HomeMy Public PortalAbout10611 DAINES DR_Building__ A'PPLIGATI 9051� ' / C OFLOSANGELES
OF
EPA-'BU'ILDING PERMIT DBUIR NGAND SAFTYDIVSIONR
FOR APPLICANT TO FILL IN - ADILDING
DRESS
BUILDING T
ADDRESS QoX , LOCALITY
`/ NEAREST
CITY - l /� ZIP 4ep CROSS ST.
NO.OF BLDGS. ASSESSOR \
SIZE OF LOT (.f j NOW ON LOT MAP BOOK _ PAGE PARCEL
DISTRICT I GROUPTYPE FIRE PR 'E EDBY-
TRACT .BLOCK LOT NO.
0('J CONST% Z�IFj— �y7i
TEL VX !__-
OWNER �II, G 4 NO.µlf• - O STATISTICAL CLASSIFICATION - SEWER
ER MAP MAP
ADDRESS Q I �) CLASS NO. '`-� / DWELL.UNITS G BK/2G,
CITY ZIP U USE ZONE MAP
ARCHITECT OR - I / t` SPECIAL -
ENGINEER NO. /�. jNO-
CONDITIONS
ADDRESS ROAD DEPARTMENT,APPROVAL REQUIRED YES ❑" NO❑
TEL. BLDG.SETBACK FROM
\
CONTRALTO GD T NO. (f'Q—
LIC FRONT PROP.LINE OF [STREET I,
ADDRESS 0 NO. O _ TOTALSETBACKFROM TYPE OF EXISTING
LIC, (l !t HIGHWAY + YARD - FRONT PROP.LINE HIGHWAY ,WIDTH
CITY • e, TY CLASS - _
CONSTRUCTION LENDER + O
NAME AND BRANCH BLDG.SETBACK FROM U
ADDRESS CITY SIDE PROP.LINE OF [STREET)
SO.FT, A• NO.OF NO.OF CHECK HIGHWAY + YARD TOTAL SETBACK FROM TYPE OF EXISTING w
SIZE V �. STORIES FAMILIES ONE SIDE PROP.LINE HIGHWAY WIDTH N
❑ + = Z_
DESCRIPTION OF WORK NEW
JO ADD CORNER CUTOFF YES ❑ NO ❑
U INOPENSPACE YES ❑ NO ❑
El IR 0
USEOF /'" DEMOL ❑ IN COASTAL PERMIT ZONE YES E] NO 'LlEXISTING BLDG. E
APPLICANT TEL
(PRINT) NO. '•/��/� Si af��� - hG
BY(SIGNATURE) `
HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND NCE
G 2 l
THAT THE ABOVE IS CORRECT AND AGREE i0 COMPLY WITH ALL ORDINANCES
AND LAWS REGULATING BUILDING CONSTRUCTION.I CERTIFYIN DOING THE
WORK AUTHORIZED HEREBY IN WILL NOT EMPLOY ANY PERSON IN VIOLATION OF / )-
'THE LABOR CODE OF THE STATE OF CALIFORNIA IN RELATING i0 WORKMEN'S COM.
PENSATION INSURANCE.
SIGNATURE OF .�� FINAL �/�. -.7 / BY
PERMITTEE _ DATE
ADDRESS / (A'
TEL. -j�rf� P.C.Fee$ Permit Fee C v
CITY NO.
Issuance Fee 7
VALUATION ! 3�] V
UUU Total Fee
PLAN CHECK VALIDATION Ck M.O, CASH _ PERMIT VALIDATION M.o. CASH
3 5 JUL 5 1 D 1 8 7.0 0 eJ
N
®1 76A63BA CE R803A 8/J7 - C
WORKERS' COMPENSATION DECLARATION
hereby affirm that 1 have a certificate of consent to self O O �EI��II�� gyp} I��y O �rI��I��`//`,,yy�r D I�}�RD ��fTryp❑��
insure, or a certificate of Workers: Compensation Insurance, ���������OII V .Il O:U�I ������U V V PLti 1111167 U��
or a certified copy' thereof (Sec. 3800 Lab C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. �Company l� 'n) �T'�... BUILDING.
❑� Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS
Certified copy is filed with the county.building in ec BUILDING i
ti n de artment. ADDRESS
DateApplicant kus, CIN ! ZIP LOCALITY
C R71FI ATE OF EXEMPTIO ROM WORKERS' SIZE OF LOT NO. OF BUDGE. NEAREST NOW ON LOT CROSS ST. 47 I
COMPENSATION I RANCE ASSESSOR
(This section need not be completed if the permit is for one TRACE' BLOCK LOT NO. MAP BOOK PAGE PARCEL
hundred dollars ($100) or less.) TE
OWNER CAL USE ZONE MAP
I certify that in the performance of the work for which this - - NO.
S �i SPECIAL } '
permit is issued, subjecshall t
of employ kany ers'Compensation
in any manner ADDRESS - CONDITIONS d
so as to become subject to the Workers'Compensation Laws. - O
- CITY ' - ZIP - ' U
Date—Applicant ARCHITECT OR TEL
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO DISTRICT .GROUP TYPE FIRE PROCESSED BY
CONST. ZONE 0
Exemption, :you should .become subject to the.Workers' �' Q' U
Compensation provisions of the Labor Code, you must forth- ADDRESS a
r N
with comply with such.provisions or this permit shall be TEL STATISTICAL CLASSIFICATION APT. CONDO. Z
deemed revoked _ CONTRACTOR .i _.
LICENSED.CONTRACTORS DECLARATION I CUSS NO.<+" 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. f .'
and Professions Code,and my license is in full fort and effect. CITY' - CLASS BK L PG /O�d VALIDATION
50. FT. NO. Of NO. OF CHECK
License Number _Lic. Class ,�'/� ••�q" SIZE STORIES FAMILIES ONE
Contract L/ 1t5{JJ �nn� L&e� }A{., — - VALUATION ,.
;1} °v{- DESCRIPTION OF WORK NEW ❑ s
Elam exempt under.Sec. - ADD 111 D
_ - _ _ ALTER El -
B.BP.C.-for this reason REPAIR $
" USE OF
-Date: EXISTING BLDG. DEMOL ❑
Signature APPLICANT TEL. FINAL
OWNER-BUILDER DECLARATION. (PRINT)_ N . - DATE ' _
I hereby affirm that I am exempt from the Contractor's License
Low for the following reason (Section 7031.5, Business'and ADDRESS 1i 1 FINA }
Professions Code): PRESENT _ - By,;
❑ I, as owner of the property, or my employees with BU ILIDING
ADDRESS G ti
wagesas their sole compensation,will do theworkand
the structure isnot intended or offered for sale(Section LOCALITY
7044, Business and Professions Code.) - -
MOVING TEL.
❑ 1, as owner of the property, am exclusively contracting CONTRACTOR NO. -_
with licensed contractors:to construct theproject (Seo- ADDRESS _- - - fi=_ .LY _ 6 F
tion 7044, Business and Professions Code.) _ tl _
REQUIREDTOTAL SETBACK FROM EXIST.,; = _•.� "
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY pROP. LINE WIDTH --
I hereby affirm that there is a construction lending agency for FRONT - {�ryi?'}t i,_
the performance of the work for which this permit is issued P.L. - - -
(Sec. 3097, Civ. C.). SIDE
Lender's Name.
m 2 LDMA Ref. IT ;j' µ).t•..
- P.C. Fee$7 Permit Fee
3 Lender's Address J
.I certify that I have read this application and state that the Issuance Fee '�7 7S— LDMA P/C# - D '
8 above information is correct. I agree to comply with all County Investigation Fee' G
ordinances and State laws relating to building construction, - Total Fee �G LDMA Perm. If
a andhere y authorize representotiv s of this County to enter -
upon t e b ntioned pgoper for inspection.purp ses - - -
a
.SEE REVERSE FOR EXPLANATORY LANGUAGE
^ Si nature of Appl im nt or gent Dat