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HomeMy Public PortalAbout6116 HART AVE_Building__ 76A6 38A CE 4803 I2/69 TEMPLE CITY G� APPLICATION. FOR BUILDING PERMIT COUNTY OF LOS ANGELES ASSESSOR DEPARTMENT OF COUNTY ENGINEER MAP BOOK PAGE PARCEL BUILDING AND SAFETY DIVISION BUILDING JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS ��� COLEMAN W. JENKINS, SUPT OF BUILDING LOCALITY FOR APPLICANT TO FILL IN NEAREST Print ort a only) CROSS ST. ' BUILDING DIS I T O. GROUP TYPEP OOiE qYgg ADDRESS 6116 N Hart. 7-E ICONST. - ��� STATISTICAL CLASSIFICATION' - SEWER MA LOT NO. BLOCK CLASS NO. DWELL,UN6TS PG .,-TRACT USE ZONEMAP NO.OF BLOGS, NO. SIZE OF LOT NOW ON LOT �.1 SPECIAL USE OF CONDITIONS EXISTING BLDG, TEL Q OWNER Wi l l i am W . Mertes NO 287-54 (BLDG.SETBACK FROM ADDRESS 61 16 . N . Hart FRONT PROP,LINE OF (STREET) TYPE OF EXISTING SETBACK HIGHWAY + YARD = TOTAL CITY Temple City HIGHWAY WIDTH FROM C.L. ARCHITECT OR TEL. + _ ENGINEER NO. BLDG.SETBACK FR ADDRESS SIDE PROP.LINE OF (STREET) TEL. TYPE OF EXISTING SETBACK HIGHWAY + YARD - TOTAL CONTRACTOR NO, HIGHWAY WIDTH FROM C.L. ADDRESS 529 E . Valley/Ci �/ 4718 - - + = a CITY - S a n- G a U r i a 1 C ASS CORNER CUTOFF YES ❑ NO ❑ O U CIQ rAel 2Nf) ktff9X State Li c : 186086 SEE REVERSE SIDE FOR SPECIAL APPROVALS LLJ ADDRESS CL. N SQ. FT. _ NO. OF NO. OF NEW, ❑ Z SIZE STORIES FAMILIES USE OF ` ADD ❑ .STRUCTURE ALTER ❑ SIGNATURE OF REPAIR�J APPLICANT ,., t DEMOL ❑ i VALUATIONS 465 . OQ APPROVALS DATE INSPECTOR'S SIGNATURE P,C, PMT. � p� FOUNDATION: LOCATION FEE S FEE $ v 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, WITH ALL ORDINANCES AND LAWS REGULATING BUILDING CON- GAS VENT, DUCTS STRUCTION. I CERTIFY THAT IN DOING THE WORK AUTHORIZED HEREBY I WILL NOT EMPLOY ANY PERSON IN VIOLATION OF THE LATH, INT. LABOR CODE OF THE STATE OF CALIFORNIA IN RELATING TO WORKMEN'S CO MPE NSAT ON i URANC fi,.�'1 NS - JE LATH, EXT, SIGNATURE OF -f HOUSE NUMBER COR- PERMITTEE RECT AND POSTED ADDRESS --J '�•A44 FINAL JOHN F. LEWIS, PRINCIPAL STR RAL ENGINEER PLAN CHECK VALIDATION CK. M.O. CASH _ PERMIT VALIDATION CK. M.O. CASH LN110 G ? ,N 'UJG.2 2 1 D -.2.0.0 :.Temple City 76A63BA CE#8 'i ® -63A PUCATI®lV �' BVIL®,��V�'..Y C.�Y \A VL I'.Y . COUNTY OF LOS ANGELES. Bui-0ING DEPARTMENT OF. COUNTY 'ENGINEER AooREss BUILDING AND:SAFETY DIVISION LOCALITY 1'1 JOHN A: LAMBIE. COUNTY ENGINEER .'NEAREST WILLIAM•A.`JENSEN,'SuRT OF BUILDING'' - "CROSS ST.; DISTRICT NO. -GR ' TY,PE.. O D BY FOR APPLICANT TO FILL IN Q CONST. BUILDING STATISTICAL CLASSIFICATION SEWER MAP;-. ADDRESS 61'.16- No'. Hart Avenue- i % - BK/ G _ - 'CLASS. NO.�DWELL_UNITS � (� LOT NO. - BLOCK --WATER NOT REQUIRED RECEIVED _ CERTIFICATE:— , . TRACT " _ K. MAP //yy HIGHWAY STATE MAJOR SECOND, LOCAL; NO. OF BLOGS. NO. (y" (CIRCLE) SIZE OF-LOT ,' ` NOW ON LOT USE-ZONE "SPECIAL USE OF - CONDITIONS ' EXISTING BLDG. - - .TEL - '- OWNER' NO; BUILDINGEXIST.'•^ SETBACK ,YARD HWY - STREET N MEQ' WIDTH'. .ADDRESS 61 16 - N Hart A.V.e T `-. C - FRONT / ARCHITECT OR - STEL P. L.. �/ e ENGINEER - - NO'­ 'SIDE a 'P..L:' ADDRESS ,.I 40-4Q q' .CONTRACTHIO W a r.d- L . R a n•d.o 1 NO�8 8 4 0.4 - u - -' - ' Ix ADDRESS..52g. F :O DESCRIPTION'`OF,,WORK.. NEW .ADD- ALTER: 'REPAIR.X . DEMOLISH' J Z. SQ. FT. NO. OF _. -NO,. OF SIZE -C','-,STORIES FA'MILIES4•, s - .USE OF t z-1• - - a. . STRUCTURE Re-roof i ng .4 n. SIGNATURE OF - - APPLICANT ,. VALUATION2nb$ - '_ --. tPPROVALS�}h� DATE :: INSPEGTOR;S;SIGNATU RE I •� P.C. FOUNDATION: LOCATION .. FEE $ _ - .FEE-$..- ° FORMS: MATERIALS FRAME: FIRE STOPS. .-. I HEREBY.ACKNOWLEDGE'THAT'I''HAVE-READ THIS APPLICATION. 4 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 IhWILL.NOT EMPLOY.•ANY PERSON IN- VIOLA-TION OF THE•LABOR CODC F,THE''STATE-OF CALIFORNIA RELAT_. ING TO WORKMEN'S . _ COMP SATION NSURA - � - -I. - r s" "L'ATH..EXT.. - - SIGNATURE OF ^IHOUSE�NUM BER COR- PERMITTEE - _ ERECT ANDPOSTED. ' ADDRESS -5��'`:E .''U�1 ��e.`w--, - a n G--a h�".�`P�- `FINAL. - _ JOHN F'.;LEWIS•.P,RINCIPA TR .URAL ENGINEER , PLAN 'CHECK' VALIDAT301V_ '.CK. M.O. :'C-A, 1' PERMIT VALIDAtI0 M:O. SASH`: APPLICATION FOR BUILDING PERMIT FOR APPLICANT TO FILL IN (Print or type Only) TEMPLE CITY BUILDING - COUNTY'OF LOS ANGELES ADDRESS 6116 No . -DEPARTMENT OF COUNTY ENGINEER CITY 'Temple Cit ZIP BUILDING AND SAF TY DIVISION NO.OF BLDGS: BUIL-DING SIZE OF LOT NOW ON COT ADDRESS TRACT GBLOCK _ - LOT NO. LOCALITY ' TEL. NEAREST OWNE NO. CROSS ST. - - ASSESSOR ADDRESS 6 116 No Hart MAP BOOK PAGE PARCEL - /+ p DISTRICT GROUP' TYPE FIRE SSED BY CITY T . C. ZIP 91780 r CONST ZONE ARCHITECT OR � TEL: ,off ENGINEER NO, STATISTICAL,CLASSIFICATION EWER MA ADDRESS CLASS NO�_DWELL,UNITS j BK�r PG TEL. CONTRACTORRandol "NO USE ZONE MAP D 1C. 044 NO. ADDRESS O•. I SPECIAL LIC. CONDITIONS CITY • Ca I CLASS San - ROAD DEPARTMENT APPROVAL REQUIRED YES 1:1 NO CONSTRUCTION LENDER NAME AND BRANCH - BLD ..SETBA'CK FROM -- - d '• - FRO T PROP.LINE OF (STREET) C ADDRESS - CITY - - L' HIGH AY + YARD TOTAL SETBACK FROM TYPE OF EXISTING C SQ..-FT. NO. OF NO. OF ' - CHECK FRONT PROP. LINE' HIGHWAY WIDTH C SIZE STORIES FAMILIES ONE U W DESCRIPTION OF WORK NEW ❑ Or ,ADD ElBLDG.SETBACKFROM SIDE PROP. LINEOF (STREET) ALTER ❑ HIGHWAY + YARD = TOTAL SETBACK F4ROMI TYPE.OF EXISTING F/G comp . 12x18 REPAIR SIDE PROP. LINE HIGHWAY WIDTH USE OF DEMOL ❑ + EXISTING BLDG, - APPLICANT TEL CORNER CUTOFF YES ❑ NO (PRINT) NO. -4040 BY (SIGNATUR.� IN OPEN SPACE YES ❑ NO Q IN COASTAL ZONE YES NO VALUATION Y. ,,O - - CATEGORICAL EXEMPTION YES NO I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS.APPLICATION ENVIRONMENTAL AND STATE THAT THE ABOVE IS�CORRECT AND.AGREE TO COMPLY IMPACT - .EXEMPTION DECLARATION.SIGNED (DATE) WITH ALL ORDINANCES AND LAWS REGULATING BUILDING CON- STRUCTION. I CERTIFY THAT IN DOING THE WORK'AUTHORIZED IMPACT REPORT PROCESSED (DATE) HEREBY I WILL 'NOT EMPLOY ANY PERSON IN'VIOLATION OF THE LABOR CODE OF THE ST TEAL CALIFO IA; IN RAE LLLA/7TING TO �} � do WORKMEN'S LO MPE NSATI I SURA E. SIGNATURE PERMITTEE ADDRESS C/r/F�r/ / '•' .. . - pp FINAL BY TE CITY San Gabriel NOL 200.- O DATEPMT/ MAKE CHECKS PAYABLE- 7U: FEE FEE 9 . 00 HARVEY T. BRANDT. COUNTY ENGINEER PLAN CHECK VALIDATION CK. M.O. CASH o PERMIT VALIDATION CK. M.O. CASH __ 76A638A CE9803 7/73 - _ p. 52"SEP 9.01 C) A98 DEPARTMENT OF BUILDING AND SAFETY. i APPLICATION FOR PERMIT COUNTY OF LOS ANGELES I � WM. J. FOX. CHIEF ENGINEER ��JJ 'J FOR APPLICANT TO FILL IN FOR OFFICE USE ONLY �/ - J DISTRICT NO./' PLAN CK.NO. PERMIT NO. ` BUILDING G./y- lJ/`]„ �Jj nqv,{{�_ d iLJ ADDRESS �p .^,�' LOCALITY '"- v'�rf_ "" } REd EIVED ? D TE F APrPL. JD.ATE ISSUED NEAREST ., CROSS ST. WWW'rr KKW//444/// BUILDING OWNER I/ ADDRESS MAIL LOCALITY ADDRESS _ �" l y�'Lt�(i�L•G.�(/ . 1^,i, v, NEAREST ' CITY & cltNO f/W i � Q CROSS ST. y .., FIRE NO.OF TYPE GROUP ARCHITECT OR V TEL. /_ /�`_ ZONE PLANS c.�/�_ ENGINEER NO. (Q BLDG. r ORD. 0 � SETBACK LINE APPROVED ,(r'TjEL. CONTRACTOR BY .DATE h='�1/�(/�.�^ �G1/LtN'gx'I.rt USEAPPROVED ADDRESS / 10 D.� Y4N. yV. N�6,.c`,/�fr�a U(.�il i ZONE BY DATE LEGALCORRECTIONS , DESCRIPTION LOT NO. BL."-- _ TRACT - NO.'OF BLDGS. _ SIZE OF LOT I NOW ON LOT ' r USE OF NO.OF NO.OF 'EXISTING BLDG. FA4, E. I ROOMS 3 • I '/, /a/, / -.S' (��`C! �i n,1.�-n !}I - DESCRIPTION OF WORKR NEW ALTERATION ADDITION n/ In/7 /i /I� �il-eock�r.Il O . REPAIR MOVING I DEMOLISH SQ.FT. NO.OF SIZE ROOMS STORIESf' ' p�7"� /} , �Osg D WALL ROOT / -�/- J'-7 r COVERING COVERING �del '�' /V��•.1)• '-A USE OF NEW <=O>=_ _�J ♦ +`/\ OV �"�V"U F/ V �- _.._ I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPROVALS APPLICATION AND STATE THAT THE ABOVE IS CORRECT INSPECTOR DATE FORMS, AND AGREE TO COMPLY-WITH ALL COUNTY- ORDINANCES FORMSLOCATION F ,MATERIALS AND STATE LAWS REGULATING BUILDING CONSTRUCTION. / FRAME: FIRE STOPS, SIGNATURE OF /_ // �[-/, W BRACING,BOLTS PERMITTEE-.�itlgrU� ,I-Q '..�.•J/'ti-- - LATH, INT. AUTHORIZED AGTy LATH, EXT. . 76AS36A 9-48 ,i oeS-3 sans SETS $ a P.C.$ PLASTER,INT. 00 . FEE PLASTER,EXT. VALUATION P ���/0 . FEE �� a FINAL ' �✓���1��! WORKERS'COMPENSATION DECLARATION v !i insurebor. erf'firmifica a of.WorkerseColmpensotionolnsurran�es or [P[P L ��T 0 O o M O LM O I C p C G3G�liv 0�' L� a certified copy thereof.ISec. 3800, lab: C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY 'Policy No. Company ` j Certified copy is hereby furnished.' FOR APPLICANT TO FILL IN A�oRess ` (0 'Certified copy is filed with the county building irispec- BUILDING tion department.• ADDRESS 43 (G LOCALITY f/ 1 NEAREST Date. Applicant CITY ZIP CROSS ST.t � CERTIFICATE OF.EXEMPTION FROM WORKERS' ho. 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 a� USE ZONE MAPS hundred dollars ($100)or less.) _ TRACT BLO/C�K 2 LOT NO. .L . 3 NO. a SPECIAL R 1 l� ,';d^ - " ..- 0, I certify that iri the"perfarmance of the work for which this CONDITIONS. Q OWN E permit is issued, I shall not employ.any person in any manner DISTRICT GROUP TYPE FIRE /PROCSED BY U so as to•becoine subject to the'Workers'Compens ion La s. ADDRESS CONSTZONE 0 CITY .. ZIP .�.IL' Q Date J •Applicant STATISTICAL CLASSIFICATION APT. CONDO. U NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL. d ENGINEER NO. CLASS NO. �A DWELL. UNITS Exemption, you should become subject to the Workers' M i Compensation provisions of the Labor Code, you must'forth-' ADDRESS SEWER MAP Z with comply with such.provisions or this permit shall be TEL. VALIDATION :deemed revoked.. . - CONTRACTOR NO. BK. PG, LICENSED CONTRACTORS DECLARATION �(�` LIC:. I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS �A 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 $ LT Q SQ..FT. NO. OF NO. OF CHECK License Number Lic.Class SIZE STORIES FAMILIES - ONE Contractor Date DESCRIPTION OF WORK NEW $ I am exempt from the licensing requirements as l am a 1 ADD licensed architect or a registered professional engineer ALTER FINAL acting in my professional capacity (Section 7051, REPAIR, DATE Business and Professions Code). USE OF. DEMOL FINAL EXISTING BLDG. B �„� Lic.or Reg.No. _Date APPLICANT TEL. Y Cr. 20 4 0.3 A OWNER-BUILDER DECLARATION l' ((PRINT) NO. I hereby affirm that Tam exempt from'the Contractor's License Law for the following reason*(Section 7031.5, Business and ADDRESS 2'0.o 3 4 0 0 Professions Code): PRESENT , BUILDING 1, as owner,of the property, or my employees with ADDRESSa• `• ( o"o 0 3[( 0.0 H wages as their sole compensation,will do the work and ' the structure is not intended or offered for sale(Section LOCALITY 7044, Business and Professions Code). a MOVING TEL.' i A.1 7r_8 2 El NO. . I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec- ADDRESS tion•7044, Business and Professions Code). / REQUIRED TOTAL 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 P.L. Lender's Name mP.C. Fee$ Permit Fee ` - Lender's_Address > 1 certify that I have read this application and state that the Issuance Fee above information is correct. I agree to comply with all CountyInvestigation Fee ordinances and State laws relating to building construction, Total Fee r— v and hereby'authorize representatives of this County to enter upon,the above-menLfiedAApprop�rtyy ffor inspection purposes. 1 n � SEE REVER$E'FOR EXPLANATORY LANGUAGE ©s .Signature of Applicant or Agent Dote .�/ /Jrn'„ /�°��Z"v-'' /. / �j•„j[JiS. ,� �/', ,� . rWO RKERS. COMPENSATION DECLARATION .2! I her@b rvirm;that I have certrficate,of consent to.self � O O � M O PERM O or a ceriif+cate�of Workers Compensation Insurance, 4L/-U O�L/11 LI V O0.[ C p C G3G & ii certified copy thereof-(Sec. 3800; Lab. C:) - - - COUNTY OF LOS ANGELES BUILDING AND-SAFETY Policy,No '-. Compony , <. - . . . .• - :�. .. l. ;certified.copy is•hereby furnished,: FOR APPLICANT TO FILL IN - - — - BUILDING v _ ADDRESS aCertified copy is filed with the county building'inspec- BUILDING tion department. `. ADDRESS 9l1 . Date Applicant•, CITY { .` Ciry ZIP D LOCALITY -^ -. ' = CERTIFICATE OF EXEMPTION FROM"WORKERS "' .•� NO: OF BLDGS. . NEAREST... 11 COMPENSATIONtINSURANCE SIZE.OF LOT X �U NOW ON LOT CROSS ST. ' (This=sectior need not-be•completed if'the permit,+s•for one - ASSESSOR •f+' hundred dollars ($100)or less.) TRACT BLOCK LOT NO. MAP BOOK ' PAGE PARCEL TEL.OWNER ' NO.1L�7` /. a/ SE OP V yr I certify+that in the performance of the work forwh+ch this V(J ! > U 'ZONE I. permit is issued, I shall not emloy any person+n+any manner p - -SPECIAL­-- p •= _ �,[r c� yy� �.`, so as'to become sublect to the'Workecs'Com ensotion Laws. ADDRESS CY V f` 1 CONDITIONS I O Date APPlicant ,... CITY -�49 ARCHITECT OR TEL.. DISTRICT GROUP..J-TYPE FIRE.; PROCESSED BY O NOTICE TO APPLICANT' If,'after making`th+s Ce`'rtificate of -- ENGINEER NO. CONST.' ZONE • (� Ezemptiont`'.you• should become subject"-To' the Workers' '- � Compensation provisions of the Labor•Code you:must,forth- ADDRESS `Q t LU IL with comply with such provisions or:this.permit shall be ., _. '. ..- _ _ -- •- STATISTICAL F T g 3 ✓ 3 _ deemed revoked. .c . . ,.• CONTRACTOR NO C N . I ST LAFI�TIO AP C DO' LICENSED CONTRACTORS DECLARATION-:I, - •- - LICs-• CLASS NO:J DWELL1 UNITS I hereby affirm that I am licensed under provisions of Chapter 9 `, ADDRESS NO. (commencing with Section 7000)of Division 3 of the Business and LIG - _ .. _ SEWER MAP Professions Code, and my I+cense is+iri''full'force and'effect.' CITY. CLASS BK :' •7 l VALIDATION � . _ . SQ.FT.J/_Q NiO.OF NO. OF . CHECK LicensePNumber Lic.Class SIZE, !� SO VALUATION RIES FAMILIES ONE z Y1_ 'DESCRIPTION OF'WORK NEW {�V Contractor •Date ..• $ I� , ADD D + I'am exempt under Sec. - Jza - -' ALTER ,a ! r. B.&P.C. for this reason REPAIR 0 $ -- _; USE OF t Date: EXISTING BLDG. DEMO L Q Signature APPLICANT TEL. FINAL I OWNER-BUILDER DECLARATION (PRINT) ,i'.r : - NO. I � 2 O U 2 A _ _ DATE ��']•: .I hereby affirm,,that I am exempt from the Contractor's License , # s - Low for the followirig-treasor (Section 7031.5, Business and ADDRESS FINAL' ' Professibns'Code)C'"' PRESENT BYE 3 BUILDING p o © I, as owner of the-.property, or my employees with :- ADDRESS - wages as their sole compensation,will do the work and 1 .\ the'structure is not intended or offered for.,sale(Section LOCALITY 7044,-Business and Professions Code). "' MOVING "` -TEL. D • 1,as owner of the property, am exclusively contracting CONTRACTOR NO. r ❑. '. with'licensed contractors to-construct the project (Sec- ADDRESS • tion 7044, Business and Professions Code). , REQUIRED- TOTAL SETBACK-EROM T CONSTRUCTION-LENDING AGENCY " SET BACK YARD HWY PROP. LINE WIDTH hereby affirm that there is a construction lending agency for FRONT the performance of the-work for whichrthis permit is issued + P. - - (Sec. 3097, Civ. C.). SIDE S ; . `t t e - - P.L. - Lender's Name o - iDMA,Ref# - m .-. _.. _. P.C:Fee-$ -- - - ... Permit-Fee - Lender s Address t • t >. I certify-that I have read this.application_and-state.that..the Issuance-Fee -t�(1 -I+ LDMA P/C#• D Q above information.is correct. I agree to comply with all County Investigation Fee 0 ordinances and State laws relating to;building construction, .- - - - - - _. -.__ .TotaI-Fee.. ..,. ...-. . t /-•3...�,•� '-LDMA Perm. #.. .____ and hereby authorize representatives of this County to enter upon the above-men oned operty for inspection purposes. r�2�-�fi �j/ Gj - SEE REVERSE FOR EXPLANATORY LANGUAGE• . ..- --- Signature-of Applicant or Agent :. ._ Date v + f WOR,, RS'COMPENSAWN DECLARATION M M tnsura`oraafcertif catharte of Wo ke s' Compensat on Insuran elf L/11I have a certificate of coent to L O Cbklr ©IJV FOR S U��[N LI V r, PAF.RU V�n LI r_-• or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING ANL 'SAFETY Policy No, Company Certified co is hereby furnished. FOR APPLICANT TO FILL IN BUILDING PY Y ADDRESS OCertified copy is filed with the county building inspec- BUILDING d C tion department. ADDRESS �+ r Date Applicant CITY (� / . ZIP (/ LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT t 7 NOW ON LOT CROSS NEAREST COMPENSATION INSURANCE (This section need not be completed if-.the permit.is for one /J ASSESSOR -Fp,- hundred dollars ($100)or less.) TRACT C9(/ BLOCK LOT NO. .0 MAP BOOK" PAGE PARCEL TEL /D. USE NE FSPENNIAL, I certify that in the performance of the vvork for which this OWNER /„ NO. v permit is issued,-1 shall not employ any person in any manner, i ADDRESS V DITIONS sous to become subject to the Workers'Co pens tion La ` U Date ® Applicant CITY _ZIP pF ARCHITECT OR TEL. DISTRICT R P, TYPE _ FIRE PROC SED BY 0 NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. CON57. ZONE U Exemption, ,you should become'subject to the 'Workers' Compensation provisions of the Labor Code, you must forth- ADDRESS "� W with comply with such provisionsor this permit shall be - ' deemed revoked. EL STATISTICAL CIASSIFI ATION APT. DO. N CONTRACTOR NO. LICENSED CONTRACTORS DECLARATIONLIC• 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 and LIC. Professions Code, and my license is in full force and effect. CITY CLASSBK •.Or VALIDATION SO.F.T. NO.OF NO..-OF, CHECK License Number Lic.Class SIZE STORIES FAMILIES ONE ' • VALUATION ! DESCRIPTION OF WORK NEW 0 MOO Contractor Date $ U(f ADD 1 am exempt under Sec. - LTER � D _. A . B.&P.C. for this reason $ .. . REPAIR.. � " ti Date: .. USE OF DEMOL EXISTING BLDG. APPLICANT TEL. rSignature APFINAL �8,0 3,4 A OWNER-BUILDER DECLARATION PRINT NO. DAT " I hereby affirm that 1 am exempt from the Contractor's License # o o 0:0,o''11 Low•for the following-reason (Section'7031.5, Business and ADDRESS FIN Pr fessions Code): BUB ILDING o I�t '1 9.9,8'8 . I, "as owner of the property, or,my employees with ADDRESS wages as their sole compensation,.will do the work and o Fo,1 9 9.8 8:g the structure is not intended or offered for sale(Section LOCALITY 7044, Business and Professions.Code). MOVING TEL. a1, as owner of the property, am exclusively contracting CONTRACTOR NO. 0 9,3 0' ,8 7 with licensed contractors"to construct the project (Sec= ADDRESS tion 7044, Business and Professions Code). t CONSTRUCTION LENDING AGENCY REQUIRED YARD HWY TOTAL SETBACK ` SET BACK 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 --�. 4 P.L. > Lender's Name m P.C. Fee$ Permit Fee 1 13 CDMA Ref. # Lender's Address g I certify that.I have read this application and state that the Issuance Fee vS t/ LDMA P/C# ' above information is correct. I agree to comply with all County Investigation Fee S ordinances and State laws relating to building construction, Total fee CDMA Perm. # R and hereby authorize representatives of this County to enter upon the ab ve-me boned pro rty for inspection purposes. a SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent - Date - - - WORKERS, COMPENSATION DECLARATION herelpy affirm that I-have a certificate of consent to.self �( LI V 01 OD U��0 u V K P E LIUnn�U insurc*ear a cer4irficate of Workers' Compensation,Insurance, L/11LI LI A LI LI V LIV lJ V LI�IUIJLI ,: or a certified copy,thereof (Sec. . . . Lab. C.) COUNTY OF LOS ANGELES BUILDING ARID SAFETY. Policy No. Company BUILDINGf / Certified copy is hereby furnished. FOR APPLICANT'TO FILL IN ADDRESS /,,(.//,, • /{ T• 4V ❑ Certified copy is filed with the county building inspec- BUILDING /� a tion department. ADDRESS i T JL CITY 4AIRLL. CIEY ZIP Q' LOCALITY Date Applicant NO. OF BLDGS. _ CERTIFICATE OF EXEMPTION FROM'WORKERS' SIZE OF LOT' NOW ON LOT NEAREST CROSS SL µ .,COMPENSATION INSURANCE AS (This section need not be'completed if the permit is for one TRACT. BLOCK LOT NO. MAP. PAGE PARCEL hundred dollars ($100) or less.) .. TEL OWNER i C RU NO. �! US ONE OP I certify that in the performance of the.work for which this IAL permit is issued, I shall.not employ-any person'in any manner ADDRESS CONDITIONS a so as to becomesubjectto'the Workers'Compensation La . 0 Datea„O 9 CITY ,, ZIP ` Applicant ARCHITECT'OR. TEL. � NOTICE TO APPLICANT.: If,, after:making this Certificate of ENGINEER NO. DISTRICT GROUP. TYPE FIRE OCESSED BY 9 CONST. ZONE � Exemption, you .should become' subject-'to the Workers' G� �f' � w Compensation provisions of the Code, yow,musT forth- ADDRESS Jam. _� a with comply with'such,proyisions or-this• permit shall be TEL STATISTICAL CLASSIFICATION APT. CONDO. N deemed revoked.' CONTRACTOR NO. Z LICENSED.CONTRACTORS,DECLARATION , LIC. CLASS NO. DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter.9 ADDRESS NO. (commencing with Section 7000)of Division 3 of.the Business LIC. SEWER MAP. . and Profess ians.Code,and my license is-in full force and•effect. CITY. CLASS BK C PG VALIDATION SQ.FT. NO. OF NO. OF CHECK'. License Number Lic. Class SIZE STORIES IFAMILIES ONE VALUATION Contractor Date DESCRIPTION OF WORK NEW El $ a V -- J I❑ ❑ D I am exempt under'Sec. ti✓� —Q - ADD ❑ Dare: - ALTER .. B.BP.C. for this reason REPAIR $ USE OF ^ EXISTING BLDG.` DEMOL.❑ Signature APPLICANT TEL. (PRINT). ' NO. FINAL OWNER-BUILDER DECLARATION DATE ✓� ` I hereby affirm that l am exempt from the.Contractor's License • Law for the followingreason Section 7031.5, Business and ADDRESS FIN Pro essions Code): ( PRESENT B j =; BUILDING I, asowne'rof the property, or employees ees with ADDRESS' wages'as their sole compensation;will do the work and . the structure isnot intended or offered for sale(Section LOCALITY 7044, Business'and Professions Code.) MOVINGTEL. L�"t CONTRACTOR NO. ❑ I, as owner of-the property;am exclusively contracting I;I t--4 9 anti with licensed contractors To.construct the project.(Sec- ADDRESS tion 7044, Business.and Professions Code.) REQUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY. SETBACK YARD HW PROP. LINE WIDTH I hereby affirm that there is a construction lending agency for FRONT t-'{ 1F3E� =ill' the performance of the work for which this permit is issued P.L. (Sec. 3097, Civ. C.). -SIDE. P.L. - \ ^�` f if i-F FIS li I•�, il.t. I,._ 1 Lender's Name LDMA Ref: #.`'. P.C.,Fee$. Permit Fee J t_s `+ ' �"• Lender's Address - a I certify that I have read this application and state that the Issuance Fee P/G# O 8 above information is correct.1 agree•to'comply with all County Investigation Fee R ordinances and State laws relating to building construction, Total Fee LDMA Perm. # . a and hereby authorize representatives of this County to enter a upon t e abov -men Toned pro erty for inspection purposes. /2 SEE REVERSE FOR EXPLANATORY LANGUAGE ,Signature of Applicant or Agent Date . WORKERS' COMPENSATION DECLARATION 7 , ;l hereby affirm'that 1 have-a.certificate of 'consent to self insure, or a certificate of Workers Compenstion Insurance, or Ll�� �L/�1 LJ O lJ V O ; �d D 0 l C p G3G a.certified copy-thereof (Sec: 3800, Lob..C) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No Company ET Certified copy is hereby furnished. FO.R APPLICANT TO FILL IN Ao�Ress 'Certified copy is filed with'the county building inspec- BUILDING h I • tion department. _ ADDRESS t'. V 1 LOCALITY •- :,y-r^-•c- C-,r v4i 1. NEAREST Date Date Applicant CITY t f`J� i 1 ice~ t ^IZIP CROSS ST. } CERTIFICATE OF. EXEMPT ION'FROM WORKERS' NO OF BLDGS, ASSESSOR,. 8 COMPENSATION INSURANCE _ SIZE OF LOT NOW ON LOT MAP BO K k PAGE PARCEL {This section need not be completed if.the permit is for one t h USe ONE NO �=` �� Yd TRACT BLOCK LOT NO./ eF —= hun`dred.dollors ($100)on less..), TELA SPECIAL LL Iscertify that in-the performance of-the work for which this OWNER ti`j _. r z• +r'+ , 'i NO/ CONDITIONS 1 DrSTRICT GROUP TYPE FIRE PRO ESSED.BY y permit is issued, I shall not employ any person in-any manner ADDRESS ' CONST. ZONE, 1 OC so os-to'become subject to the.Workers'Compensation Laws. 09 e" �' i f CITY'' r 1 'V-ZIP 1 Date App! t STATISTICAL CLASSIFICATION APT. CONDO. O NOTICE TO APPLICANT:.,If, after making'this Certificate of- ARCHITECT OR TEL. CL Exemption, you should become subject to the Workers', ENGINEER. NO. CLASS NO. c. %�1 DWELL. UNITS LAJ Compensation provisions of the Labor Code, you must forth- ADDRESS . SEWER MAP with .comply.with.such provisions or this permit,shall be �,.P :" ,O TEL. 7 VALIDATION deemed revoked.. CONTRACTOR ! % NO. BK. PG, LICENSED CONTRACTORS DECLARATION LIC. I hereby off irm that l am licensed under provisions of Chapter 9 ADDRESS NO. VALUATION (commencing with.Section7000)'of Division 3 of the Busiriess.and LIC. � Professions Code,'and my license is in full force and effect. CITY' CLASS S 0 SQ. FT. I NO. OF NO. OF CHECK License Number �Lic.Class SIZE + t, ,j STORIES FAMILIES' ONE ' DESCRIPTION OF WORKr.{i . NEW �. Contractor Date a. ADD p I am exempt.from the licensing requirements as I am a ,.. �,� y,!+„ i....et; licensed'architect`or a registered professional engineer cd ALTER FINAL acting in my professional REPAIR capacity (Section. 7051•; DATE p o 0 Business and Professions Code). USE OF R DEMOL FINAL EXISTING BLDG. By. o Lic.or Reg.No.' Date APPLICANT TEL. 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 I ADDRESS .� Professions Code); PRESENT BUILDING 1; I; as owner'of. the property or my employees with ADDRESS' I wages as their sole compensation,will do'the work-and the structure is not intended'or offered'for sale(Section LOCALITY 7044, Business and-Professions Code). MOVING - TEL..- ( I, as'owner of the property,nm exclusively contracting CONTRACTOR NO. with licensed contractors to construct the.project (Sec- ADDRESS t tion 7044; Business and Professions Code). ®�o ` :REQUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING-AGENCY' SET BACK YARD HWY PROP. UNE WIDTH rti I hereby affirm that there is a construction lending agency for FRONT `Lr i I the performance of the work for which •this permit is issued PA, (Sec. 3097, Civ. C.). SIDE C1 P.I. ; �1 Lender's Name i o P.C. Fee£ Permit Fee m Lender's Address: w 1 certify that I have read this application and state-that theIssuance Fee c above information is correct. I agree to'comply with'all County Investigation Fee 0 ordinances and State.laws relating to building construction, Totol Fee r m and hereby authorize.representatives of this County to enter oo Q. upon the above.mentioned property for.inspection purposes: O +,f` '`� %j.• ,4 SEE REVERSE FOR EXPLANATORY LANGUAGE �, / Signature of Applicant.or Agent Dote .