HomeMy Public PortalAbout5611 GOLDEN WEST AVE_Building__ 7GA888A CE#80811-67 APPLICATION FOR BUILDING PERfiIIT _1
COUNTY OF LOS ANGELES BUILDING
DEPARTMENT .OF COUNTY ENGINEER ADDRESS
BUILDING AND SAFETY DIVISION Of
JOHN A.'LAMBIE,COUNTY ENGINEER NEAREST r
CASSATT D GRIFFIN,SUPT OF BUILDING' CROSS ST
DISTRICT NO: GROUP TYPE SEWER MAP
FOR APPLICANT TO FILL IN "� G
J CONST
BUILDING / l. I. Q1 �]'' STATISTICAL CLASSIFICATION
ADDRESS I:,At / \ -
' - CLASS NO DWELL UNITS_-_A
LOT NO BLOCK MAP STATE YES
NUMBER HWY
TRACT USEZONE SPECIAL
/I�� NO OF BLDGS. CONDITIONS
SIZE OF LOT V NOW ON LOT
USE OF t�
EXISTING BLDG u 'k1 1 BUILDING EXIST.
/� SETBACK YARD HWY STREET NAME WIDTH
a 04
OWNER ,t . rl - FRONT-
MAIL �^' P L
ADDRESS 1 J G;6 me ��� SIDE
TEL P L
CITY 1'39 _! No I
ARCHITECT OR TEL. NSPECTION RECORD
ENGINEER 3 - NO
ADDRESS
yl p� /ea.✓ o 7--1A,-r_ o o S
CONTRACTOR ,P)O if ' NO FL-C3Q7�
�ii�t` v-hld' Ivu - G O -r-,o w Foal-,ie FG
ADDRESS If-0O Si
/ DESCRIPTION OF WORK "v T/ `
NEWv ADD ALTER REPAIR DEMOLISH -
SQ FT. NO OF NO OF - r
SIZE /4 Q -_ STORIES - FAMILIES ,
USE OF STRUCTURE"
SIGNATURE OF , I I APPROVALS
APPLICANT
DATE INSPECTOR'S SIGNATURE
ADDRESS LOO (}'+I�iGGa. FOUNDATION LOCATION -
FORMS.MATERIALS '
.� y� /-��, P C. $ ,,,�7 FRAME FIRE STOPS.
i _/ FEE- BRACING.BOLTS
VALUATION $ FURNACE LOCATION. -
FEE GAS VENT,DUCTS
1 HEREBY ACKNOWLEDGE THAT 1_HAVE-READ THIS AP- LATH, INT /�{f
PLICATION AND STATE THAT THE ABOVE IS CORRECT AND
AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND �1
STATE LAWS REGU TING BUILDING C NSTRUCTION LATH.EXT. FF//"->�;//
SIGNATURE OF d/r - HOUSE NUMBER COR-
PERMITTE RECT AND POSTED �)
C
ADDRESS �� FINAL' (
CLYDE N. DIRLAM, PRINCIPAL STRUCTURAL 'N ER
PLAN CHECK VALInA7qON CK M.O. CASH PERMIT VALIDATION CK. M O. A3
M_� l,'2-054:0Y03' ,l 9 ... 1:a' _6:0,4 : ®- r
WORKERS'COMPENSATION DECLARATION ''' ` /
1 hereby affirm that I have r certificate of consent to Self APPLICATION FOR B U I L D�I N G' PERMIT\ '
insure, or a certificate of Workers' Compensation Insurance,_
or
a, 3800,thereof(Sec 3800, Lob C )
COUNTY OF LOS-ANGELES BUILDING AND SAFETY ,
Policy No Company,
❑ CertiBUILDING
fied,copy is hereby furnished FOR APPLICANT TO FILL IN ADDRESS`- H
❑, Certified copy is filed with the county building mspec- BUILDING jj /
tion department ADDRESS , -- �� _ (�' LOCALITY
NEAREST —
Date -Applicant CITY ZIP Cj CROSS ST
CERTIFICATE OF EXEMPTION FROM WORKERS' y t' NO OF BLDGS 3 ASSESSOR i
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL
(This section n'eed'not be completed if,the permit is for one / USE ZONE MAP
hundred dollars ($100)or less ) TRACT / / 3 BLOCK LOT NO' NO 0
TEL r SPECIAL }
I certify that in the performance of the work for which this OWNER c NO CONDITIONS' ,• 9116
permit is issued,.)shall not employ any person in any manner DISTRICT GROUP , TYPE: FIRE PR ESSED'BY Q
-so as to become subject to the Workers'Compensation Laws ADDRESS (fit CONST' ZONE
I��� R / -
/pate Applicant /'��• Cn w/may, CITY ZIP STATISTICAL CLASSIFICATION v - APT CONDO O f
JlJJJ I.-
NOTICE TO APPLICANT If,. after making This Certificate f ARCHITECT OR TEL W
ENGINEER NO CLASS NO _ ,r DWELL UNITS
Exemption, you should become subject to the Workers' IL
Compensation provisions of the Labor Code, you'must forth- ADDRESS - - SEWER MAP N
with comply 'with such provisions or this permit shall,be TEL
deemed revoked CONTRACTOR :' NO �d VALIDATION
BK PG;
LICENSED�CONTRACTORS DECLARATION LIC
I hereby affirm-that I am licensed under'provisions of Chapter 9 ADDRESS NO 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 CLASS $ Q ,
SQ'FT NO OF NO OF CHECK
License Number Lic,Class SIZE STORIES FAMILIES ONE
DESCRIPTION OF WORK. NEW ❑ $
Contractor Date .
' _
❑ I am exempt under Sec t'- ADD ,
ALTER ❑ FINAL Z—V
B 8P �C for this reason :��lC �YJ ii'" REPAIR ❑ DATE
USE SE OF EXISTING BLDG 7rLG DEMOL C] BY AL/� _
Signature APPLICAN
PRINTT �5� �TIy�Q�1lt J'NL 4 i{/ ;
OWNER-BUILDER,DECLARATION
I hereby affirm that I am exempt from the Contractor's License 1f
Law for the following reason (Section 7031 5, Business and ADDRESS T5 ki� Pi ►. : '
Professions Code)- PRESENT
❑ BUILDING _ ;2 2.2,0.'5 A
I, as owner of the property, or my,employees with ADDRESS t
wages as their sole compensation,will do the work and # e 10_o o,o
the structure is not intended or,offered for sale(Section kADDRE
,
7044, Business and Professions Code) TEL
❑ I,'fis owner of the property, am exclusively contracting CONTRACTOR NO 2 ° 1 9,9,181
8- '
with licensed contractors to construct the project (Sec- o'o
• tion 7044, Business and Professions Code) I ( ,
ED TOTAL SETBACK FROM EXIST `
CONSTRUCTION LENDING AGENCY K YARD HWY PROP LIN WIDTH o'5,2.4—'8 3.
hereby affirm that there is a construction lending agency for - -
the performance of the work for which this permit is issued =
(Sec 3097, Civ C ) ,
< Lender's Name /7�$ Permit fee U // 3 f" -
Lender's Address W
I certify that I have read this application and state that the Issuance Fee
a above information is correct I agree to comply with all County Investigation Fee fj
' ordinances and State laws relating to building construction, g Total Fee 9.9-
and hereby authorize representatives of this County to enter
upon the above-mentioned property for inspection purposes ;
SEE REVERSE_FOR EXPLANATORY LANGUAGE ®3
e
Signature of Applicant or Agent Dote