HomeMy Public PortalAbout5702 ENCINITA AVE_Building__ APPLI CATION FOR BUI I ER T
FOR APP-LICANT TO FILL IN (Rri n1 0� rvp.oe oDly) {
BUILDIN v i coUN OF LOS AN S
ADDRE Z DEPARTMENT OF COUNTY ENGINEER
CITY
BUILDING AND SAFETY DIVISION
OF BLDGS. BUILDING ��jj p
SIZE OF LOT lqAW ON LOT ADDRESS op�� �G4`Ca
a. 10 )
TRACT - / BLOCK LOT NO. 8ZZ LOCALITY
TELe / BAREST
OWNER NO. ('� CROSS ST.
_ ASSESSOR
ADDRESSMo MAP BOOK PAGE PARCEL
DISTRICT GROUP TYPE FIRE SEED BY
CITY
AZIP CONST. ZONE �.
RCHITECT OR TEL. .U� s
ENGINEER NO.
` STATISTICAL CLASSIFICATION SE� M P
ADDRESS _ CLASS NO_12/ OWE LL, it
41.�a T .
CONTRACTOR NO E.ZONE NOP O
IC. in SPEA
ADD1
RES�� NO.2// �iyy� CICONDITLIONS
CITY LIC. /�
CLASS-"-37 ROA DEPARTMENT APPROVAL REQUIRED YES NO �
CONSTRUCTION LENDER
NAME AND BRANCH BL G.SETBACK FROM
FR NTPROP.LINEOF (STREET) d
ADDRESS CITY _ TOTAL 3ETBA CK FROM TYPE OF EXISTING
NO. OF NO. OF CHECK HIG WAY + YARD - HIGHWAY WIDTH O
SO. FT. FRONT PROP, LINE U
SIZE STORIES FAMILIES ONE O
+ -
DESCRIPTION OF WORK NEW ElED
ADO BLDG.SETBACK FROM a
SIDE PROP. LINE OF (STREET(
ALTER ❑ TOTAL SETBACK FRO YPE OF EXISTING
REPAIR EDZ
HIGHWAY + YARD - SIDE PROP. LINE HWAY WIDTH
USE OF DEMOL ❑ +
EXISTING BLDG.
APPLICANT TEL CORNER CUTOFF YES ❑ NO
(PR NT) N0.
IN OPEN SPACE YES ❑ NO
BY (SIGNATURE(
QQ Y
IN COASTAL ZONECATEGORICAL EXEMPTION❑ YE$ NO
VALUATION .�
I HEREBY ACKNOWLEDGE THAT HAVE READ THIS APPLICATION ENVIRONMENTAL
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY IMPACT EXEMPTION DECLARATION SIGNED—(DATE;
WITH ALL ORDINANCES AND LAWS REGULATING BUILDING CON-
STRUCTION. CERTIFY THAT IN DOING THE WORK AUTHORIZED IMPACT REPORT PROCESSED (DATE)
HEREBY I WILL NOT EMPLOY ANT PERSON N VIOLATIOOF THE
LABOR CODE' OF THE TE OF .CALIF NIA r.' - LYING TO
WORKMEN'S COMPEN E.
SIGNATURE OF
PERMITTEE _
ADD. T.
CITY C NO. /I (NTEPQ/F�// / BY `
11:I/:E (JIECKS 11M.1/3Ll' T0: FEE $ FEE
HARVEY T. BRANDT, COUNTY ENGINEER j —7
PLAN CHECK VALIDATION CK: Mo. GASH _ PE VALIDATION CK. , M.O CASH
76A638A CE980312/72 ' Y�� 2 ` - 675 JUL 13, 1 D 21 .75A V
COUNTY OF LOS ANGELES ' •"BUILDING AND SAFETY'
BUID"' RESS-
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO.FILL IN +f
I hereby affirm that I have a certificate of consent'to self insure, GUI DING ADDRESS �P
or a certificate of Workers' Compensation Insurance;or a certified 7' 2 -;;,,,/
copy thereof 3(Sec.3800,Lab.•C. CITY ZIP
Policy Nolk�.i�4—y Company S�n7� .Fu•+•/n �E �� G/ [) LOCALITY
SIZE OF LOT NO.OF-BLDGS.NOW ON LOT- JZ
7ICertified copy is hereby furnished. 70 -3 5 NEAREST CROSS ST.
❑ Certified copy is filed with the county building inspection TRACT / I BLOCK LOT NLFs y
department. /l 10 ! i7 Li USE ZONE MAP NO. `
Date �y L Applicant. �.� /i/4/4 0 ASSESSOR MAPA. PAGE PARCf�L -
t 7 0 3 fL'72. SPECIAL CONDITIONS + // pq�_ •/•
CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER_ TEL N0.
COMPENSATION INSURANCE E' 7 u y ,Sa zS` WITHIN 1000 FT OF SCHOOL? y ves No
(This section need not be completed if the permit is for one hundred ADDRESS
dollars($100) or less.)
S-7 b .DISTRICT GROUP TYPE CONST FIRE ZONE PROCESSED BY
CITY
1 certify that in the performance of the work for which this permit / �6 J Z(IP 1 ''� 7 C? O /� �� d
is issued, I shall not employ any person in any manner so as to r . . O' /l-
become Subject t0 the Workers'Compensation Laws. ARCHITECT OR ENGINEER TEL.NO.
STATISTICAL CL�AJ$SIFlCATION APT CONDO
Date ' Applicant ADDRESS CLASS NO. `" DWELL UNITS
NOTICE TO APPLICANT. If, after making this Certificate of RED RED TOTAL SETBACK FROM EXIST '
Exemption, you should become subject f0 the Workers
CONTRACTOR TEL NO a SETBACK YARD. HWV PROP LINE WIDTH
Compensation provisions of the Labor Code, you must forthwith' T// LNUU-E,—/ V-rI L-S -7.z ER/ _3 L FRONT
comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC.NO. PL }
.2 1— Lr GL ST SIDE d
LICENSED CONTRACTORS DECLARATION e, O
CITY LIO LASS P.0 _
I hereby affirm that I am licensed underprovisions of Chapter 9 I G-TLC /7n - f SEWER MAP
(Commencing with Section 7000)of Division 3 of the Business and SO.FT SIZE NO OF STORIES NO.OF FAMILIES
Professions Code,and my license" is in full force andel effect. 3 a- / NEW ❑ BK PG D ii O'
License Num )/ber -R 2 /S LTD. Class ,�1 DESCRIPTION OF WORK ADD - VALUATION j V
4/-3 5t� a iZL�Oxu enl eoa $ 312,600 'AC.CT.A a
Contractor /.li /.4U ut7G Kra Date .ALTER _ ❑
❑ 1 am exempt under Sec. T, 0-4 REPAIR ❑ Cr)
B.BP,Cdor this reason DEMOL ❑ DMA P/C a 1
DateUSE OF EXISTING BLDG. I El' URM f .R ,, ACI,T :F
Signature APPLICANT(PRINTI Q wC. 71 t I•.L TEL NO. 73 ..LOMA Perm x 131)1 �4i1.i1?
❑ 1, as owner of the property, or my employees with wages as '-VA-�� /i `� - 1 7 ZTEi'�G
their sole compensation, will do the work and the structure is ADDRESS - - - 1 {���---ryry
not intended or offered for'sale (Section.7044, BueinBBa antl @r Zi S f /1]ar•I TZ-oxL /lIi$�. FINAL DATE Q T�I T At. /0 -"79
Professions Cade.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL �" 1 / rr �+'
OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE 000 J (.FaLb1'+ E]�1a7
❑ as owner of the property, am' exclusively contracting with OR
SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION'GUIDE] FINAL BY ; _ >
licensed contractors to construct the project'!Section 7044, YES No El
Business and!Professions Code.) ^>?".3�•
WILL THE INTENDED USE OF THE BUIDUNG BY THE APPLICANT OR FUTURE BUILDING
CCCUPANT,REOUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH '
CONSTRUCTION LENDING AGENCY COAST AIR OUAUTY MANAGEMENT DISTRICT GOADING)SEE PERMITTING.CHECKLIST'FOR 1 i I: �1 / C�fy�
GUIDELINES *1.; Cj�1(_t(j-ciiiii-ii 4: ,
hereby affirm that there is a construction lending agency for YES❑ Np❑ - ;� , < c-,.�: - ,{, 1:
the performance of the work for which this permit is issued(Sec. ' i,)� - "�
HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE GOADED PERMITTING `
3Dg],I'.IV.C.) CHECKLIST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE -
TITLE 2 CHAPTER 2.20 SECTIONS 220.100 THROUGH 210.140 CONCERNING HAZARDOUS '
mLender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD. 4. r
Lender's Address I oo,ER OR AGENT
IM
1 certify that I have read this a ication and state under penalty
"a P.C.FEE PERMIT FEE -
p of
perjury a the above r anon correct. agree to comply LSD .5 //a
US with all ty Drdin as tl Sta laws relating to building l"% G�
ED const ti n, nd er y au on presentative, of this County ISSUANCE FEE - +
a
`! d to 7 4 n e bov - e ned property for in.Pe tion Purposes. �`/��0 _ , 4�y'+1 _ 1d'. TJf R v,„^?N T
dS INVESTIGATION FEE TOTAL FEE
A"ADale (o-7 O'
SEE REVERSE FOR EXPLANATORY LANGUAGE
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