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DEPARTMENT OF BUILDING AND SAFETY APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES BUILDING� I �D I
WM. J. FOX. CHIEF ENGINEER
FOR APP NT TO VLL INFOR OFFICE USE ONLY
BGCJ
DISTRICT NO. PLAN CK. NO. PERMIT NO.
UILDIN
ADDRESS
LOCALITY RECEIVED BY DATE OF APPL. DATE ISSUED
NEAREST
CROSS ST. BUILDING
ADDRESS -
OWNER
MAIL LOCALITY
ADDRESS NEAREST
C TE CROSS ST.
CITY ry
FIRE NO. OF I TYPE GROUP
ARCHIT CT OR T ZONE I PLANS _
ENGINEER ry ,
BLDG. - ORD. NO.
" SETBACK LINE
ADDRESS L' �/h.�.. APPROVED
T BY DATE
CONTRACTOR "' USE APPROVED
��yy ZONE BY DATE
ADDRESS `-� '4•s. HOUSE NUMBERING
LEGAC
DESCRIPTION I LOT NO. / BLOCK MAP NUMBER FIELD CHECK BY
TRACT - NO. ASSIGNED BY DATE
� NO. OF BLDGS. CORRECTIONS
SIZE OF LOT`V O �� I NOW ON LOT
USE OF y NO. OF
EXISTING BLDG, V �(,�� I FAMILIBS / -
DESCRIPTION OF WORK
NEW I I ALTERATION I I ADDITION
REPAIR I DEMOLITION I I I p
$0. FT. NO. OF
SIZE ROOMS 8 IES ` Z
EXT. WALL ROOFeD
r
COVERING �CCO�V�ER�IN�G V
USE OF STRUCTURE rJ ✓"
APPROVALS
INSPECTOR'S SIGNATURE DATE
I HERESY ACKNOWLEDGE THAT I HAVE READ THIS AP- FOUNDATION: LOCATION
PLICATION AND STATE THAT THE INFORMATION GIVEN IS FORMS, MATERIALS
CORRECT.
I AGREE TO COMPLY WITH THE CORRECTIONS LISTED FRAME: FIRE STOPS,
HEREON AND WITH ALL COUNTDINANCES AND STATE BRACING, BOLTS
LAWS REGULAT BUILDI G ON RUCTION. FURNACE: LOCATION,
SIGNATURE OF GAS VENT, DUCTS
PERMITT
_ LATH, INT.
ADDRESS
LATH, EXT.
AUTHORIZED AGT.
C�
PLASTER, INT.
7ewe3ew• DHsi fano �0 P. C. $
FEE PLASTER, EXT.
VALUATION $
FEE FINAL
I
DEPARTMENT OF BUILDING AND SAFETY APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES S ' ® '
WM. J. FOX, CHIEF ENGINEER
FOR APPLICANT TO FILL IN FOR OFFICE USE ONLY
DIBTRI5�NO. PLAN CK.NO. PERMIT NO.
BUILDING
ADDRESS `
LOCALITY / RECEIVED BY DATE OF ADPL. DATE IBBUED
NEAREST
CROSS ST. g2 _
BUILDING "
OWNER ADDRESS ✓ 'J
MAILLOCALITY C-
ADDRESS a 2
� NEAREST
TEL CROSS ST.
CITY ZIP 24 O. FIRE NO.OF T PE. GROUP
ARCHITECTOR TEL ZONE PLANS ,f'
ENGINEER NO.
BLDG. ORD.NO.
ADDRESS - SETBACK LINE
APPROVED
TEL BY DATE
CONTRACTOR Z NO.
USE APPROVED
ADDRESS ZONE BY DATE
LEGAL CORRECTIONS
DESCRIPTION'S LOT NO. BLOCK
TRACTT '
1 NO.OF BLOBS.
SIZE OF LOT � I NOW ON LOT
USE OF I NO.OF f I NO.OF�
EXISTING BLDG..& 't�'. FAMILIES ! ROOM
DESCRIPTION OF WORK
NEW ALTERATION ADDITION O
A
REPAIR MOVING DEMOLISH p
S4•FT. NO.OF Z
SIZE ROOMS STORIES /t r
WALL I ROOF
COVERING i n cry COVERINGUSE o
BUILDING W a a
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPROVALS
APPLICATION AND STATE THAT THE ABOVE IS CORRECT FOUNDATION: LOCATION INSPECTOR DATE
AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES FORMS,MATERIALS
AND STATE LAWS REGULATING BUILDING CONSTRUCTION.
FRAME: FIRE STOPS,
SIGNATURE OF BRACING,BOLTS
PERMITTEE -, LATH,INT.:
AUTHORIZED AOT LATH,EXT.:
OBS-3 50M SETS rae $ _ _ - FFEE
PLASTER,INT.
PLASTER,EXT.
VALUATION - ' FINAL
APPLICATION FOR BUILDING PERMIT
FOR APPLICANT TO FILL IN (Print or type only)
BUILDINGS �� COUNTY OF LOS ANGELES
ADDRESS DEPARTMENT OF COUNTY ENGINEER
CIT ZIP '7 C� BUILDING AND SAFETY DIVISION
NO.OF BLDGS. BUILDING �--/�/ •� ��
SIZE OF LOT-S.0 XJ6 0 NOW ON LOT ADDRESS
TRACT BLOCK LOT NO. 'LOCALITY Gr
OWN NO NEAREST
CROSS ST, A
ASSESSOR
ADDRES MAP BOOK PAGE PARCEL
DISTRICT GROUP TYPE FIRE PROSS
CEED BY
CITY ZIP d CONST le ZO
ARCHITECT O TEL ��
ENGINEER NO.
STATISTICAL CLASSIFICATION SEWER MAP
ADDRESS CLASS NOA_�__DWELL.UNITS BK PG
CONTRACTOR TEL. _ �S�Z MAP
LIC.
ADDRESS f tjNO, SPECIAL
LIC. CONDITIONS
CITY CLASS _
ROAD DEPARTMENT A PPROVAL REQUIRED YES❑ NO ❑
CONSTRUCTION LffNDER
NAME AND BRANCH BLDG.SETBACK FROM
FRONT PROP,LINE OF (STREET)
ADDRESS CITY HIGHWAY } YARD TOTAL SETBACK FROM TYPE OF EXISTING
SQ.SIZE STORIES FAMILIES !
FT. NO. OF NO. OF / E CHECK FRONT PROP. LINE HIGHWAY WIDTH
ZON
+ _
DE4C RIPTION OF WORK NEW 1:1
DD ❑ BLDG.SETBACKF
SIDE PROP.LINEOF (STREET)
LTER HIGHWAY } YARD = TBACK FROM TYPE OF EXISTING
EPAIR❑ E�Rgil LINE HIGHWAY WIDTH
USE OF } _
EXISTINP BLDG. nEMOL ❑
APPLIC T / TE CORNER CUTOFF YES NO ❑
(PRINT) F4Q N0� � Iti
IN OPEN SPACE YE3 ❑ O ElBY (SIGNATURE)
t �] IN COASTAL ZONE YES ❑ NO
VALUATION�Y CATEGORICAL EXEMPTION YES❑ NO ❑
I HEREBY ACKNOWLEDGE THAT 1 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. I CERTIFY THAT IN DOING THE WORK AUTHORIIED IMPACT REPORT PROCESSED ( TE)
HERESY I WILL NOT EMPLOY ANY PERSON IN -VIOLATION OF THE
LABOR CODE OF THE STATE OF CALIFORNIA IN RELATING TO
WORKMEN'S COMPENSATION INSURA NCE.
N
31GNATUR r
PERMITTE
ADbR ESS
FINAL BY
TEL. DATE
CITY NO. t
MAKE CHECKS PAYABLE TO: FEE FEE F
HARVEY T. BRANDT. COUNTY ENGINEER 0 -6
f�
PLAN CHECK VALIDATION CK. M.O. CASH _ PERMIT VALIDATION(CK. CASH
U 3 SJ G=MAT b 1 U J -9.0 0
76AO38A CE#a03 7/73
es 76A63BA
CE#QM(REV.11/78)
APPLIC.A . 10 OR BU I PERMIT .
COUNTY OF. LOS ANGELES_ BUILDING AND SAFETY,-_,
FOR APPLICANT TO FILL IN ADDRar C-14
BUILDING (I Ltoq
ADDRESS LO(rALTTY
NEAREST
d ZIP 1 CROSS ST.
NO.OF BLDGS, ASSESSOR
51ZE OF LOT O NOW ON LOT MAP BOOK PAGE P
" DISTRICT ' GROUP TYPE FIRE E55 BY
TRACT BLOCK LOT NO.
OWNER C T�b�U - r —
STAT15T1CAL CLPSS CATION } S MAP
ADD - - - CLASS NO.�PWELL UN T5 BK.. PG
crrY - Zip
ARCHITECT OR TEL VALUATIONQ QQ OG
EN GI N EER NO
ADDRESS BL FPOM
TEL FRONT PROP.UNEOF ISTREETI
CONTRACTOR NO. TOTAL SETBACK FROM TYPE OF EXISTING
LIC HIGHWAY + Y FRONT PRQ?.LINE HIGHWAY 'WIDTH
ADDRESS NO.
- Uc }
CITY CLASS -
CCXJSTRUCTI BLDG.SETBACK FROM
NAME AND BRANCH SIDE PROP.L1N� TI
OF ISTREE }}}...
HIGHWAY + YARD TOTALSETBACK FROM TYPE OF EXISTING O�
ADDRESS CITY SIDE PROP..LINE HIGHWAY WIDTH O
SO.FT. NO.OF NO.OF CHECK -+ cm
SIZE STORIES I' FAMIUB - "-CNJE - C)
IISE E MAP D
DESCRIPTION Or-WORK - - NEW . . / SPE
.. � SPECIAL •'r ,
ADD CONDMONS y�
BY JCV
..
FDATE
USE OF DEMOL
EXISTING BL ]REPAIR
-
APK(MN T I t.A-hK D C Uj( T
BY ISIGNATU
I HEREBY
gOAVCV40V-EDGE THAT I HAVE f�,�D U D STATE �O 3 Q 3 A
_THAT LAWS REGl1LATINall 1=13 Tb QO/�1PL All ORDINANCQ .-
LbifiG G fTdICTION. CEiTI THAT IN DOING THE
WORT(AUTHORIZED HERBY I WILL NOT EMPLOY ANY PERSON IN VFOLAT}ON OF '# O O 0.0 O.1
TFIE 4A80R CODE OF THE STATE OF CAU FQRN IA IN RE.ATI NG TO WOWMEYS CQA� - -. )
PENSATION 1NSU WX:E.• ' `G O O 4 J,0 O'.
SIGNATURE O 40_ _ 4 3 Q Q iS
PERMITTEE
ADDRESS 0613-80
to
CITY
I.C. Fee$ PermR Faq -
Issuance Foe
Total Fee C/
APPLICATION FOR BUILDING PERMIT
FOR APPLICANT TO FILL IN (Print or type only)
BUILDING COUNTY OF LOS ANGELES
ADDRESS DEPARTMENT OF COUNTY ENGINEER
CIT ZIP OT11 ,zo BUILDING AND 14 SAFETY DIVLSION
QA NO.OF BLDGS. BUILDINGJ
SIZE OF LOT d NOW ON LOT I ADDRESS Q (! `
TRACT BLOCK I LOT NO. LOCALITY
T NEAREST
OWNE -� CROSS ST.
ASSESSOR
ADDRESS MAP,BOOK PAGE RCEL
Q- DISTRICT TYPE FIR PR ESSED BY
CITY Zip 0 0 /� T. z E
ARCHITECT R TEL. ,0
ENGINEER NO.
STATISTICAL CLASSIFICATION SEWER MAP
ADDRESS CLASS NO L—DWELL•UNITS BK PG
CONTRACTORS TEL. ZONE NO.
6
LIC.
ADDRESS NO. SPECIAL
CITY LIC.
CONDITIONS
CLASS RO D PARTMENT APPROVAL REQUIRED YES❑ NO ❑
CONSTRUCTION LENDER
NAME AND BRANCH BLD .SETBACK FROM
FRO T PROP.LINE OF (STREET)
ADDRESS CITY = TOTAL SETBACK FROM TYPE OF EXISTIRG L�
SQ. FT NO. OF NO. OF CHECK HIG}IW } YARD - FRONT PROP. LINE -HIGHWAY WIDTH
SIZE D ISTORIES FAMILIES ONE
}
DESC RIPTI F WORK NEW El d7
DD BLDG•SETBACK FROM ZL
SIDE PROP.LINE OF (STREET)
LTER HIGHWAY } YARD TOTAL SETBACK FROM YPE OF EXISTING
=
USE OF
E }PA SIDE PROP. LINE
HWAY WIDTH
_
EXISTING BLDG. EMOL ❑
P T NE rI CORNER CUTOFF YES ❑ NO
IN OPEN SPACE YES ❑ NO ❑
BY (SIGNATURE)
IN COASTAL ZONE YES ❑ NO ❑
VALUATION$ 4aLo - CATEOORICAL EXEMPTION YES[] NO ❑
I HEREBY ACKNOWLEDGE THAT I 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. I C[RTI FY THAT IN DOING THE WORN AUTHORIZED IMPACT REPORT PROCESSED (DATE)
HEREBY I WILL MOT [M PLOY ANY PERSON IN VIOLATION OF THE
LABOR C DE OF THE )TAT[ .C'
CALIFORNIA IN R[LA TI NG TO
WORKMEN' CO MPENSATIO IMS RAN
SIGNATU F
PERMITT
ADDRESS
FINAL BY
CITY 7p DATE
MAKE CHECKS A YABLE TO: FEE PMT,Q
FEE FEE $
HARVEY T. BRANDT, COUNTY ENGINEER 7,-;t--o
f
PLAN CHECK VALIDA'T'ION CK. M.O. CASH _ PERMIT VALIDATIO C M.O. CASH
8 1 Z JUN 13 3 D 7.2 0 A98v
4'8 28. 1 13 1 .D 1 2.0 0 •
7BA630A CEGBOS 7/79'
I t
WORKERS'COMPENSATION DECLARATION..,
1
I hereby affirm that I have a certlflcate of con"nt to sA f
Insure, or a certlflcate of VN a'rs Compensation Insurance, APPLICATION FOR BUILDING P E RM I T
or a ceritfled copy thereof(Sec 380Q, Lab. C ) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No Company BUILDING /
. Certified copy Is hereby furnished. -fa FOR APPLICANT TO FILL IN ADDRESS
❑ Certtfled copy Is filed with the county building Inspec- BUILDING
tion department.. ADDRESS. V 1✓ LOCALfTY L
fti NEAREST
Date Applicant QTY ZIP CROSS ST.
CERTIFIQATE OF EXEMPTION FROM WORKERS' NO.OF BLDG& ASSESSOR
COMPENSATION INSURANCE Sig OF LOT 410 NOW ON L I MAP BOOK PAGE PARC`$
USE ZOt�.
(This se cloll:need fioi be cam 'leted.ff.the petmlt Is for one-` ,. �T. BLOCK LOT �TEL ES:PEC�LAL
MokP
hundred dol4ars (;100}or less.� .I certffy that In the performance of the work for which thlf OWNER ftOtZ d
permit Is issued, I shall not employ any Peron In any manner D ILT. GROUP TYPE
Y f. Z RE PROCESSED BY 0
asWTAPICA
asubject tot Worker Compensatl ��ITECT OR CITY ZIP �' 3TATUrAL Fr_ATION AFT. CO1D0.nNT: If, making thl: ofd
Exemption, you should become subject to the Worker' NE R �' CLA55 No.=�`DWa1- uNfTs IL
Compensation provlslons of the Labor Code, you must forth- ADDRESS SEW Z ,
with comply with such provisions or this permit shall be _
deemed tevoked. TEL
CONTRACTOR NO. BK PG, A-T VALIDATION
LICENSED CONTRACTORS DECLARATfON LC_
I hereby affirm that I am Ilcensbd under provisions of Chapter 9 ADDRESS NO. VALUATION
(ommencingwith Section 7000)of DlvWoA 3 of the Buslnew and UC
0fesslom Code, and my license Is In full force and effect. CITY CLASS Ilk
ti SQ. Fr YW I NO.OF NO:OF / CHEO ►
License Number LIE Claes Sig STORIES FAMILIES ONE
Contractor pie DESCRIPTK>N OF WORK NEW ❑
ADD ElI am exempt under Sec-
ALTER FlIiA1
B.dP.C. for this reason ❑ DATE
REPAIR
Date' USE OFFINAL
EnTnNG BLDG. / t DEMOL ❑ � >
Signature APPLICANT — TEL
OWNER-BUILDER DECLARATION NO.
I hereby affirm that I am exempt from the Contractors License
Low for the following reason (Section 7031,5, Bushes and .
Professions Code):
F] 1, as.owner-of the property, or my employees with AAp REST'S
w09e6 as their sole compensation,will do the work 9nd 1'9 Q$7J A
the structure Is not Intended or offered for sale(Section
.710a,.Business•and Professions Code} MOVING TEL
1, as owner of the'property, am exclusively coniracting RACTOR NO. #? 0 0 0 0 0 1
with licensed contractors to construct theproject (Set= ADDS 2'� 2.6550
.tion 7044, Bull and Professions ode . _
i I RED TOTAL SETBACK FROM E(ST. 2 6'5-5 0
CONSTRU ON LENDING SE7 an YARD FW' PROP. U WIDTH ► 0 0
iSac.hereby affirm that there con on lending agency for FRGNT �, —f33
he performance of the w Ich this permit Is Issued P.L 3097, Civ. C.} SIDE
s Lenders Name'
C
enders Address P.C.Prm Fee; PeIt F.
I certify that I hav read this appllcatlon and wte that the I....Fee
above Information Is correct. I agree to comply With all County ImeulQatlon Fes
ordinances and State laws relating to bullding construction, Total Fie
and hereby authorize representatives of this County to enter
u n the abov meRt n Inspectlon purposes.
to Revow POR EUMIAP ATORY LANGUAGE _
Slgra of Applicant or Agent .