HomeMy Public PortalAbout8721 GARIBALDI AVE_Building__ f F. ti Wi0RKEW OOAAPENSAT10N DECLARATION � f�
' Manby affirm t+hat I have r 6ernfomp of floe In to Insurance, APP. I CATI O N FOR. M D I N G P E RM I T
' Inu{pe; or a Z`ertF(Jcate of Workers' Compensation Insurance, - .. '
or a cer. d copy thereof (Sec 39N, Lab. �) _
--77 COUNTY OF LOS ANGELEf lsIJILDINQ AND tAFETYOkm ..'
Icy No. I Company
Ctartlfied copy la hereby fymished FOR APPLICANT TO FI IN ADS ' y
u aooREss. 02�
Certffiedcopy Is filed with fc u bullding Jr- ILDING ,.,.:
tion department. 'rN'' ANDS
-T
� 'i� ti y
Date Applloant L ZJP - LOCALTY
CERTIFICATE NO. OF tST.
b(EA11Ff1Cyd SIZE OF LOT NOW ON IAT CROSS ST. �p `` [
OONWQJSATION I NSU RANCE S 3 EC,tO
(This Mctlon'need'rot be'completed if the permit is for one'. TRACT.'" BLOCY LOT NO. AGE CO pAR��Z
hundrbd'doIIars{;100)'or ASSESSOR
leu.)
OW 6t
I certify that In the perfgrmance,of the work for which this n NO. ?
SPECLAL
permit is Issued,1 shall p¢t empI any n In arty,manner . ADDRESS l7
so.m to become pNbIQcT to,the Wdr�cers mpensatIon 4cws. O
_ CITY
Date Applicant ARCHrrECT OR TEL 5 ICT GROUP. TYPE _ BY Q
CY
NOTICE TO AMCANT: if, aftgr.malFing.thl4 Certtficate of INEER : _ NO. _ CON$T.'. E.. .
Exemption, .you,}fwuld become sub��ec�t. to the Workers I �jI 7
Compensgtlon provisions bf the Lam Code,.you must,forth vv -� V
with comply with. such provislons' or..this. permit }hall be `� TB_ 1? SrAT�Sp� TION APT. CONM �
deemed revoked i - Z
LACENSEDCONTWACTQR.$DECIARAl1ON d 7 nwai`.uNiTs .
I hereby affirm that I am licensed under pr--ons of Chapter 9 �V NO ��N0.
(commencing with Section 7000),of.DlvIsIon 3,of•the Business A r 1 (!�,�f'� y LIG SE�n^�
and Professlons Qndmy Ilcer#,o h In fulrforceao4affed. Kl✓ Y 1T Y� ti� SSS X.AP PG. I dG VALIPATFON
SQ. FT. NO. OFN0. OF O�OC'
Ucertse Number' �3 c Cla . SIZE STORIES FAMILIES ONE V
r1
'Date
9,77,4
Gonodorss , DESCRI PT0N OF NEW El
J s
ElI am exempt'under'Sec
ALTER ❑
B.&P:C. for this:reason Q" 1 REPAIR ;
1W OF
ISI _
EXISTING G \+ - DEh50L LJ ~
Slgngtvro
APPLICANT - NO. _ FINAL J `f
-B LDER T10N. DATE
d hereby affirm that am exempt from the Contractors License 1
Law for the following reowri (Sedlon 7031.5, Buslne# and. °��' FINAL:
Professions Coda)::. PPONT w 9CT•-L
T
BU I LIN NG _
❑ I, as owner of. the prop", or my employs wMh I
-wages asthelr solo rompensatlon;will do the work and -
l
the structure_Isnot InterKled or offered for sale(,5ectloo LOCAIITY ' 1 ��
7044, Bualn."esa and Professions Coda.) - MQVNNG- TEL _ -
❑ I,as owner.of the property,am exdvslvely contractIN CONTRACTOR NO. TI}TAI - 325-- 43
3
r,.
vk�th dlcnrtsed coni,actgn to.construct the protect (Sec- -
ADDRESS
-tion x'044,'"Iness'and Professions Code,) =� )✓5 r,; t,• i � �.
CCNSMJCT10N LENDING AGENCY YAC
��the-re Js a construction lending ggerxy for the work for which this p*rtnit Is Iwu6P.L:PDE . -I]> 1 ''21 3/92 .
lenders Name LDMA Ref. / 152I 1 .rX 11 1: %
Lenders Address P.C. Fee Permit Fee
I certlfy that I have�*ad this application and state that the - vs - LAMA P/C f ,
above Information litorrect.I opreb to comply with alfCounty invesi.1gatioli
ord hcp and State knvs nlatingto building con><tructlorl;. Total Fee b .�`� UWA P&rm.
a ereby authorize representatives of this County to tinter
thq proper,for I o -
fd Rrvmu tot DITL.ANAToay LAmGUAGF
Signature of'Applkant or,A4em Date -
A-C[/IEO, 'J.BS ATI BUILDING PERMIT
7EAC3B � APPLICATION FOR
COUNTY OF LOS ANGELES BUILDING
DEPARTMENT OF COUNTY ENGINEER ADDRESS L D
BUILDING AND SAFETY DIVISION LOCALITY *--�o G L-
JOHN A. LAMBIE. COUNTY ENGINEER NEAREST
COLEMAN W. JENKINSAUP'T OF BUILDING CROSS ST. FJ
DISTRICT NO. GROUP TYPE PRO E89ED Is
FOR APPLICANT TO FILL IN CONST.
BUILDING STATISTICALL^CLASSIFICATION 'SEWER MAP
ADDRESS F7 2-1r CLASS NO. DWELL UNITS W� BK PG
LOT NO. LOCK USE ZONE MAP .�j a�
1,, L
TRACT Q I SPECIAL
NO. OF SLOGS.
SIZE OF LOT NOW ON LOT
USE OF
E XIBLDG. SETBACK FROM
��d� TEL FRONT PROP. LINE OF (STREET)
OWNER4,-/V"'/ /'Y! NO. TYPE OF EXIDTI NS SETBACK HIGHWAY YARD = TOTAL
ADDRESS HIGHWAY I WIDTH F M
OC L
y� .
CITY /S 1kr2- +
ARCHITECT OR TEL. SSETBACK FROM
ENGINEER NO. lTDG.D[ PROP. LIN! OF (STREET)
TYPE OF EXISTING SETBACK HIGHWAY + YARD = TOTAL
ADDRESS HIGHWAY WIDTH FROM C.L.
TEL. + _
CONTRACTOR<7N NO
�'i , LIC CORNER CUTOFF YES NO
[ADDRE ^`�-, NO
CITY I LL SEE REVERSE SIDE FOR SPECIAL APPROVALS
DESCRIPTION OF WORK
a
ADD ALTER REPAIR DEMO LI9H
NO. OF
STORIES FAMILIES '
RE .Z le %
RE OF
NT
ON$ ¢D
APPROVALS DATE I PECT ,,,A.UR[
PMT. 4aFOUNDATION, LOCATION PEE FORMS, MATERIALS
FRAME, FIRE STOPS,
1 HERESY AC KNOWLCP
DG[ THAT I HAVE READ THIS APLICATION E@ACING BOLT
AND RATE THAT THE ABOVE IB CORRECT AND AGREE TO COMPLY FURNACES LOCATION
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGUUITING GAS VENT. DUCTS
7UILDI NG CONSTRUCTION. I CERTIFY THAT IN DOING THE WORK
AUTHORIZID HERESY I WILL NOT EMPLOY ANY PERSON IN VIOLA- LATH. INT.
T10N OF THE WOR CODA OF THE STATE OF CALIFORNIA R[LAT-
INO TO WORKMEN'S CO FENSATIO URANCE. LATH. EXT.
• L
SIGNATURE O HOUSE NUMBER COR-
PERMITTEE e' RE AND PQ5TED
ADDRESS F I N A L
JOHN F.�L�E�WIS. PRINCIPAL ST U AL ENGINEER
PLAN CHECK VALIDATION CK. M.O. CASH _ rLLLLYIIl VA.LIDATIO CK M.O C✓AIH
LAC06 7 7 OtS OCT25 1 A 4-.00^' V
76A63e4, CEPeOS a-66 APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING
DEPARTMENT OF COUNTY ENGINEER ADDR ESS
BUILDING AND SAFETY DIVISION LOCALITY
JOHN A. L.AMBIE. COUNTY ENGINEER NEAREST
COLEMAN W. JENKINS¢UP'T OF BUILDING CROSS ST. O 1J
DISTRICT NO. GROUP TYPE PROCESSED BY
FOR APPLICANT TO FILL IN CONST.
BUILDING STATISTICyAAL. CCL�LA991FICATION SEWER MAP
ADDRESS t CLASS NOZ�_ ZDWELL UNITS BK PG
LOT NO L_ J221, kFS BLOCK USE ZONE MAP
NO.
TRACT ` f ,. SPECIAL nn
SIZE OF LOTS /3)C DO NOWOON LOTS l�
USE OF .a /Y�/
EXISTING BLOO, BLDG. SETBACK FROM
��+ /7-�{/�.n
-OA)
FRONT PROP. LING OF .Q O..�TALi7 1 (STREET)
OWNER NO, TYPE OF EXISTING SETBACK HIGHWAY YARD = TOTAL
ADDRESS J7 FROM C L.
+
ABLDG. SETBACK FROM
ARCHITECT OR TEL.
ENGINEER NO. RIDE PROP. LING OF (STREET)
TYPE OF EXISTING SETBACK HIGHWAY + YARD = TOTAL
ADDRESS HIGHWAY WIDTH FROM C.L.
TEL. + _
CONTRACTOR NO I
O
LIC CORNER CUTOFF YES NO U
ADDRESS NO
LIC SEE REVERSE SIDE FOR SPECIAL APPROVALS-CITY CLI qq
O
DESCRIPTION OF WORK
EL
NEW AS ADD ALTER REPAIR DEMOLISH Z
Q.FT. NO. OF NO. OF
.SIZE STORIES FAMILIES
USE OF -7—
FTLS
STRUCTURE J V/] C.� fes(!
SIGNATURE OP l
APPLICANT
VALUATION$ P"�� � APPROVALS DATE INVECU R SIGNATURE
P.C. PMT. .�O - FOUNDATION, LOCATION
FEE$ FEE$ FORMS, MATERIALS
FRAME, FIRE STOP-9.I HED
REBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION BRACING BOLT
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY FURNACE: LOCATION
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING GAS VENT. DUCTS
VUILDING CONSTRUCTION. I CERTIFY THAT. IN DOING THE WORK
AUTHORIZED HERESY I WILL NOT EMPLOY ANY PERSON IN VIOLA- LATH. INT.
TON OF THE LABOR CODE OF THE STATE OF CALIFORNIA RELAT-
ING TO WORKMEN'S Nff SATS RAN LATH. EXT.
SIGNATUR
E
HOUSE NUMBER COR-
PE,RMITT« RE T AND S D
ADDRESS e&' F I N A L ./
JOHN F. LEWIS. PRINCIPAL STRAL ENGINEER
PLAN CHECK VALIDATION CK. M.D. CASH _ PERMIT VALIDATION CK. M.O CA24A
06 7 6 4 =25 -- 1 h 11.50-
DIVISION OF BUILDING AND SAFETY BUILDING
Depar�ent of Ooomty Ekjteer
qty of Los eng+elm APPLICATION
WM. J. FOX, CouNTY ENOINKER
FOR APPLICANT TO FILL IN FOR OFFICE USE ONLY
DI■TRIDT ND. PLAN DK.nm R>m.No. rKRMIT MD.
�� 030
IIIY DATE CW Aryl_ DATE IiLlm
L OCLA QTY
NZARE■T 1 t)
■UILDIN■
ADOREIN
17WNKR ' .
�Ty
ADD
!*/1Rttr
• TEL DRUM■T.
ally FIRE Nll OF TYPE -w - OIlDI!
ZONE PLAN■
AROHITL=DA TEL
EMO 1 N EQ NO. KLMM. N d
■CTILAOK LINK
T13- z A� i '�mvw DATE
CONTRAOTOR NO. HOU■K HUM■ICRINO
MAA NUMBER NO. AMIMNICD n
L Z2AL
DE■ORIPTIOM LOT HOP Ift ■LOOK CMRFZTKM
TUADT 0 3
MO. OF r■+�
■= OF LOT x es Q NOW ON.LOT
UIZE or N D.OF 'CfL
1009TINEI KLA rAMLLLM
O
70
NEW ALTERATION ADDITION /
REPAIR DEMOLITION
FT. NIL OF Lo
RODM■ IIrrcmm
KXT.WA-LROOF
OOVEItIH■ QOVEIYH■ �{ r4
um or■TRUOTURIL
F J
V
IN■PIDTION FOR A"ROVALS
DDOUPANDYA■ IN■PKOTOR'e■IONATURK DATE
FOUHDATIONILOOATIOM
1 HKRKIFY ADKNDPA-IM K THAT 1 HAVK PLEAD THI■ AP- FORMW MATKRIAL■
PLIDATION AND ETATK THAT TH11 INFORMATION MWEM L■ FRAMKI FIRE■TOP■,
C W RKOT. 3RAUlNM,,WlaLTE
1A■RIK TO COMPLY wrrH ALL Downy ORDIMANOn � � LOCATION.
AND
STATE W■ RE■ULATIM■ ■UILDIH■ OON.WrRLJOTION.
MAN VENT DLIOT7
■IONATUPW OF 1 LATH, 1PCT.
FIRM
/ LATH. KXT.
ADDRIM
PL.A■rXR, 1 MT.
AUTHORIZED ANT
G PLAtrEP, IXT.
HOURE NUM■LR DOR-
. RI=AND PD■T M
VALUATION FR ® F 1 NAL /O
7AAA24.. o W 3 1-aa
1
DEPASTbENT OF COMM ENGUN.Bg
r LIVISION OF
COIINTYBOOFF ANDDLOS f2m- R B U I L D I N G
WILLIAM J. FOX, CouNTY ENGINEER APPLICATION
QASSATT D. GRIFFIN, SUPT Or BUILDING
FOR APPLICANT TO FILL IN FOR OFFICE USE ONLY
7UILDINGDISTRICT O. MAN Cx.opt Ria.No. PIDtMrr No.
ADDRE■T 3
gym, R[C[1 BY DATA OF APPL DATA I"UM3
N[wRZST cgoqm*T. Y1-7
UILDINQ
T1 ADDRIlS L
OWNER LJ
MAIL LOCTY
ADDRAM ALINEARIBT
sa inTaAT— CROSS ST.
QFTY
ARCHITICT OR TIL. FIRI .NO. OF TBPA GRW
0401N0401NOM NQ, ZONA PLANS
BLDG. ORD. NO
SETBACK LIN[
TAL- US"
APPR
CONTRACTOIR M ZO — BY A
HOUR[ NUMBERIN4
LWAL&L MAP mumapt O. ASSIGN ■Y
D[BCRIPTIO N BLOCK _
CORRECTIONS
TRAgr LC G
NO. OF
OF LOT F BMM-20.NOW ON LOT
UBA or
NO. OF - - -- -KXIVTINCI
- DION OF WORK o —
EW Q
/W Z
REPAIR DEMOLITION
SO. FT. NO. OF
SIZI c) ROOHf STORIES _
KXT. WALL ROOF Q
COVERING G 1
USI OF ST'RUCTURI
L r�
Z21 712& I-Irwr7-
APPROVALS
IIVBPECTOR'S SIGNATURE DATA
FOUNDATIONi LOCATION
MATKRIALS
I HAMMY ACMOWLKDGA THAT 1 HAMA RIAD THIP AP- FRAM[: FIR[BTOPS, _
PLICATION AND STAT[ THAT THE INFORMATION GIVEN 18 BRACIN BOLTS
CORRICT.
1 AW= TO COMPLY WTrH ALL COUNTY ORDINANCES FURNACE: LOCATION,
AND $TATE LAWS REGUL.A71NG BUILDING CONSTRUCTION. GAS VIINI' DUCTS
SIGNATURE OF LATH, INT.
PERM
LATH. [XT. /' D
ADD
PLATTER. INTO
AUTHOMX=AGT.
/�J� PLATTER, KIT.
FQ HODS[NUMBER COR-
RECT AND POSTED
vwLuwnoN PKE �C7 F.MAL
74AGS" cSf• 9-M
- J
`rGAei8A a#05O7.7.505APPLICATION FOR BUILDING PERMIT- �.
BUILDING AND SAFETY DIVISION BUILDING
cd C-ity L;IIghLow ADDRESS '
Coontp of Lon AagolM LO LTTY I
JOHN A.LAMBIE, COUNTY ENaINxxg NEAREST
CASSATT D.GRIFFIN, SUP-T OF NUILDINS CROSS ST. Y O
DISTR�NO, R UQ .�.PE - SEWER MAP
FOPLIB APCANT TO FHl IN SK Pq
CONST.
BUILDING
ADDRESS W 7 STATISTICAL CLASSIFICATION
LOT NO. - BLOCK CLASS. NO DWELL. UNTTA
P 87ATH _�, O
NUMAMBER ' HWY
TR'A'CT USE ZONE SPECIAL
NO. OF BLD.GS. CONDITIONS'
SIZE OF LOT O NOW ON LOT
USE OF
EXISTING
I - 8UE. ACK 'YARD HWY STREET NAME WIDTTH
OWNER FRONT dF
MAIL I P. L
D
ADRESS �` SIDE _
S TELN.
(� I%(o P. L.
ARCHITECT OR TEL, ngSP'y.�� ON BIECOBD
ENGINEER NO. -
0
ADDRESS
TEL
CONTRACTOR NO.
D _
DESCRIPTION OF WOGS F c o e
tJEW ADD ALTER REPAIR DEMOLISH
. FT. NO. OF NO. OF
IZEL5 FICIRIMS FAMILIES -
USE OF STRUCTUR
APPROVALS
SIGNATURE O �
APPLICANT DATE INSPECTOR'S SIGNATURE
ADDRESS FOUNDATION: LOCATION -.
FORMS, MATERIALS
P. C. f FRAME: FIRE STOPS,
FEE BRACING, BOLTS
FURNACE: LOCATION,
VALUATION FEE f� j� GAS VENT, DUCTS
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS AP- LATH INT.
PLICATION AND STATE THAT THE ABOVE 18 CORRECT AND
AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND LATH EXT.
STATE LAWS REGULATING BUILDING CONSTRUCTION.
SIGNATURE OF HOUSE NUMBER COR-
PERMIT 1! RECT AND POSTED -
ADDR FINAL
JOHN A. LAMBIE, COUNTY ENGINEER CLYDE N. DIRLAM PRINCIPAL STRUCTURAL E-NGINEER
PLAIT CH= VALIDATION CK. m.o. CATH PEMT VALIDATION m Y.O. CASH
LACO 6 6 0 1 X 2 9 1 - 2.0 0
APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATIO14 FOR APPLICANT TO FILL IN
I hereby affirm that I have a Ger hlcaW of coneent tO aefl nsue, BULDNO ADORES
or a certificate of Vkrkere' Compacraetion Inaarence,or a certified
copy thereof(Sec.3800,Leh C.) • zip
PoBcy No./3 g!>?'--S– peTTY�k?� N I) LOCJU rrY
82E OF CIDT NO.OF BLD3a NOW ON LOT
❑ Certified copy Is hereby furnished. NEAREST CRO33
rhM1ed copy
Is fled with the ooLu ty bulidlrp Inepedion TRACT BLOCK LOT NO
/ -� use Zx� MAP Na
Date y 4 f Appkk�ant ASSE38OR MAP BOOK PAGE R�F1OF1
CERTIFICATE OF EXEMPTIO M WOL CONDITK)NS
RKERS' ePEcuu � 0/
COMPENSATION I CE S- h"�4'*^b t`a 41Y G —4 Pa a wTFm 1000 Fr.OF SCHOOL? YES NO
88 D9970CT OROUP TYPE CONST. ME ZONE PROC>83eD BY
(Bike section need not be cortpketed f the permit Is for one hurdned ADDREg.} t
doftam($100) Or k m&) CITY / _ZIP
el—
I oertfy that n the performicnce of the work for whloh this permf /�,
Is haus I shell not employ arty person n any manner so as to ARCHITECt OR m TEL Na 3
become Subject to the M xiors'Compensation Law& SWIST)CAL CLASSaFr—ATI N APT CONDO
Date Appk-Tt ADDFIE33 CLASS Na p2 1 _ Mma-L LmT3
NOTICE TO APPLr,4.NT..- If, after making this Corttfoeta of REOUIFED TOU1L SETBACK FROM EXIST
Exemption, you should become subject to the MNbrkers' . TEL Na SET BACKW3D FIM/1' PRt�OP L1WDTH
Cortpensa(fon provisions of the Labor Code, you must fortltvNth VT
I�b�77 R/�T iV ?1q?–
FRONT
comply with such provisions or this permit shall be deemed revoked. ADORELIC.NO. p
LICENSED CONTixis9�RACTORS DECLARATION tin S 1-�0 Balms
LIC. PL
I hereby affirm that I am Iloerrsed underprovfabrb of C xq ter 8
(commencing with Section 7000)of Dhrlebn 3 Of the Buahieae and 8Q Fr.SIZE , NQ OF STOFES N0.OF FAM?ES BEWEA MAP
Professions Code,and rry Ilcense IS In full force and effect NEW ❑ BK Po
io , Q
tdcerm.Number !-a-I 51-L Lic.Clear DE8CRFT10N OF YODW N ADD ❑ WLUAlC N V
contractor lir(��. (Zgc5 7Y'>err A to 6 /'F 'q �� ,v crGA $
ALTER 11
❑ I am exempt under Sec REPAIR
BhP.C.for Wa reason 48-1 R.s DEMOL ❑ LnMA P/C r 1
Date USE OF EXISSTINO BLDG URM ❑ ACCT.'Lr
re A/P/pJv�i(PFNIT) TEL N 83303
a 4a LDMA Perm r
El I, as owner of the Or rrrrd
y eoyeee wtlh wages as r` –ZD 2 a z i i.15 —
their sole Ido the work and the structure Is 1 I TEM
TOTAL 156 _ 15
not hTtanded or offered (Section 7044,sate (S 7044, Buelnees and .� �� �� Fe3AL o.�TE
Prc(eeslona coda.) wa.L THE!M*UCANT OR PJR6 ra■DM Oca,R,++T HA1RC A FV2AF1D0Lb MMC _1 qS
OR A MIXIlFE CON-VJN 7 A I-WNflOUe MUEFAAL EOlY1 TO OR(YE46i H YFE .
LIlicensed contraoLors to corxtruoi4 as owner of ft property, � the project (Seofion 7044 A+roLwre SPEC,+�ON n-E HAZArDa>e WCMALB rFORIAAnON aUK)e? FUtAL BY 1' }• F
Business and Prc(eeabr s Code.) YEe El YSLT
L THE MT E7CED UBE OF THE ar+m Rf THE APR_K'.M1T CH FUTIFE R rr ryQ '
OCCUPANT R&OUM A PST FOR CQH0TP1UURC1N OR MOCVICKr"MOM THE SOUTH _
CONSTRUCTION LENDING AGENCY. COAST A"MW TTY'rWAaIENT 0f8T:ucT MCAQ W SEE POVArrTM a-EnaSr FOR
I hereby affirm that there.Is a corTeh udipn Iending agency for p6
No 0000–OW 1 6/14/95
the perbrmenoe uUthe worts kc whish this permit is lamed(Seo. IFVVEFFEAD HAZAFDOUauASSiSLa aI AND T4 WAG►OP�LTTNO [�i�� 1 A1111'26
3097,Ctv.C.) a-EtSaraT. w UNDER TFE Los ANGELES COUNTY�
TmF 2, n-FK)UGH 2-M140 CONCEF04W HAZARDOUS
Lenders Narng FOR A PEFMT FROM THE eG0►O.
Lenders Address
O awns OR Att«T
1 certfy that I have read tie appikcati n and state Under penalty P.0 � PERMfT FEE /
of perjury that the above Wormafon Is correct I agree to corrpfy �O
with ell DMTty Ordl ncae and State kawe refating to txflfdrp
tocor Y5.r r> ebhoraby euthortre for hapeotlon Purposes-itMee of U* County t88L1AfJ(E FEE / d
o INESTX AAT)ON FEE TODAL FEE (s f
^ .APr
SEE REVERSE FOR EXPLANATOFTY LANGUAGE
WORKEIRS COMPENSAT1oN DEC�ARATFON
hereby affirm that I have a certificate of consent to self A p p L l CAT I O N .FOR BUILDING p E RJAA I T
in.suro, or a certificate of Workers'.�gmpenaatlon Invuraace,
or a certffred copy thereof (Sec 3800 COUNTY OF LOS ANGELES MALDING AND SAFETY
Policy Nofl� f0 7 Company
❑ Certtfied_copy is.hereby fumished. . FOR APPLI TO FILL IN BUILDING j..g /..
❑ LertFfied copy tafiled artrh rf; .co nfy bu Ingirmpec- BUI NO . / _
tlon department. r
ADDRESS
6,46d4 It. 4V
CITY ZIP LOCAL"
Dafe�Applicant':' NNcq3�� NST •
CERTIFICATE C>� - FROM WORKEIRS" 'SUM OF Lor Ndw ON Lor CROSS Sr.
COMPQqsA110N INSURANCE ASSE�soR
(This section need not be tom 'feted•if the permit I,i for one TRACT BLOOC LOT Na M.p gppC S PACS �' PARCEL hundred dollars-f;100)Qt•aess.�' - USE mNE
owrER NO. d
I certify that In the pedormart of the work for Yrhlch this-
permltdsI*ued, I shall notpmploy PRy,pgrson-In any manner ADDRESS SPECIAL
rrl(JtJS "
so as to,become subl�to.the.Workori Cpmpensatibn Laws'. O
CRY C ZIP . . . . . . U
Date-Applicant- ARCH OR TEL NSTRICT
NOTICE,TO:AF?LIC NT: .If, after-rpaklnq this.Certificate-of WEER . NO. GROUP TYPE O
ZQbLF-
Exemption, .you.should become subject to the. Worked,
Compensation provisloris o#.the Labor Code, you must forth- ADDS
jeh comply with such pro,lIvlons•or ,thl# p&nnit a}wll be. TEL STATISTICAL CLASSIFICATION AFT. N
demed revoked.... Cx WMCTOR r NO. z
LJcp15E0 CONTRACTORS'DECLARATfON - l JIG CRSS PIO. DWELL UNITS.
I hereby affirm that I am licensed under provWor*of Chapter 9 ADDRESS N0'
(commencing wMhe
Sctior> 7000)of Dlvislop 3 of the-Pvsinbss UC AARP
aPdProfessions andttryllcpniel6infull force effect. CIY' _ _ CLASS �� gK PG.
VALtaAWN
SQ FT. OF NO. OF C}iEOC
Ucense Number Q c. sass '� S� STORIES FAMlU6 OPE -
VALUATION
Contractor / pate P DESCRIPTION OF WORK NPN ❑
}h, i� A - ADD 10
❑I am exempt under Sec rV / r ,4 L ,
ALTER 1E1 -
B-BP.C. for this reabn 4: �Q� 1 �✓"- f2FPA1R ❑
LIS�QF
. DUSTING BLDG. DEIVO ❑
Slflnature APPLICANT _ TEL
(PRINg
ER-BUILDER DECLARATION NO'
I hereby affirm that I am oxerrjpt from the Contractor's Ucer;e DATE Z ?J
Law for the follmyln'g reason ($ectlpn 70315, Busln_ou',and '''DDR FINAL
Professions Code): My- '_ .
❑ I, as,owner property, or my employees with of the BUDDING �• T.i
�.
woges.as their sole compgnsatlon,'wlIl do th3307e work and LGClLffY
the structuri Isnot Intended or offered for sale(Soctlon 1
7044, "Irma andgrofeesiont Lode.) MOWING TEL
❑ I,as owner of the am exclusive contrdctl cotgn ACfC R NO.
Property,. exclusively n9 ANT.TIL
witfrllcensed contractors to"construct t o prole-c' (Sec= _
tion 10", Buarnesa'gnd Profe"lora Code.) ADOf 55 Bj7 10.63
TO
COs'tSTRum)N LENDING AC4il` Y YARD I�WY 2 I1�
I h"by-gffirm that there is a constriction lending agency for FRONT
the performance of the work for which this.permit Is Issued P.t -lam
(Sec. 3D7/, ay. ¢) SIDE: TOTAL 192.., 38
p+�
Lenders Name t
S f LDW Ref. • r L� y�
^` Lenders Address
P. Fee 17 Permit Fee v `•Ca WK .Cu
I certtfy that I have read.this appllcation and state that the Issuance o? - LDMA P/c'/ n
above Information 4 correct.'I agree to comply-with all.County nvesrigatbh.F« / � ]-0]•1 n2 2 f92
ordinances ander I� latlrtd to buitAing conliructlon, Total Fee 1�0 �i!O LDMA Perm. 1� 1 rf r11��
and h a ntative4 of this Coun to enter dC
.uponbov " e for"Inspectlon p
a iii MAW 1'O!l7PLf1NATO Y LANGUA 04
nater.of Applicant or Agent Dclte