions or,this permit shall be TEL - STATISTICAL CLASSIFICATION ^ APT CONDO a7
deemed revoked. _ CONTRACTOR NO it Z,
LICENSED CONTRACTORS DECLARATION LIC CLASS NO DWELL UNITS - --.:- 1>
' I hereby affirm,that I am licehsed under provisions of Chapter 9 _ ADDRESS NO
LIC SEWER MAP i Vit'-$ t
(commencing with Section,7000)-of Division 3 of the Business • � _ -,)�.(.IL:
ond•Professions Code,and my license ism full force and effect CITY CLASS BK t / VALIDATION
GG SQ FT/ NO OF ' , NO OF CHECK (
License Number'th!"3�l' - Lic Class � SIZE Q STORIES FAMILIES ONE
Yy1�.�`' y``,��J� j _. VALUATION Ttljr`i. 357. 00
Contractor AJZr`0.I �0+1w1 Gr3efMi afe I DESCRIPTION OF WORK NEW ❑ /�/-7✓ O41 y
❑` _ 41 _ ADD s / v .��` ''f• �F {IP_I
I am exernpT under Sec l� 017A T 14
ALTER ❑ , ='�` ih - - }_!I`
B&P C for this reason Edf I
Date USE OF :
EXISTING BLDG IDFMOL ❑ -
Signature - ,,/ _ _ `
APPLICANT TEL( - FINA
g OWNER-BUILDER DECLARATION (PRINT). -TE �2 '�F!"D DATE l`�/ I � _ AM '•(
1 hereby affirm that I am exempt from the Contractor's License ! D V• , /,_ ! ���`
Law for the following reason (Section 7031 5, Businessland ADDRESS 7 ✓Cvim • 7
Professions Code) = PRESENT {'
BUILDING
❑ I, as owner of the property„or my employees with ADDRESSri
'"'�`�
wages as their sole compensation,will do,the work and` Lw, 77_7
` _
the structure is not intended or offered for sale(Section LOCALITY4A,11780 ; t -r jIJ. i.
7044, Business and Professions Code ) - - , MOVING TEL
CONTRACTOR. NO
- ❑ I, as owner of the property, am exclusively contracting _• '
with licensed contractors to construct the project'(Sec- ADDRESS' F3Lz m
ADDRESS-
tion 7044, Business and Professions Code') ""HD
REQUIRED,- TOTAL SETBACK-FROM EXIST Y' rfG`_.JFv.., `r (FaII
CONSTRUCTION LENDING AGENCY. SET BACK YARD` HWY PROP LINE WIDTH
=•1 1
I hereby affirm that there is a construction lending agency for FRONT ' 0 �ij e IJ(1
the performance-of the work for which this permit is issued 'P L
(Sec 3097, Civ C ) SIDE
PL
Lender's Name Lit i[:t_i- 4•"li{_ j _1 :1_
LDMA Ref• #
P C Fee$ i Perm, Fee si:� t
Lender's Address * � t � t , •` '- L r�)! 7-*'t'-r
I certify'that [.have read this application and'state That the Issuance Fee y G �� LDMA P/G
8 above information is correct I agree'to comply with ail County Investigation Fee
ordinances and State laws'rel n to building construction, Total Fee 0�Jv LDMA',Perm # „
a and hereby authorize repress a ves of this County to enter
upon thea ove- ntioned o rty for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
•u re of Applicant or Agent. Date -