HomeMy Public PortalAbout5221 GLICKMAN AVE_Building__ 70A888A CE#808. 1-81 APPLICATION FOR OR BUILDING P R IT
COUNTY OF LOS ANGELES BUILDING
DEPARTMENT OF COUNTY ENGINEER ADDRESS z
BUILDING AND SAFETY DMSION LOCALITY
JOHN A. LAMBIE, COUNTY ENGINEER NEAREST
WILLIAM A. JENSEN SUPT OF BUILDING CROSS ST.
DISTRICT NO. -GROL116 TYPE P SSED BY
FOR APPLICANT TO FILL IN [CONST.
CONST t
BUILDING F� /' I / STATISTICAL CLASS FICATION S ER MAP
ADDRESS..s � LSL/c, / - 1 K PG
CLASS.NO. 'J DWELL. UNITS_L
LOT NO. BLOCK WATER NOT REQUIRED ❑ RECEIVED
�+ CERTIFICATE: Li
TRACT 27_ MAPHIGHWAY STATE MAJOR SECOND, CAL
S/X �� I NO.OF BLDGS..�� NO l (CIRCLE)
SIZE OF LOT (o NOW ON LOT USE ZONE SPECIAL
USE OF _ �['� CONDITIONS
EXISTING BLDG. I/
T'/ �►y �•
OWNER V,D�U.� PES L�/� NOTELM 4j't{1. l BUILDING EXIST.
^� SETBACK YARD HWY STREET AME WIDTH
ADDRESS S�%Z� 7t�7iY�LE C/'t3' �L�y' FRONT
ARCHITECT OR TEL. P. L.
ENGINEER NO. SIDE
P.L. }
ADDRESS J /� INSPECTION RECORD O
CONTRACTOR /jf6W&-4F- AI'6 N0.,f6-2,$/l_ - U
ADDRESS,')r,yZT
1 ( V),/LC 45-r-Y RL-® 0
O
DESCRIPTION OF WORK u
O;
W
i a
EW ADD ALTER REPAIR DEMOLISH - Z
FT. NO.OF NO.OF
$IZE Z�� STORIES FAMILIES
USE OF Y
STRUCTURE
SIGNATURE OF
APPLICANT
VALUATION
APPROVALS DATE INSPECTOR'S SIGNATUftf
P.C. PMT. ��. �� FOUNDATION: LOCATION A -F
FEE $ FEE $ FORMS,MATERIALS _
FRAME: FIRE STOPS,
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION BRACING, BOLTS
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY FURNACE: LOCATION, I
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING GAS VENT DUCTS
BUILDING CONSTRUCTION. 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 STA E CALIFORNIA RELAT.
ING TO WORKMEN'S C PE TIO I U NCE. f'
J� / LATH, EXT. -
SIGNATURE OF l� v HOUSE NUMBER COR-
PERMITTEE RECT AND POSTED
ADDRESS FINAL J .
CLYDE N. DIRLAM, PRINCIPAL STRUCTU AL ENGINEER
PLAN CHECK VALIDATIONOK. M.O. CASH PERMIT VALIDATION aKM.o. CASH
Lj-ALO 6 fi 2 9 Nov '? 2 3 U 2 5.0(�
LA,,o7 3 1 9`0 NOV2 3 1 D 5 3.50- 1
WORKERS'COMPENSATION DECLARATION
hereby affirm that I have a certificate of'consent to self APPLICATION F®R BUILDING PERMIT .
- insure, or a certificate of Workers'Compenstion Insurance,or
y.eertified copy thereof (Sec. 3800, Lab. )
Policy No. 2�� 3��ompany �r?� COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING
ADDRESS
Certified copy is filed with the county building inspec- BUILDINGyZ ill // a
I!on department. ADDRESS (J >c/\/yJ LOCALITY
NEAREST
Date Applicant CITY ZIP dam(% CROSS ST. ren
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. OF BLDGS. � ASSESSOR
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL
(This section need not be completed if the permit is for one USE ZONE MAP
hundred dollars ($100) or less.) TRACT-r!.4730 BLOCK LOT NO.� NO. f`
TEL. 1� ( SPECIAL CONDITIONS
NER ' }
OW /LIQ
I certify that in the performance of the work for which this ®
� I
permit is issued, I shall not employ any person in any manner DISTRICT ADDRESS GROUP TYPE CONST ZONE- FIRE PROCESSED BY LJ
�S
so as to become subject to the Workers'Compensation Laws. � /' 19
Date Applicant CITY ZIP STATISTICAL CLASSIFICAJION APT. CONDO. L)
NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL.
Exemption, you should become subject to the Workers' ENGINEER NO. CLASS NO. DWELL. UNITS
t/3
Compensation provisions of the Labor Code, you must forth- ADDRESS SEWER MAP �
with comply with such provisions or this permit shall be
deemed revoked. CONTRACTOR ��j Z BK. PG, �� VALIDATION
LICENSED CONTRACTORS DECLARATION + �T�• C Sh 71
LIC.
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS 2- - �,¢Q' &i NO. ��Ei VALUATION
(commencing with Section 7000)of Division 3 of the Business and LIC.
Professions Code, and my license is in full force and effect. CITY i CLASS $ ��
SQ. FT. / STORIIES FAMILOIES � CONEK
I
License Number Lic.Class SZE
g
Contractor Date DESCRIPT OF WORK NEW
am exempt from the licensing requirements as I am a �Ui UJ`L.rk� ADD
licensed.architect or a registered professional engineer ALTER EJ FINAL
acting in my professional capacity (Section 7051, REPAIR DATE
Business and Professions Code). USE OF FINAL
EXISTING BLDG. DEMOL
Lic:or Reg. No. Date APPLICANT TEL. By LL _`
OWNER-BUILDER DECLARATION (PRINT) NO.
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and ADDRESS 3 2.6
Professioris Code). PRESENT
El
BUILDING
I, as owner of the property, or my employees with ADDRESS a o o o ° 1
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section LOCALITY 2 r0 0 4 3,00
7044, Business and Professions Code). MOVING TEL.
I, as owner of the property, am exclusively contracting CONTRACTOR NO. o o 0 11 J Q Q
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code). [I 1 3j—82
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH
REQUIRED TOTAL SETBACK FROM EXIST.
I hereby affirm that there is a construction lending agency for FRONT
the performance-of the work for which this permit is issued P.L.
(Sec. 3097, Civ. C.). SIDE
P.L.
Lender's Name
mP.C. Fee$ Permit Fee
Lender's Address
w I certify that I have read this application and state that the Issuance Fee
aabove information is correct. I agree to comply with all County Investigation Fee / r
0 ordinances and State laws relating to building construction, f�
w
an -heree uthorize representatives of this County to enter Total Fee s
on iffe:t oma! - roperty for inspection p os . .
a SEE REVERSE FOR EXPLANATORY LANGUAGE
not.-
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