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DEPARTMENT OF BUILDING AND SAFETYjg'X 8 &NAPPLICATION FOR PERMIT
COUNTY OF LOS ANGELES �� � ��B
wk J. FOX, CHIEF ENGINEER.
u A
I Ir8 E
FOR APPLICANT TO FILL IN FOR OFFICE USE ONLY
DISTRI O. PLAN CK. NO. PE MIT NO:
BUILDING• , // // f J. �[ _ `�
//f-
ADDRESS �'f-b/S /�' IIL� - . N
LOCALITY - REC IVED BY DAT OF APPL. DATEISSUED
NEAREST / q 0.514
9 ` >' • ����
CROSS (,•�.ST. .(, F !�lI� .7 BUILDING
ADDRESS J/ e L
OWNER
MAILLOCALITY - . T
ADDRESS, ,2 f /o# SJ CROSS ST. {ri vJ
TEL.
CITY S.4 xi-L NO. FIRE NO. OF _ TYP G 'P
ARCHITECT OR TEL. ZONE PLANS y
ENGINEER NO. �� BLDG. r� /
a SETBACK LINE T
ADDRESS APPROVED - �
TEL. A t BY - DATE
CONTRACTOR �y�[J �� ,7y /S ZONE / APPROVED DATE
ADDRESS y' jL/46 t4 7 HOUSE NUMBERING
LEGAL'
DESCRIPTION I LOT NO. BLOCK MAP NUMBER �" MELD CHECK BY •
TRACT NO. ASSIGNED BY , ATE V_IX—,('
O. OF BLDGS: - CORRECTIONS
SIZE OF LOT p9 y floN ON LOT
USE OF NO. D
EXISTING BLDG, D� C I FAMILIES •' 'U -
DESCRIPTION OF WORK
NEW !�' I - I ALTERATION .I I ADDITION
O
REPAIR 'DEMOLITION
SQ. FT. NO. OF O
SIZE ���• ROOMS STORIES - - Z
D
EXT. WALLCROOF - I'
COVERING J �'v� I COVERING Ce I-ife
•USE OF STRUCTURE
��5, ��C� d- 1• Ari /� ('�-r2. � �� '
APPROVALS
FI INSPECTOR'S SIGNATURE DATE
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS AP- FOUNDATION: LOCATION /
PLICATIONAND STATE THAT THE INFORMATION GIVEN IS _ FORMS, MATERIALS, 'Pr�G�C
CORRECT. - -
I AGREE TO'COMPLY WITH THE CORRECTIONS LISTED FRAME: FIRE STOPS,
HEREON AND WITH ALL COUNTY ORDINANCES AND STATE BRACING, BOLTS t.`�jv,..( �/ 'l��✓,
LAWS REGULATING RUI DING CONSTRUCTION.
L/1,�/ FURNACE: LOCATION,
SIGNATURE OF / GAS VENT, DUCTS
PERMITTEE (1(�/
LATH, INT.
ADDRESS
LATH, EXT.
AUTHORIZED AGT.
p- PLASTER, INT.
L781AG38A D1383 10-80 $ / P. C. $0 FEE /�/s®� PLASTER, EXT.ALUATION (, FEE $ �"'�" FINAL '
I
WORKGRS' COMPENSATION DECLARATION
I. here` affiret that I have o certificate of consent to. self. p O O p M O o� M O D nn
insure, or a certificate of Workers' Compensation Insurance, C�`�
or a certified copy thereof (Sec. 3800, Lab. C.) �:' '
COUNTY 0 LOS ANGELES "'gUILDIIN AND SAFETY
Policy No. Company
[&--Certified copy is here'by'furnished. FOR APPLICANT-TO'.FILL, IN ADDRESS GL/'.f UA/
. ❑
Certified-copy is filed with the county building ins p• BUILDING
tion department. ADDRESS
CITY,,: v C&q ZIP I LOCALITY * L45 /.
Date4&-2-111 Appliccin NO. OF BLDGS. NEAREST
CERTIFICATE OF EXEMPTION F OM WORKERS SIZE OF LOT NOW ON LOT . CROSS ST.
COMPENSATION INSURANCE ASSESSOR }�
(This section need.not be completed if the.permit is for one TRACT BLOCK LOT NO. MAP BOOK PAGE. (/ PARCEL ®�®
hundred dollars ($100) or less.) L L ��� TEL' USE ZONE MAP
// / f NO. NO.:
OWNER
I certify that in the performance of the work for which this SPECIAL
////-
Permit is issued,-I sholl_noi employ any,person in any manner ADDRES L Ll.r' �'v "` / CONDITIONS CL
so as to become.subject to,the Workers' Compensation Laws. 0
CITY L/G ZIP
Date
Applicant ` RCHI ECT OR L,
FIRE PROCESSED BY
NOTICE TO APPLICANT:,df, after.-,making this*Certificate of• ' INEER. O. DISTRICT GROUP TYPE CONST. ZONE 0
Exemption, you should become subject- to the Workers' (i f�,[ '/ w
Compensation provisions of the,Labor Code, you must forth- ADDRESSD a
with comply with such. provisions or'this permit shall be ' f O G t9 STATISTICAL CLASSIFICATION APT: CONDO. N
deemed revoked. CONTRALTO L4a�d.� /• / - Z
LICENSED CONTRACTORS DECLARATION UC.�p/� CLASS NO. 7� DWELL..UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS o/ �/���� NO. OO Gs /d
LIC. SEWER MAP
(commencing with Section 7000)of Division 3 of'.the Business CITY TLr�%%�G� CLASS
:ond Professions.Cod ,an y license is i full force and effect. gK. pC,. VALIDATION
SQ. FT. NO. OF NO. OF CHECK
License Nu er s 'v SIZE STORIES FAMILIES ONE '
.�� VALUATIO
E El.Contract
ADD El OF WORK NEW '
❑I am exempt under Sec. / -_— D
ALTER ❑
B.&P.C. for this reason- REPAIR ❑ $
Date: . USE OF
EXISTING BLDG. DEMOL
Signature APPLICANT -TEL. FINAL
OWNER-BUILDER DECLARATION (PRINT). NO. DATE
hereby affirm that I am exempt from the Contractor's License ADDRESS
.Law.for the following reason (Section 7031.5,.Business and FINAL "
Professions Code)`. PRESENT By,
BUILDING
❑ I, as owner of the property, or my employees with ADDRESS '
wages as their sole compensation,will do the work and - z
the structure isnot intended or offered for sale(Section LOCALITY
z
. 7044, Business and Professions Code ) MOVING- TEL. � ,: 1,,,_€�Ji
El
CONTRACTOR -NO. t
1, as owner of the property, am exclusively.contracting
• with licensed contractors'to construct the project (Sec- -- :I,
ADDRESS f t;.•_�
tion 7044, Business and Professions Code.): to
REQUIRED TOTAL 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
the performance of the work for-which-this permit is issued P.L. ' ' •"Lr("�,-_fI__", _
(Sec. 3097, Civ. C.). SIDE`
'
Lenders Name.
$ �B t� LDMA Ref. #
P . Fee$ Permit Fee
Lender's Address A11-11:9
o .I'certify that I have read this application and state that the Issuance'Fee LDMA P/C#
8 , ' above information is correct:I agree to comply with all County Investigation Fee' �D
R ordinances and State laws rel ting'to building construction, Total Fee LDMA Perm. #
a and hereby authorize repres tat' f this County to enter
o t above-me a p r r in ed' urpos
a
_,10 _ SEE REVERSE FOR EXPLANATORY LANGUAGE
gnat re of ApplicaXor Agent Date