HomeMy Public PortalAbout9716 DAINES DR_Building__ 78A69$1 dL`#'809.7.58 APPLICATION FOR BUILDING P E RM I T
BUILD
BUILDING AND SAFETY DIVISION ING
Department of County Engineer ADDRESS
County of Los Angeles LOCALITY
JOHN A. LAMBIE. COUNTY ENGINEER NEAREST
CASSATT D. GRIFFIN, SUPT OF BUILDING CROSS ST.
ISTRICT NO. ROUP I TYPE SEWER MAP '
FOR APPLICANT TO FILL IN BK PG
CONST..
BUILDING /
ADDRESS TATITICAL CLASSIFICATION
'�'----+,— -
LOT NO. BLOCKT[NUMBSER
LASS. NO.--(! UNIT
Sp
MAP �f�a- `, STATE
HWY .YES (_
TRACT/,�;.,7 ` y
(/,� USE ZONE SP CIAL
NO. OF BLDGS. J(/I� CONDITIONS
SIZE OF LOT.�� I NOW ON LOT (1/ V
USE OF
EXISTING BLDG BUILDING EXIST.
SETBACK YARD HWY STREET NAME .WIDTH
C
ER P
FOL.
MAIL ( j°^
ADDRESS SIDE
TEL. _i P. L.
CITY NO ARCHITINSPECTION RECORD
ENGINEER
TEL.
ENGINER NO. ✓ -
ADDRESS �^
EL. V
CONTRACTOR
ADDRESS V -
DESCRIPTION OF WORK _
NEW ( ADD ALTER REPAIR DEMOLISH
SO. FT. NO. OF NO. OF
SIZE STORIES _ FAMILIES
USE OF STRUCTURE
APPROVALS -
SIGNATURE OF
APPLICANT DATE INSPECTOR'S SIGNATURE
ADDRESS S (�(// OUNDATION: LOCATION
FORMS. MATERIALS
P. C. S FRAME: FIRE STOPS. I1 ry
FEE BRACING. BOLTS
,��� S FURNACE: LOCATION.
VALU/11jj0 �� s?L�"�• FEE !� `� GAS VENT. DUCTS r
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS AP- LATH. INT.
PLICATION AND STATE THAT THE ABOVE IS CORRECT AND
AGREE TO COMPLY WIT A -COU iY ORDIN CES AND LATH, EXT. - '...�
STATE LAWS REGU I BUI CO RUCTION. - I —
SIGNATURE OF HRECT AND POSTED OUSE NUM13ER R
PERMITTE
ADDRESS _,FINAL
JOHN A.L BIE, COUNTY ENGINEER,/ �pCLYDE N. DIRLAM, PRINCIPAL.STRUC URAL ENGINEER
AN CHECK VALIDATION /CTC.y' M.O. CASH / ]r PERMIT VALIDATION cK M.O. CASH
0 9 �� J!�t 17 1 6ko
® i ice. 1 5 5 31- AUG 2.S 1 3 8:;5 fltn
APPLICATION FOR BUILDING PERMIT
r, COUNTY OF kOS ANGELES BUILDING AN SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICAN TO FILL IN %UILDING ADDRESS / /„
I here y affirm that I have a certificat of consent to self, sure, BUILDING ADDRESS / �/ L
r a e 'cafe f, rkers' mpen tioan e,or A certifiecY r
t- eOf( C^) gpV�X�le j/ _j �l CIT lent ZIP �] LOCALITYP Co �/(//l�U/ /`J/ SIE OF LO-1- NO.OF BLDGS.NOW SON LOT
❑ Certified copy is hereby fur ished NEAREST CROSS ST.
❑ Certified cop is filed wi he c y byins ectio TRACT BLOCK LOT NO.
department. USE ZONE MAP NO.
Date ntyl/ ASSESSOR MAP BOOK PAGE PARCEL
SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' OWNE
COMPENSATION INSURANCE (y� WITHIN 1000 FT.OF SCHOOL? ves No
(This section need not be completed if the permit is for one hundred ADDR
dollars($100)or less.) DISTRICT GROUP T E CONST. FIRE ZONE PROCESSED BY
ZIP r
I certify that in the performance of the work for which this permit CITY
S, Of fes_
is issued, I shall not employ any person in any manner so as to J�
ARCHITECT OR ENGINEER TEL NO. ' '�lG'�'�
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 I A REQUIRED TOTAL SETBACK FROM EXIST
Exemption, you should become Subject t0 the Workers' C C R• / SET BACK YARD HWY PROP LINE WIDTH
Compensation provisions of the Labor Code, you must forthwith j (i FRONT
comply with such provisions or this permit shall be deemed revoked. A E S LIC/N P L
LICENSED CONTRACTORS DECLARATION SIDE
LIC. A S P L
I hereby affirm'that I am licensed underprovisions of Chapter 9 /T SEWER MAP
(commenci it� )of Division 3 of B ne8�8A1d SO.FT.SIZE NO,OF STORIES NO.OF FAMILIES
Profession C d - li e is in full forceend? ct. .. NEW BK PG p
License Nu Lic.Class l CRIPTI N WO ADD ❑ V LUA D�,
Ccz
ontractor' Date l Date ALTER 1:1
REPAIR ❑
W
LIS 'l� .l C(�5
❑ I am exempt under Sec. ��jj $ N
/7'•S
B.&P.C.for this reason DEMOL ❑ z
LDMA P/C#
Date: USE OF EXISTING SLOG. URM ❑
Signature APPLICANT(PRINT) TEL NO. LDMA Perm#
❑ I,:as owner of the property, or my employees with wages as Z Vis_�-# n
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 a 7�f_
Professions Code.)
WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL
❑ I, as owner of the y, y g OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE J 9 ^LE Ir!
property, am exclusive) contracting with AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY
licensed contractors to construct the project (Section 7044, M—'
Business and Professions Code.) YES El No Els_)i i -L _� m 45
WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING ��JJ
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH •t�i.t!?: �-= ?o-r
CONSTRUCTION LENDING AGENCY COAST AIR QUAUTY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FOR
GUIDELINES. _ Ey,���•�i,T� ,i�I i
I hereby affirm that there is a construction lending agency for Yes El No❑
a the performance of the work for which this permit is issued(Sec.
m 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,
w TITLE 2.CHAPTER 220 SECTIONS 220.100 THROUGH 2.20.140 CONCERNING HAZARDOUS - S ji)!j—!�Ri I!_�i 4/9"
Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD. J — y' y
CL Lender's Address gl l
OWNER OR AGENT '
o I certify th I have this 'on and state under penalty
of perjur hat the e' ormation is orrect.I agree to comply P.C.FEE PERMIT FEE ��
with al my o i I ' an I State aws relating to building
m cons D on, eby a tho epre entatives of this County ISSUANCE FEE )
e er pon the bo e e io prop ty for inspection purposes. CX
a .
�p INVESTIGATION FEE TOTAL FEE/ .
n s�pnawre.oi nodlwm o em oa�e
SEE REVERSE FOR EXPLANATORY LANGUAGE