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76M444-CE 4875 9-68 MISCELLANEOUS APP ICAT10ip
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER ADD EISS a
BUILDING AND SAFETY DIVISION LOCALITY
, !
JOHN A. LAMBIE, COUNTY ENGINEER
COLEMAN W. JENKINS, SUPT. OF BUILDING NEAREST
CROSS ST.
FOR APPLICANT TO FILL IN olsr&rcr-%N G TYPE P cEss
CONST.
BUILDING j
ADDRESS MAP /ry HIGHWAY
N0. C/ (CIRCLE) STATE MAJOR SECOND LOCAL
LOCALITY �^ USE ZONE SPECIAL CONDITIONS
NEAREST
CROSS ST.
LEGAL REQUIRED YARD HWY STREET NAME EXIST.
DESCRIPTION LOT NO. BLOCK SETBACK WIDTH
FRONT
NO. OF BLOGS. P,L.
TRACT NOW ON LOT SIDE
USE OF P.L.
SIZE OF LOT EXISTING BLDG.
OWNER.
MAIL
ADDRESS �1 L °'�' "�j/ / •
TEL. 4 �/Y(Y�/ '.+�� 1�.. •//J^ N __ , .. rte {� �.:, ,1 �11,C,.
CITY NO. A
APPLICATION FOR t�!f,t 6 �i� r` _'". . —' C=)
OCCUPANCY , ! t P CC
INSPECTION L/ SAFETY PERMIT t O
VI
TRAILER USE W�
GO
USE OF STR CTURES R DEVICES Fat
a
C
LIMITED TIME USE
DATE DATE
FROM: TO:
INSPECTOR'S
APPROVALS DATE SIGNATURE
OCCUPANCY APPROVAL
IHEREBY ACKNOWLEDGE THAT I HAVE READ THIS GROUP OCC. LOAD
APPLICATION AND STATE THAT THE ABOVE IS COR-
RECT AND AGREE TO COMPLY WITH ALL COUNTY TRAILER USE
ORDINANCES AND STATE LAWS REGULATING SUCH
WORK AS INDICATED HERE N. ,
SIGNATURE OF rSAFETY PERMIT
PERMITTEE TEMPORARY
s `-
STRUCTURE APPROVED
ADDRESS TEMPORARY
STRUCTURE REMOVED
oed
FEE S �/r,�,�) FINAL APPROVAL
APPLICATION VALIDATION JOHN F. LEWIS, PRINCIPAL STRUCTURAL ENGINEER
(NOT A PERMIT) E>... CASH PERMIT VALIDATION CK. M.0. CASH
7 2 U D 1 5.0 0 'W
WORKERS'COMPENSATION DECLARATION CE 875
(11-84) MISCELLANEOUS APPLICATION
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800,Lab.Q.
Policy No. A
Company FOR APPLICANT TO FILL IN BUILDING 3
DDRESS
Certified copy is hereby furnished. 4UILDING 41,a 2 yr�i� V LOCALITY
ADDRESS /Y
Certified copy is filed with the county building inspection OcALITYI �M 141 j NEAREST.CROSS ST.
Date Applicant EAREST �,l //! � 77 I`J� DISTRICT NO. G U TYP PRO fiSSED BY
CROSS ST. V (/y (�L� OM1L T.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. / BLOCKMAP ) HIGHWAY
NO. !/ /� (CIRCLE) STATE MAJOR SE ND LOCAL
NO. OF BLD S.
(This section need not be completed if the work involved TRACT NOW ON LOT USE Z NE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE of
SIZE OF LOT EXISTING BLDG. �' d
I certify that in the performance of the work for which this / o
permit is issued, I shall not employ any person in any manner OWNER ,��V �� y
so as to become subject to the Workers' Compensation Laws. AIL aP/ {��jyy�/�/��/ '/ OCCUPANCY GROUP
ADDRESS ��. J LA9_1/i�. 0k 1� O
Date Applicant G3
C°� r MQ TEL. b�n �7�/n(�� OCCUPANT LOAD W
NOTICE TO APPLICANT: If, after making this Certificate of clrY J a GCr No. Q d /V Ga Z
Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE: _
Compensation provisions of the Labor Code, you must forth-
with comply With such provisions or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION E] No Spec. Knowl. El
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT (LIST ITEMS BELOW)
9 (commencing with Section 7000) of Division 3 of the Busi- NO. OF EXITS
ness and Professions Code, and my license is in full force and
effect. PARKING SPACES REQ'D PROVIDED
License Number Lic. Class LIMITED TIME USE
Contractor Date DATE DATE
' FROM: TO:
D I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer SIZE OF NO. CF INSPECTORS
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SI ATURE
iness and Professions Code). DICE L )t/,t p�tfl„e f�
r � , K w/!il /T`VUJ FINAL APPROVAL
ESENT USE OF BUILDING ^f
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi- a
ness and Professions Code): No. PARKING 70,8 7 U,9 A
0 1, as owner of the property, will do the work and the SPACES PROVIDED
# o • 0 • 88
structure is not intended or offered for sale (Section
7044,Business and Professions Code). o o D o o,o • z
CONSTRUCTION LENDING AGENCY ROPosED USE of BUILDING
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.C.).
Lender's Name
PROPOSED MAX. OCC.
Lender's Address771 bb
PERMIT FEE
I certify that I have read this application and state that the
above information is correc ree to comply with all County ISSUANCE FEE
ordinances and State ./S,,__1at1nff to building construction, 6
and hereby Apthorizg/reqfes Ives of this County to enter TOTAL FEE
u on the a me property for inspect n p poses.
j 1r,
�r,+ SEE REVERSE FOR EXPLANATORY LANGUAGE
Sign ture o ermi D to �j