HomeMy Public PortalAbout9415 GIDLEY ST_Building__ , 'WORKERS'Cdl�PQdSATION DECLARATION
= ,
fn
re bra cer that., have a ce,tCome of co
A; APPLICATION FOR BUILDING PERMIT
Irtsuro, br a certlfltate of W erY' Compensation Insurance,
J;F` ceAlfled'copy thereof Sec - -"
( �� C.) COUNTY OF LOS ANGELES BUILDING AND S' FETY ;
PollcyµCertNi -, Company .._,. .,., -_ '- - -
ed copy Is hereby fumlahed. ( R APPLICANT TO FILL IN BUILDING
Q - ADDRIS.
�ertlfted copy Is.filed wlth't.he county'buffding Inspec- - ' BUILDING
Hon department: ADDRESS
Date Applicant• t any zip LOCALITY
CERTIFICATE OF E7EMPllOtd FROM`WORKERS' }�( OF B1DG5.- -- rEArzFs�-..
. .`.COMPENSATION INSURANCE • . SIZE OF LOT ON LOT CROSS ST. .
(Thls section need not'be completed if the permit Is for one - TRACT BLOCK. LOT NO.
-' "r' ,rc,
hundred dollars $100)or less. AMP BOOK PARCEL
( ) USE ZONE
I cert)fy that In tf;e pprforrnpnce c)f.thA work for wfil�h.thls OWNER- y �' NO• }
pefrrtlt is Issued, I sF.Il not employ.any person In any manner _ _t _ _ _-`.. I SPECWL- -
W as to becomd sd ubleto thb Workeri'Compensatlon Laws. 3
CCNDffIONS
R ary`Ge-wi_ G _11P-. _ _ _ ..-- - ... -- i
Dote I rcan;'
t
NOTICE'TO APPLICANT:'It, after maklriq this q cat• ARC}ifIECT OR Ta' DISTRICT P, TYPE_ RRE:. _ BY
r✓ffR !
mExempeption,-you should (become sublets'to'the Workers �T;
nsatlon provisions'of.the-Labor'Code, you must forth- ADDRESS ft SD r Nop. a v"' ,
with comply with.such.provisions ,or .thl&.parmit shall be - - -
d}emed-f.e.voked. CONTRACTOR TEL..
STATI$TICA1 CLASSIF TION APT: I'QbNDb.
LICENSED CONTRACTORS DECLARATION - - -- - -- - - - - CLASS NO_ DWELL UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO.
commend wtth,Sedion 7Ob0 of Dlvbbn 3 of the Busiriess and _ -_- SEWER MAP
( ng ) - •- 71G - - -
Profeesloru Code, and my license Is In full fotce and effect. CITY CLASS PG. -— VALIDATIOTI
FT. _ NQ.OF. . r' NO.'oF.-_
Lrgense Numb LIc.Clan STORIES 4JL7 FANUES ONS i
VALUATION
Cgntrador DESCRIPTION OF WORK
Dg'° ADD'. 6�, .
I am exempt under Sac IALTER
B.BP.C. for this reason REPAIR $
- use OF
Date: - - USE OF BLDG. (Tr I _
$19naturel - PR ZS! �� Rte
OWNER-BUILDER DECLARATION _ DATE
I hereby affirm that I am exempt from the Contractors License
Law for the following-reason (Sdctign 7031.5, Business and ADDRESS
FI
Professlonk Code): ` __. J
BUILDING
I, as owner of the property, or my employees with
wages ditheir Tole compensation,will do the work and {
the structure Is not Intended or offered for sale(Section LOCALITY
7041, Business and Professrons Code). h50VING — - TEL--'. -
NO.
I as owner of the prop", am exclusively contradln •
P P�Y� Y 0
with licensed contractors to construct the project (Sec- - ADDRESS
tion 7044, Buslness and Professions Code).
_ YARD HWY -TOT
CONSTRUCTION LENDING AGENCY IAZE PROP. UW WIDTH 1
I hereby affirm that there Is a construction lending agency for FRONT
the performance of 11-m work for which this permit Is-issued -P. - -- - -- - .. .L. . . .1. .- .
(Sec. 3097, Cly. C. - SIDE
B _
P.L . - - _-_
Lenders Name LDh4P Ref.
Lener- - .-- P.0 Fee$ � ,�. - Permit Fee , - - - - - x-7.6 a 6 A -�
d
s Address
i '� t� # o 'o 'o o a � •
I certify thart I have read this Ilcatlon.and-state that.the .... . ,_ � __. _ _ _ `� 1_1 �. _ •
aPP Iswanco Fee• V. LD /C# - '
-i 3-�a'o o� •
above Information Is correct. I agree to comply with all County Investigation Fee
ordinances grid State laws relgting to.bulldin9 construptlon,
and hereby authortze representatives of this County to on Total Fqe LDMA
upon the above-mentioned pro Jrty for Inspection purposes.
M KKV9W POt DO'LANATORY LANOUAW
- S`IgWhl`lro cyt ApplkaM t .• _ pule
1 .
•` ", KERS'QOMPENSATION DECLARATION
hereby affirm that I have r certificate ns consent to self APPLICATION FOR BUILDING P E RM I T
Insure, or a certificate of Worker
' of
Compensation Insurance,
or a certified copy thereof (Sec. 3800, Lab. C.)
COUNTY Of LOS ANGELES BUILDING AND SAF
Policy N9. TCompony
Certified copy Is hereby furnished. W77FOR APPLICANT TO FILL IN ,ppmVZ" r
❑ Certified copy Is flied with the county building Inspec- 6IJ ILDING
tion department.
Date Applicant CITY G ZIP LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' AREST
SIZE OF LOT / ONS NE
ST.
COMPENSATION INSURANCE
(This section need not be comleted If the permit Is for one ASSESSOR
hundred dollars ($100)or less. - TRACT BLOCK LOT NO. MAP BOOK PARCEL
TEL
I certlfy that In the performance of the work for which this NO• }
permit Is Issued, I shall not employ any n In any manner SPC{lA1 [1
so as lo become subject to the Workers Cmpensotlon Laws. ADDRESS COtDOlOt9S Q
Cm TEL-
71P
Date ApplI n-I i A�� �
NOTKE TO APPLICANT: If, after making this Certl o NO _ DISTRICT TYPE FIRE BY O
Exemption; you should become subject to the Workers' O 1' ZONE
Compensation provisions of the Labor Code, you must forth ADDRESS ��� l/
with comply with such provisions or this permit shall be TEL
deemed revoked. STATISTICAL F APT. Z
UCPNSED CONTRACTORS DECLARATION UG CLASS NO DWELL UNrrs "t
I hereby affirm that I am II oehead under provIsloro of Chapter 9 ADDRESS NO.
(commends' with Sedbn 7000)of blvlslon 3 of the Buslrmss and ( LIC. SEWER MAP
ProfessM Code, and my license is In full force and effect. Cm CLASS PGL VALFDAT10N
SQ. FT. NO. OF tJO.OF CNEC7C
License Number Llc.Clam+ SIZE STORIES IDES ONE
VALUATION
Con"Xictor Date DESCRIPTION OF WORK NEW
:
I am exempt under Sec. ALTER ,
B.3P.C. for this reason REPAIR =
USE OF DEMOL
Date: EXISTING BLDG.
Signature APPLICANT TEL �ri� PINAL 7 6.Q 2 A
OWNER-BUILDER DECLARATION PRI DATI '� ''
I hereby affirm that I am exempt from the Contractors License
Law for thq following reason (Section 7031.5, Business and ADDRESS FINAL # 0,16 o
Professlons Code): PRESENT By
BU 11.DI NG
I, as owner of the property, or my employees withADDRESS I u 1 7 1.7
5
wages as their sole compensation,will do the work and
the structure Is not Intended or offered for sale(Section LOFTY ' • •.� 7.1.•7 5,
7014; Business and Professions Code). MOVING TEL.
I, as owner of the property, am exclusively contracting OR NO. 0 a 0 5,. 8 7
nADDRESSwith liceed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code).
TOTAL SETBACY FROM
CONSTRUCTION-LENDING AGENCY YARD HWY PROP. uE
rDTH
I hereby affirm that there Is a construction lending agency for FRONT
the performance of the work for which this permit is Issued , P. -
(Sec. 3097, Civ. C.'). SIDE
P.L
Lenders Name
LDMA Rif. t}
$ P.C. Fee$ Permit Fee
Lenders Address
I certify that I have read this application and state that the Issuance Fee O J CJ LbMA P/C i
above Information Is correct. I agree to comply with all County Invwrlyatbn Fee
ordinance• and State laws relating to building construction, Tomi Fee 1-7
LDMA Perm. /
and hereby authorize representative•of this County to enter i
upon the above-"ntloned pro for Inspection purposes.
SM EFVRft KW DCLANATO[Y LANGdIAGA
of nt or Date _ /
TEMPLE CITY
76A638A CE#803 1-62APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING�. — -� o
DEPARTMENT OF COUNTY ENGINEER ADDRESS
BUILDING AND SAFETY DIVISION LOCALITY
JOHN A. LAMBIE, COUNTY ENGINEER NEAREST
WILLIAM A. JENSEN, SUPT OF BUILDING CROSS ST.
DISTRICT NO. GROUP TYPE PR C SS BY
FOR APPLICANT TO FILL IN co
BUILDING F STATISTICAL CLA5,SIFICATION SEWER MAP
ADDRESS BK P
CLASS. NO. --DWELL. UNITS
LOT NO. BLOCK WATER
CERTIFICATE: NOT REQUIRED RECEIVED ❑
TRACT MAP -- HIGHWAY SLOCA
NO.OF BLDGS. NO. (CIRCLE) TATE MAJOR SECON
SIZE OF LOT NOW ON LOT USE ZONE SPECIAL
USE OF CONDITIONS
EXISTING BLDG.
TEL.
OWNER NO. BUILDING YARD HWYSTREET NAME EXIST.
ADDRESS
C SETBACK A WIDTH
FRONT 1
ARCHITECT OR TEL. P. L. 2-d
ENGINEER NO. SIDE
P. L.
ADDRESS d
0
I
CONTRACTOR TEL. V D NO.
Ix
ADDRESS - �', O
DESCRIPTION OF WORK U
CL
NEW ADD ALTER REPAIR DEMOLISH Z
SQ. FT. NO. OF NO. OF
SIZE STORIES FAMILIES
USE OF
STRUCTURE F
SIGNATURE OF ' �f.
APPLICANT
VALUATION $ 1�
APPROVALS DATE INSP .TOR'$SIGNATURE
FEE $ FEE $ FOUNDATION: LOCATION • �: �.
-•�- FORMS, MATERIALS
FRAME: FIRE STOPS,
1-HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION BRACING. BOLTS
AND'STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY FURNACE: LOCATION,
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING GAS VENT, DUCTS
BUILDING CONSTRUCTION. I CERTIFY THAT IN DOING THE WORK
AUTHORIZED HEREBY I WILL NOT EMPLOY ANY PERSON IN VIOLA- LATH. INT.
TION OF THE LABOR CODE OF THE STATE OF CALIFORNIA RELAT-
ING TO WORKMEN'S COMPENSATION I URANCE. i
LATH. EXT.
SIGNATURE O HOUSE NUMBER COR-
PERMITTEE RECT AND POSTED 'f
ADDRESS 49 1 FINAL
JOHN F. LEWIS, PRINCIPAL STRUCTURAL EN R H
PLAN CHECK VALIDATION CK. M.O. CASH _ PERMIT VALIDATION CK. M.O. CAS
�{�{I�
L_t Lt 7 4.� r,<G J 1 I D CS.C� J~ �
°�°°°s APPLICATION FOR BUILDING PER
,55
1. IT 1
55
DIVISION OF BUILDING AND SAFETY BUILDING I
ADDRESS
Deportment of County Engineer
County of Los Angeles LOCALITY i
JOHN A. LAMBIE, COUNTY ENGINEER NEAREST
CASSATT D.GRIFFIN, SUPT OF BUILDING CROSS ST.
I
FOR APPLICANT TO FILL IN DISTRO. 'TP TYrf SEWER MAPCONST. K
BUILDING � NUMBERYES O
O
ADDRESS / �/ MAP HWY
LOT NO. BLOCK USE ZONE SPECIAL
CONDITIONS
TRACT
NO.OF SLOGS. C.
_SIZE OF LOT I NOW ON LOT / B NG YARD HWY STREET NAME EXIST.
USE OF
SETBACK WIDTH
EXISTING BLDG. FRONT 9 30
OWNER �, -� /u/�1. � /�j SIDE
AIL /�— /�JJ�� P. L.
ADDRESS G/�r/L.�+� O TRACT DWELL. 1 UNIT
CITY ,/eV,`f�� � O
NW 5 INDUSTRIAL
1 DWELL. 1 UNIT 6 PUBLIC BLDG.
ARCHITECT OR TEL 2 DUPLEX 2 UNITS ADDN..ALT., ETC.
ENGINEER N 3 APT. UNITS
8 7
ADDRESS 4 COMMERCIAL ISCEL
�
CONTRACTOR 04 ,,_,.,,, 9�, NO' INSPECTION REC
ADDRESS
DESCRIPTION OF WORK
NEW ALTER REPAIR DEMOLISH
SO. FT. NO. OF NO. OF
SIZE STORIES FAMILIES
USE OF STRUCTUR
SIGNATURE OF
APPLICANT APPROVALS
ADDRESS DATE INSPECTORS SIGNATURE
$ FOUNDATION: LOCATION
Za D 7EE
FORMS.MATERIALS
FRAME: FIRE STOPS.VALUATION .. BRACING, BOLTS elf FURNACE: LOCATION.
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS GAS VENT.DUCTS
APPLICATION AND STATE THAT THE ABOVE IS CORRECT
AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES LATH, INT.
AND STATE LAWS REGULATING BUILDING CONSTRUC-
TION.
LATH. EXT.
SIGNATURE OF HOUSE NUMBER COR-
PERMITTEE RECT AND POSTED
ADDRESS FINAL
JOHN A.LAMBIE, COUNTY ENGINEER _YAIDATION CLYDE N. DIRLAM.CHIEF BLDG. INSPECTOR
rl_CK MO CASH
107299'09 SjN27 1 6 n
� RFPABTMffiP! OF COUNTY EtfGItEM
FDIVIffiON OF BUILDING Axc��MTRND 2 1�53 B `®�
comrrr of Los A
WLLIAM J. FOX, COUNTY "GINER APPLICATION
CASBATT D. QRIFFIN, SUr'T OF SUILGIH4
FO APPLICANT TO FELL IN FOR OFFICE. USE ,ONLY
DISTRICT NO. PUH Cx.ow R>ta-No. PRH IT NO.
BUILDING
ADDRESS 2.
LOCALX Y IVSD _DATFIOPI D7K ISS
7
HEAREST ek cC i v8
—0948 41T, u
OWNKR 61\r b\'lMAILS ADD"" /
DRESS f LOCALITY .
d To- CROSS ST A-1 Al Z CITY NO.
OR TEL FIRE NO. OF TYP GROUP'
ARCHITECT
QIN ZONE PLANS "Z S.-__ .4=;
BLDG. ORD. NO.
ADDIUM SETBACK LINE
CONTRACTOR ?1 r{ Nom- { Ui6 APPROV M .
V v`,�
my
DA
ADD d ���� ,` ( HHOUB< +NUMGERING
LKQAL NUMBER �/ IJ MO. ASSIGN GY
DMSCRIFTION LOT NO. BLOCK _
COAR=ONB
TRACT
,( (� NO. OF■LOGS
SMK OF LOT 6`7 NOW ON LOT
USE OF NO. OFMWIING
- DTiON OF WOES D -
�yy Q_
REPAIR DEMOLITION
v�q FT. NO. OF
iIZI ROOMS STORIES
E][T. WALL ROOF
COVERING COVERING O
USE Otr STRUCTURE d .
i
x— .Q G X,
APPROVALS
IN/O SISNATURE DAT=
FOUNDATIONi LOCATION
FORKS, MATMUALS
I HAY ACKNOWLEDQE THAT 1 HAVE READ THIS AP- FRAMEi FIRE BTOrS. ��-
I-UCATION AND STATE THAT THE INFORMATION GIVEN 18 SRACIN BOLTQ
CORRECT.
1 TO commy wrrH ALL COUNTY ORDINANCES FURNACES LOCATION.
AND !STAT[ LAW1 U N¢ BUILDING CONSTRUCTION. GAS VKNT DUCTS
SIGNATURE Cdr
LATH, INT.
PE1RM
1 y �, LATH. Ql.
ADD
PLASTER, INT.
AUTHOR[=AST.
P7-.AtQ77L IXT.
s HOUSE HUMSMR
COR-RECT AND t'OSTED
VALUATION FIEZ 'L b FINAL
k_WtEthcrt,j
RS'COMPEL 1S 110N DECLAR4TIbfJlnsbF*,oacetl of Wok"'Compe�uo��ro "' .�. APPLICATION � FOR BUILDI-�V-G•- PERMIT
o`r'a ter}fled tdpy thereof (Sec:'399,1 b. C.) ,. COUNTY OF LOS ARGELIA BUILDING AND SAFETY.
Poll�ryNoCompany ^
Certified copy rs hereby fuml'hed. R APPLICANT TO FILL IN BUILDrNG `
ADDRESS
Certlfied zopy is-filed with"th s.cpunty bugdlnp fnspec- twILDINc3
tion ofepartrnept. ADDRESS "4
Ddte ., _ Applicant' CITYa4k LOCALITY
CERTIFICATE OF,tXEMYTK)N FROM ' tVo: BLDGS. T
COMPENSATION INSURANCE Sig OF Lb.T "f� N101N ON L T ST. . -
(thli section need not bs'•corh Ieted_tf-thr permlt,]t:for'arm TRAt7 gLOIX' LOT AMESSCkC 1. ' pAR($
fiundrbd.dolJ4n.J$i00)'bf less - _
I cart ify.that'in the performan`re of the work foot i fhlchi.fhIa }
-iseimlt Is lived, I'sholl not amploygny�eradn In any p5ahner
so as to become subject to the,Wor/kkeersCompensottan nWS
" Applicant'/1 '•/1 h1aYT�,r CITY PP. . 1 1 - -
} .
NO TO. ICANT; lf,-after Yriakinp thls tfio to ARCsip�GT OLO DISTRICT GROUP TYPE R BY 0...
Exertiptioo, you'4houfd -become, fabject to .the Workers' OST. ZONE13
Cempensa}[on oroAsjora of the Labor'Code, you muat.forth- // + ,� .0B
with (romphy with such provisions or_thts petmit shale be (Q�J
deemed revoked. CONTRACTOR / �3 _Zx STAnsn FICA APT. U)-
-LiCENSED coNTRACTQRS DECIARA ION UNITS Z
`,_ -
... I hereby affirm that I am licensed under provbilone of Chopw.9 V. ,;PA.2
S2Y48R MAP..
(�rnm!me�ndn�QQ w,�}th$edkxi 7000)of plvblon 3'of the Business and
ProtesalpntiCo�{q, and My 114ensa Is In filll'force and effect. cnY ;
FT; . .
6"Numbet LIc!Closs r bti
VALUATION
MCRContractor Da}� I OF _
4 am exempt under&K. ADD
ALTER
BARC.'for this recswn RttPAIR =
Date: lfIIt Dlh10L �.
'S1arkiiU4.. ..._ APPLICAfJT
O.WNER-BUILDERDECLARATION INT NO. DAT� f�� .
I hereby affirm that I am exofW from the Cohtroctors License _
_Lcw'fci the}oljowlhlp realbo (Section 7031,3, Business and t
PrcfeMlonsMG
1I, as owner of the prop ; Qr mylem0loyis -with I�
l erty
,DDRESS ; o _
w%XM as thelraole compenigtign,will do the work'dnd t
th*sttacture-'Is not InteTided,or offered for'salb(Section QTY
70", Buslgass and'Profesalons Code) MOVING iB
I, aiawrw of the property, am'excluslvely coptrogdnp• 7 9.2 Q.
wltfr licensed controctors to cohstruct the¢coject (Sec-
ADbREM
tion 7044, Busloesrand Frofsr"brts Code} r¢
EbfJSTpL)C170(J LENpING AGETVCY Vim
YARD }lMnl Ute D - e o (�, `
a.hweby offlrm tbot there'ts"'a construKtion lendinq.agency for FRONT r
the peFm "'
Pororof thea
,wiafor which this p*rmit Is Issued F~.L• 6 Q 5�p
ti(sec: 3097, clv.'C.) :; s+ -0 7..0 1 i 8 7_
P.L
Lenders Name
LDW Ref. 0
$ leTlder s Address P.0 Fee Fee s/
I.unify that 1,have-reod.,fhIs application.and sfate that the esuand FN J D t � LD"P/C t
a abovd informatlpn is corsel+t. I egree to oorap}y fru
wtth 911-Gounty 1n rn
ordingnc*t and State laws rel6ting to bull 1nq coniction;
herebyT I D,tiJ
R and authorize reprisenlatlwn of this Codnty' "ter
ter WMA
_I4pon the above-mentlor»d property.for Irupectjgp.Qurpd�es� r w Qtlf W t'Ot bI^ANATORY LAgQUA4lll
\ SiQnahire of Appl bent-or DaM ;
APPLICATION FOR BUILDING PERMITto ]
COUNTY OF LOS Al CELE'S .r ]BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO F1LL IN 0
I hereby afflrm that I tare a owtMoate of conaerrt to seff Inure,
or a certificate of Vrbrkors'Compensatb hiaurance,or a cerfffled
copy tfFe, (Sea 3800,Lab C.)_ � � !7
�� No, SIZE T NO.OF BLDG&NOW ON LOT
Cerfffled copy b hereby funlehed. NEAREST CROSS SOL.
❑ Cerfffled copy b fW wfth the oxwrty.buMing Inspection TRACT BLOCK LOT Na
1 USE ZOf,E MAP Na 7 7 !7 � 1 •
DateILI>�i�•e��to P,�` s'TY ASSESWR E �L
SPECcorarnoNs
CERTIFICATE OF.EXEMPTION FROM WORKERS' 7 YES No
COMPENSATION INSURANCE �4 ) K4 wrn-w 1OW FT.OF SCHOOL?
(Tide eecion need not be oorrQleUed H the permit le for one hundred ADDRE
D18113}CT I OAOUP TYPE CONST. FIRE SSFD BY
dollars($100) or lee.&) 9 d4 :' 1 .`6
I codify that h1 the performance of the work for which this penrdt ? LE Ur , d ,Q - - 3
Is Issued, I &hall not employ erry person In any manner oo as to ARq-=OR ENGPJEEA
become sub to file Workers' 1Bw.& s ti T CONDO
-I� }f� rLop at v MN .11TlON
Nb1i( rod aPPL1Gwr K, after makhg Cerlfficate of O 4 D3 , ' Cugs�D DWELL uN]TS Tank; EXIST .
Exomptlon, you should become subject to the VAxkere• TEl NO. SET BACK yip HVVY PF OP UNE 'n
Compensat n provwcns of the Labor Code, you moat foraw tthvh (L
comwith such prwrrft 4alons or this parshall be deemed wA*ad. (1 ADDRESS FRDNT
ply TOTAL '570 93
LICENSED CONTRACTORS DECLARATION1 �3 saaE l �fEtS �1 .9L
I hereby afftrm that I am licensed urxk3c wblone of Chapter 9 Lla PL
µ.P
(cmnnvxx*g wfth Section 7000)of DMMon 3 of the Business and Sa Ff.81E40.OF STORES 40.OF FANCIES -00
NEW ❑ BicPo
Code " d
Prufeesione Comy 8cer�ae Is In full force end effect ��yy�_,yy�
License Number U,CLaas DZPTOF WORK ADD ❑ LILIC-00tH q� 1/9
Contractor Date 0 T, f • ALTER $ 1542 i 10:2[=
Q I am exwo under Sao. REPAIR E.3 $ Q d07?• --
BAP.C.for this reason DEMOL ❑ LDMA P/C r )yJ
Date: B URM ❑ rn
(Parrr) LDALA Perm,f .23 Z
❑ 4 as Owner of the property, or rfry ernpfoyeee wfth wagee es _ - - - - Ep ACCT.JL
thair Sofa =T&r>effiion, wnl do the wgrk and the strTx;t<ue is Q �r 187.65
not Intended or offered for sale (Section 704-4, Business and �� o?O 7. r, DIAL DUE
Pra(eealcm Code.) YA L THE APPLKJJfr OR FUTLM F1ILDW OCQFYNr WOLE A FV2ARX 9 MKTFUL
To OR W
EOU
M
A F
R A WXTl COrfP!!10 V,UF�OU& ASEF6�L AL EAER THAN THE
❑ 1 as owned of the property, am e1adLFafvely oorr7aciirp with OAArOLKM 8PECFED ON TFE HAZARDOl1B NWSLL3lFOF&W-00H OLIJET FWAL BY j 1 -ITM
licensed contre� m oonstruct the protect (Section 704-4, YEs❑ No❑
B�,MV368 and Protenskne Coda.) M1m.-� TOTAL 187 - 65
%,LL THE NTEFDED ued of -r-E Rt ry..a BV 71-E APPLICJwT CR R MXIE N rr DM
OCCLF FCOl1RE A PUNT FPR COI�TRl1CTgN OR►IOOHCADN FlaDM TFE 8OUTH 1 _ 1V7. 1
CONSTRUCTION LENDING AGENCY �T AP ouurrY"QO"D ENT M TVCT MCAQW off PERMnTM a-Eaa'sT F019
C✓t IDE ..PA
hereby affirm that there to a mtetrLF d n Ierldlnu agency tcw YFO❑ NO❑ Vi ri TlL ■W
�y the performance of the work for wNct]bis permit Le i&erled(Sec- I FwE FF-AD THE 14AZMEOUS M,9FRAL3 NFORUXF ON OFLE AND THE a Acw PEAMnTNe -
3b97,Cfv.C.) - CFfCh11ST.I UIDEF7S'VM MY FF0UA rTa UMER THE LOO ANEEeP"! COOS•
TFLE-2,aWTER 220 SECTOrS 220100 T"W" 220.140 KkZAFDOUe
Lenders Name 1r-TER ALS FEPORTNAND OR CUMAN0 A P£FW FROM THE 8C000&-OWI 0Jl 19
/9
3
Lenders AddressL�OR A09NT 9&30 1 10 5'
5Q� I codify that I have read thIa application and state under penalty
of perjury that the abode Information Is correct I agree to oorpfy P.a FEEIf G PERMIT FEE o
with all county oni>naro and State Laws reiettlg to buldng x ,(�
const—kri, and hereby a mpmw(TWlves & this Caulty / G/ nSL FEE �o
a2 the above property for I d Cc
/ VVESTnATION FEE TO-DLL FEE ^
°D J iJ
n v Au.+ Of r
SEE REVERSE FOR EXPLANATORY LANGUA13E