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HomeMy Public PortalAbout5569 HALLOWELL AVE_Building__ APPLICATION FOR BUILDING PERMIT FO -A9 ANT TO FILL IN (Print or type only) COUNTY OF LOS ANGELES BUILDING5 �j�J� f DEPARTMENT OF COUNTY ENGINEER ADDRESS CITY c�✓1 1 e— ��^F ZIP --717go BUILDING AND SAFETY DIVISION O.OF BLDGS. BUILDING SIZE OF LOT 3>K �, NOW ON LOT CJ ADDRESS TRACT BLOCK LOT NO. I LOCALITY TEL �p�,�y NEAREST OWNER y -Ir ,,,4 NO. �' `f/c+ CROSS ST. ASSESSOR ADDRESS C> ✓G AGE PARCEL po MAP BOOK,, P -CITY �GVY1 "ei 6� Zip gl7fDISTRICT GROUP TYPE FIRE ESS BY +a CONST. Z ARCHITECT OR TEL. i toy ENGINEER NO. STATISTICAL CLASSIFICATION WER AP TEL. ADDRESS CLASS NO. DWELL.UNITS �K3 PG CONTRACTOR NO. J/nE ZONE MAP r� LIC. . �� SPE ADDRESS No. vJ � SPECIAL LIC. CONDITIONS CITY CLASS ROAD DEPARTMENT APPROVAL REQUIRED YES ❑ NO ❑ CONSTRUCTION LENDER NAME AND BRANCH BLDG.SETBACK FROM FRONT'PROP.LINE OF (STREET) ADDRESS CITY TOTAL SETBACK FROM TYPE OF I EXISTING SQ.F NO.OF NO.OF CHECK HIGHWAY + YARD = FRONT PROP.LINE HIGHAY WIDTH SIZE STORIES FAMILIES ONE _ DESCRIPTIO OF WORK 700 NEW ® + / ►/ ❑ r � G ADD BLDG.SETBACK FROM 0� O C/ ! `/ SIDE PROP.LINE OF (STREET) O ALTER ❑ TOTAL SETBACK FROM TYPE OF EXISTING w HIGHWAY + YARD = SIDE PROP.LINE HIGHWAY WIDTH USE OF REPAIR ❑ Z EXISTING BLDG. DEMOL ❑ + APPLICA TTEL CORNER CUTOFF YES ❑ NO ❑ (PRINT) 9G1 �U6 NO IN OPEN SPACE YES ❑ NO ❑ BY(SIGNATURE) IN COASTAL PERMIT ZONE YES ❑ NO ❑ VALUATION IHEREBY ACKNOWLEDG THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL ORDINANCES AND LAWS REGULATING BUILDING CONSTRUCTION.I CERTIFY THAT IN DOING THE WORK AUTHORIZED HEREBY I WILL NOT EMPLOY ANY PERSON IN VIOLATION OF THE LABOR CODE OF THE STATE OF CALIFORNIA IN RELATING TO WORKMEN'S COM- PENSATION INSURANCE. SIGNATURE OF PERMITTEE ADDRESS FINAL BY TEL. DATE CITY NO. MAKE CHECKS PAYABLE TO: F E $ FET HARVEY T.BRANDT,COUNTY ENGINEER- ___j ` j f—v �() PLAN CHECK VALIDATION CK. M.O. CASH PERMIT VALID N CK. M.O. CASH 83 7,-,APR 21 2 3 .6 181.80 q 76A638A CE N803 3.75' WORKERS' COMPENSATION DECLARATION �intuureh%rebora cert;f catte,ofeWorke s' Compensat ohave a certificate of n eInsurancent to f APPLICATION FORBUILDING PERMIT or.o certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company BUILDING ❑ Certified copy is hereby furnished. fIORPPLICANT TO FILL IN ADDRESS"� ❑ Certified copy is filed with the county building.inspec- [ADDRESS ILDING w`` 11 Tion department. DRESS * O1� ., T ZIP LOCALITY Date Applicant' to I NO. OF BLDGS. `+©�� NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' ZE.OF LOT NOW ONLOT 1'" CROSS ST. COMPENSATION INSURANCE ASSESSOR •— (This•section need not be completed if the permit is for one ACTBLOCK LOT NO. MAP BOOK/ �� AGEd�J ARCED hundred dollars ($100) or less.) . TEC. WNER NO. I USE ZONE MAP` I certify that in the performance of the work for which this NO. permit is issued, I shall not employ any person in any manner SPECIAL Q CONDITIONS so as to become subject to,the Workers' Compensation Laws. Q CITY #P-L CAr-f ZIP U Date Applicant ARCHITECT R TEL./M��� NOTICE TO APPLICANT: If, after.making this Certificate.of ENGINEER (�� NO' %- DISTRICT GROUP CON ZONE P OCESSED BY Q Exemption, you should become subject to the Workers' N � ��rf _ ITYPI FIRE 2 �j Compensation provisions of.the Labor Code,,you must forth- ADDRESS * . Q ✓ Z� p with.com I with such provisions or this STATISTICAL CLASSIFICATION. APT. CONDO. p y p permit shall be TEL. deemed revoked. CONTRACTOR 0%44 NO. z LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. SEWER MAP (commencing with Section 7000)of Division 3 of the Business LIC. ' and Professions Code,and my license is in full force and effect. CITY CLASS BK PG :r- VALIDATION SQ. NO. OF ho2 NO. OF / CHECK �_ License Number Lic. Class SIZE ? STORIES �w FAMILIES 1 ONE -VALUATION Contractor Date DESCRIPTION OF WORK NEW ❑ /�// �{ �u. -01`_`_: ❑I am exempt under Sec. ADD ❑ S d d p ► r h -y: . ALTER ❑ B.&P.C. for this reason — REPAIR ❑ $ ;1J i i L USE OF Date: EXISTING BLDG. DEMOL ❑ +: 7.7 Signature APPLICANT �y TEL. g (PRINT), ll N FINAL �!� ;r OWNER-BUILDER DECLARATION . DATE ���. ` L•a to"'�' I' I hereby affirm that Lam exempt from the Contractor's License .may Law for the following reason (Section 7031.5, Business and ADDRESSVp �� • FINAL Professions Code): PRESENT By i-h i1'i.c--i;, I�M j BUILDING V " ❑ I, as owner of the property; or my employees with ADDRESS— as ' S', ; .,r ; : Y� i",x ; wages as their sole compensation,will do the work and t - _, the structure is not intended or offered for sale(Section LOCALITY 7044, Business and Professions Code.) MOVINGTEL. I, as owner of the property, am exclusively contracting CONTRACTOR NO. with licensed contractors,to construct the project (Sec- V Jj•-. ADDRESS tion 7044, Business and Professions Code.) REQUIREDTOTAL SETBACK FROM EXIST., CONSTRUCTION LENDING'AGENCY SET.BACK YARD HWY PROP. LINE WIDTH 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 i•. i P.L. Tzu a:' t'_i Lender's Name _ -T- I t"•7 ••�• Lender's Address P:C. Fee $ / Permit Fee G� Fri F--i 1 certify that I have read this application and state that the Issuance Fee ~CDMA P/C# -tT' ► above information is correct.]agree to comply with all County Investigation Fee. .--.E 8 ordinghces and State laws relating to building construction, Total Fee / �� / / — LDMA Perm. # !i- and t7J eby authorize repre ntatives of this County to enter �__. upo ntion prop rty for inspection rpores. .3L ) p. �•. / , r SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applica or Agent Date 4'.;t '~� t•..'a I•.5 "