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76A838A CEPS03 B-83 APPLICATION FOR BUILDING PERM. T
COUNTY OF LOS ANGELES BUILDING .
DEPARTMENT OF COUNTY ENGINEER ADDRESS
BUILDING AND SAFETY DIVISION LOCALITY
JOHN A. LAMBIE, COUNTY ENGINEER NEAREST
WILLIAM A. JENSEN, SUET OF BUILDING CROSS ST
DISRCT N Gr' P TYPE CESSED B
FOR APPLICANT TO FILL IN �. CONST. L T
BUILDING- - . STATISTICAL CLASSIFICATION _ EWER_M_AP
ADDRESS / /' BK P
.(/71 CL ASS. NO.-ALI—DWELL. UNITS '✓
LOT NO. " OCK WATER El
NOT REQUIRED RECEIVED 11CERTIFICATE:
TRACT MAP .9 HIGHWAY
/7 NO. OF BI-DGS. NO. -C, IGIRCLEI STATE MAJOR SECOND LO L
SIZE OF LOT ' / ved NOW ON LOT USE ZON SPECIAL
USEOF CONDITIONS
EXISTING BLDG.
TEL r
OWNER , Ly,fl Al //�///�®FNB. BU DING EXIST.
` �+ •' I 5 TRACK YARD HWY REST NAME WIDTH
ADDRESS QI7 FRONT �� -
ARCHITECT OR - _ TEL P. L '�rX C,(,.,
ENGINEER NO. SIDE
ADDRESS - TEL. "�^ " � O
CONTRACTOR NO.'• - •'- J (( y + U
ADDRESS
DESCRIPTION OF WORK t 0 0
fAAl-,cr--DSL.., a
NEW ADD ALTER REPAIR, DEMOLISH ,per ''yeep4�. N
O. FT. NO. OF NO. OF �L'1�1wA��l •� 'Y1 lf'Mt4'"'.
SIZE STORIES FAMILIES
USE OF .�. a Q
STRUCTURE j -
A77" hl ,
T �• ,r1 �(l 1
SIGNATURE OF•
APPLICANT G•� '
VALUATION $ + _
APPROVALS DATE LINSPECTOR'$SIGNATURE
P.C. :7 PMT. FOUNDATION: LOCATION
FEE $_ (f FEE $ �� FORMS. MATERIALS _Vi
FRAME: FIRE STOPS. pea
I HEREBY ACKNOWLEDGE THAT'I HAVE READ THIS APPLICATON BRACING, BOLTSANDSTATE THAT THE ABOVE'IS CORRECT AND AGREE TO COMPLY FURNACE: LOCATION.WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING GAS VENT. DUCTS
BUILDING CONSTRUCTION. 1CERTIFY THAT IN DOING THE WORKAUTHORIZED HEREBY 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 C MPENSATION INSURANCE. /�� ]-�p LATH. EXT, i'/ J SIGNATURE OF //� - '�-7 / HOUSE NUMBER COR-
SIGNATTEE ///+((��_� L_-CLL REST AND NUMBER CO ADDRESS FINAL '� LIM
yE-gy+�ar: .
JOHN F. LEWIS. P INCIPAL SyRHC(�TUR L ENGINEER
t/PLAN CHECK VALIDATION cK. M.D. CASH PERMIT VALIDATIO GIF CASH
�b- 7200 DEC 31z3 •o _ 30.25A
7 3 3 -7 kO JAR! 7 1 D'. . 6 0.50-/
WORKERS' COMPENSATION DECLARATION „ r /� {{77�� ,gp p gyp p, p yew @@��I,� �L p�
, hereby affirm that haver certificate of consent to self /p* par_P L I{r ./Cp y �®N .FOR B �Fl -®I N g ar qtr E R/Itl�OB B _-
in ure or a'certibcote.of Workers' Compensation once '• �" (rN11 LS �178""U u u V [6 �'84r II PS Y®N ,
o�`ry,�/� �6/ ec 3 , Lo //� ,COUNTY OF LOS ANGELES" ' ° "BUILDING AN '•SAFETY ^' '
'PLCydd�C/ / �6mC�J
❑ Certified copy Ts her by furnished. FOR APPLI NT TO FILL IN ADDRESS �L /L^• . "
Ifwith th cou buildins c "'' RAUDDRESS�
G. -- - - i" -
tion de rtment. S -
❑ Certified co is , r - _
P 0�
Date - ZIP LOCALITY
_ O. OF BLDGS.r NEAREST
CERTIFICATE OF EXEMPTION:FROM WORKERS'_'; LOT NOW ON LOT - h. CROSS ST.
COMPENSATION INSURANCE - - • _
ASSESSOR - _ -
(This section'need not be completed if the permit is for one - ' .• BLOCK LOT NO' MAP BOOK •-PAGE - PARCELhundred.dollars ($100) orless ). - L, '/- . 76 Y77 USE ZONE x. MAPNO.
;;I certifythat-in the performance of the work for whichthis f _ SPECIAL permtl is issued, I shall�nofemploy any person in anyimanner - S' �' 0-' - CONDITIONS --so,asto,become subject to 1he.Workers'-CompensotionLaws: _ 0_N f: ZIP b - r' =a .a,:Date• Applicant CT-OR TEL. .. DISTRICT ' GROUP TYPE - FIRE PROCESSED BY-- Q
NOTICE-TO APPLICANT df, after.makin this Certificate of - ER - - -- NO. - U
9 CONST. ZONE
._Exemption,- you should becdme"subject to the,:Workers
"Compensation piovisionsiof the Labor Code, you',must forth -- ` ADDRESS.',....
.'with„comply.with such,.provisions ort_this permit shall,be'. •= ' / •TEL. Y STATISTICAL.CLASSIFICATION - APT. . CONDO. Z
deemed,revaked i CONTRACTOR ANO. —
` LICENSED CONTRACTORS DECLARATION �' LIC. /, CLASS NO. a I DWELL UNITS-
- hereby affirm that lam licensed under provisions of Chapter 9. i ADDRESS NO. - 1
•jcom mencing///���+++II Se ion-7 )of Division 3 oY he Busiyyy���;s i LIC.
SEWER MAP'
,bond ProfessioAs¢ �¢� ICense Is jn fuR fo a r _.•',� ' CITY' - CL455 BK.L•pG- � _ VALIDATION
CE1 C� t SO FT NO. OF NO. OF CHECK - -
License Numb L Cla SIZE ST RIES - FAMILIES ONE'
e .L - -- - a - -VALUATION '
Coniracta(�AJvt///l�t/ Date DESCRIPTION OF NEW ❑' S �j/LO Q�
.: 'am exempt,under Sec. ' .ALTER_❑
B 8P C 'for this reason': - (
�.'. ., REPAIR ❑ $
. '
..Date: i < USE.OF ':= _,,_ .._ ... un _
i"S O f
•. , _ _ EXISTING. DUZBLDG. � -
Signature "'' t APPLICANT. ::�', TEL.. q/J FINAL -
OWNER-BUILDER DECLARATION - (PRINT): NO. J`j > +• ,
t•I hereby affirm that am exempt from the Contractor's License DATE
Law,for thetfollowmgtireason (Section 7031:5, Buimess and, ADDRESS' - FINAL /`•v Z"y 1 -
• Professions.Code) ...•'.:r PRESENT -^ - - - _:'•By ' A
+ BUILDING
❑s osowrier of the property, or my employees with v ADDRESS U� U7
wag es as their sole compensation will do the work and - - - - ` .A:r 1 '
- :the structure is not intended or offered for sale(Section LOCALITY ® ` - f
7044, Business�ond Professions Code ) . - MOVING,- - - TEL: _ I I ENp
. F CONTRACTOR NO .
❑. -'I;as owner of the properiy;.am exclusively contracting' +��
•- with licensed contractors to construct the-project (Sec. '-"' ' --` "' " - " ' -- 1 63
)'_... ,. ADDRESS - _
tion 7044, Bus ness and Professions Code ) •t TOTAL i r ti 6-
REQUIRED- TOTAL SETBACK FROM EXIST.
CHEC7% 1 1 u�
I 'CONSTRUCTION LENDING'AGENCY -_- '.=SET-BACK -YARD Hwy =_-._-. ...,PROP. UNE--- -WIDTHOct.
( I hereby;affirm that th-ere�is a construction lending agency for _ FRONT _ _ _ ,• - T= {.HANGTE - _ -
-'T he.performance of.the work for which th is-perm it issued "P PLp
-( .Civ. C ) . .-SIDE
LendersN y _ PL'
Sec 3097
aIn Q- - , ;-10/30/92
�$ - LDMA Ref. R _ { -li
Ono 00011
• Permit Fee /U� r��' • 6i78 11
Lender s A dress� - • - - '
�o 'I certify' `1 h have'redd t appbcotion'and'itate that.the w Issuance Fee i LDMA'P/C 8-
Ig above 'rmation is corre_ agreey
` ordins and Staf' la- r luting,to-buildi g-mnstructioq. Total Fee `-d. -� LDMA Perm. p - -
a and he Liy out on r entatrves ofthis ounty I enter _ _
'upon gu/d - enlio r p tv ns p l�
cti Pu s s ��
SEE REVERSE FOR EXPLANATORY LANGUAGE
SignaWre of ApplicaN or Agent ate - - '