HomeMy Public PortalAbout5838 GOLDEN WEST AVE_Building__ `ieweaeA'ce#eoa i.58' APPLICATION FOR BUILDING PERM .IT 1
COUNTY OF LOS ANGELES BUILDING
'DEPARTMENT OF COUNTY ENGINEER ADDRESS
BUILDING AND SAFETY DMSION 'LOCALITY
JOHN A.LAMBIE,COUNTY ENGINEER NEAREST
CASSATT D.GRIFFIN SUPT OF BUILDING CROSS ST.
DISTRICT O. GROUPI TYPEI P CESSED BY
FOR APPLICANT TO FILL IN CONS
BUILDING / ✓ I SEWER MAP '
ADDRESS STATISTICAL CLASSIFICATION RK PG
_ CLASS.NO. DWELL. UNITS
LOT NO. � 4 BLOCK MAP STATE
NUMBER o(i(J—(/ HWY. YES NO
TRACT_ ' /P USE ZONE SPECIAL
NO.OF SLOGS. CONDITIONS
SIZE OF LOT NOW ON LOT (fie(
USE OF ,
EXISTING BLDG. EXIST.
[ WIDTH
BUILDING- YARD HWY T NAME
OWNER I�Li� ,PJ
SETBACK
"
MAIL, P.L.
ADDRESS. SIDE
TEL. P.L.
CITY 7;�F No INSP CTION RECORD
ARCHITECT OR TEL.
ENGINEER NO. /
ADDRESS 'l
CONTRACTOR .. �/' NO.
DESCRIPTION OF WqLff
NEW ADD ALTER REPAIR DEMOLISH
SO.FT. NO.OF �hI NO.OF
SIZE 4'� �' STORIES t FAM ILIES
USE OF STRUCT t'
• ems,- - � /LJ
SIG ATURE
OF 3 �, � APPROVALS
PLICANT
� DATE INSPECTOR'S SIGNATURE
ADDRESS •� rti ��t '7 FOUNDATION. LOCATION
$ FORMS,MATERIALS
P,C• -S FRAME. FIRE STOPS.
FEE • :BRACING, BOLTS
VALUATION $4r 10LFURNACE- LOCATION.
FEE — GAS VENT.DUCTS
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS AP- LATH,INT.
PLICATION AND STATE THAT THE ABOVE IS CORRECT AND
AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND
• STATE LAWS REGUJLAT4 G t! LDING CONSTRUCTION. LATH,EXT.
SIGNATURE OF ✓ `—if_^ HOUSE NUMBER COR
'PERMITTE RECT AND POSTED
ADDRESS �` FINAL -
CLYDE N. DIRLAM, PRINCIPAL STRUCTURAL EN
PLAN CUCS VALIDATION CK/ M.O. CASH PERMIT VALIDATION CK mo CASH
LACO'6 4 1 .2 LOCO NOV 6 1 A 2.0 0 •
Or
�yy��. Wql:KtRS' COMPENSATION DECLARATION
t hSre', affIrmsth 'I have certificate of consent to self APPLICATION
P P:L I CATION FOR BUILDING• PERMIT
+' insure, o.•a cer�(Icate of Workers' Compensation Insurance,
.or a cerfif.ed copy thereof (Sec 3800, Lab C ) _
COUNTY OF LOS.ANGELES; BUILDING ANDS F. TY'
Policy No, Company.
BUILDING
❑ Certified copy is hereby furnished FOR APPLICANT TO FILL IN ADDRESS ((/
❑ Certified copy is,filed with the county building inspec- BUILDING
tion department ADDRESS - 3 AENt c�31C AJC
Date Applicant CITY 1�LE CL ZIP ( V, ' LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO OF BLDGS NEAREST•
COMPENSATION INSURANCE SIZE OF LOT 50A Iq NOW ON LOT ( CROSS ST
(This section need not be completed If the permlt,is for one TRACT , BLOCK , LOT NO. MAP BOOK PAGE PARCEL
ASSESSOR
hundred dollars ($100)or less,)
I certify that In the performance of a ork for which this OWNER 1 L Et2ktAlV i�E Z 1''
TEL
S 01' USE NE NOP
permit is Issued, I shall not employ y p son In ony anner ADDRESS G t. �r SPECIAL
so as to'become,subject to the'Wor ers'Comp s I n laws. CONDITIONS U
XR CITY °. ,' ZIP �
Dote J l Appl(cant ARCHITECT ORp'�� ,l� TEL• c DISTRICT GRO P TYPE FIRE PROCESSED BY O
NOTIC -TO. APPLICANT- If, after making thI Certificate of ENGINEER rlflwitiL �5�' NO CONST Z E ,Exemption,'you should become subject to the Workers' A \ (/JKx// '�`�N V
Compensation provisions of the Labor Code, you must forth- ADDRESS (0J� CA Ro5A v �� " a
with comply with such provisions or this permit shall be TEL STATISTICAL CLA$$IFIfATION APT CONDO fn
deemed revoked CONTRACTOR NO V!C/ ,
LICENSED CONTRACTORS DECLARATION; LIC CLASS-NO -DWELL UNITS Z
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO SEWER MAP 9
(commencing with Section 7000)of Division 3 of the Business and LIC . _ �9 9 0 A '
Professions Code,'and my license is In full force and effect CITY CLASS SK PG VALIDATION�3
SQ FT. NO OF NO .OF CHECK
License Number Lic.Class SIZE JD7 STORIES FAMILIES 1 ONE
• _ n/i♦t. AAS VAL 10 It • 39207
Contractor Date DESCRIPTION OF ORK A DD 11J&Jf 't ED NEW ❑ $ 11 _
❑ I am exempt under Sec iuLL?,A?H>r ST - t L pcm ADD , ? • 3 9 2 0 7 v
n ALTER 06,27;'-88
B.BP C. for this reason iM ode DF .•Q XE. w REPAIR ❑ $ 0
Date USE OF k1p".EXISTING BLDG DEMOL
Signature APPLICAN'
TEL , 6 D FINAL
OWNER-BUILDER DECLARATION PRINT t LEL iJDF Z NO I ZS 3`1 DATE
�.
zL
I hereby affirm that I am exempt from the Contractor's License c //'� 1
Law for the'followlhg reason (Section 7031 5, Business and ADDRESSS 0 3F 6oiD&-UkJC�S't A�1E; FIN t'
Professions Code) BY
❑ j, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and `''• ' '` '��.\,;' fit ;, 1��\� .t 0,
LOCALITY
the structure Is not Intended or offered for sale(Section - - - �, � ,•.`� tit
7044, Business and Professions Code) MOVING TEL 2 0 3 9.6 A
I, as owner of the property, am exclusively contracting CONTRACTOR NO
with licensed contractors to construct the project (Sec- ° 4`7 7
tion 7044, Business and,Professlons Code) ADDRESS
REQUIRED TOTAL SETBACKo o 4 ] 1,`] 5 6
CONSTRUCTION LENDING AGENCY SET BACK -YARD HWY •PROP LINE WIDTH v
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 8 1 0,—8 8
(Sec 3097, Civ-C.) SIDE
PL,
Lender's Name
m
PC Fee$ ✓ /} SMA Ref #
Lender's Address V Permit Fee /) ��!
I certify that j,have read this application and state that the Issuance Fee vt�� LDMA P/C#
a
raboveation Is correct. I agree to comply with all County Investigation Fee
nd State jaws relating to�building construction, Total Fee LDMA Perm #authorize repro ntativee of this County to enterve-me on property for pectlon urposes f /' s� �t ` Yt•`' \f
I� ;fit`!• k j.t .�.
� SEE REVERSE FOR EXPLANATORY LANGUAGE �
pli
Signature of Apcant or Agent { v '