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76A638A CE'10032-63 APPLICATION FOR BUILDING PE - MIT
COUNTY OF LOS ANGELES BUILDING
DEPARTMENT OF•COUNTY ENGINEER ADDRESS J .
BUILDING- AND SAFETY DIVISION LOCALITY
JOHN A. LAMBIE, COUNTY ENGINEER NEAREST t
WILLIAM A. JENSEN, SUPT OF BUILDING CROSS ST
DISTRICT O GR, P [TYPE S
FOR APPLICANT TO FILL IN coNsr;
r
BUILDING -7n A' - STATISTICAL CLA IFICATI ON, ER MAP
ADDRESS 672,2(2'2 lVot Knufrr-m-P IK - G/
' CLASS NO DWELL UNITS "'� 7/
LOT NO So,� -LOT SO� BLOCK WATER
CERTIFICATE. NOT REQUIRED ❑. RECEIVED ,
TRACT /V 5� MAP /`I O HI HWA) STATE MAJOR SECON LOCAL
' MM �/ NO OF BLOGS. NO U ,
SIZE OF LOT S-V X 2 oO NOW ON LOT USE ZONE SPECIAL '
USE OF p �• �+ Qp� CONDITIONS -EXISTING BLDG -RESP DE/�ICE — GRRgG-E -
OWNER G()IL CFCD'SFtW yER NOL*127-d 4,?2 L ING "
YARD HWY STREET NAME EXIST.
d�• /� SETBACK- WIDTH
ADDRESS ZZ Me- K' uFFMfft4 � cl FRONT- � /� /O '
ARCHITECT OR' - TEL 'P• L. ' (,,J
ENGINEER NOSIDE
P/ L ! /yy" D /� J� ��t�y�'/
ADDRESS C
TEL / �9'//, _!Y, 4-4jX g � ,41--�'L -.P.7'!,r O
CONTRACTOR /— NO„[
ADDRESS x.C/i ,Ji O
DESCRIPTION OF WORT;
CNEW ADD. ALTER REPAIR DEMOLISH y�Z
SO T -3Z STORIES / NO OF
ESUSE OF m
STRUCTURE
SIGNATURE O -
APPLICANT I I
VALUATION "
• 'APPROVALS -.DATjE INSPECTOR'S SIGNA PRE4
PC PMT ,.¢� FOUNDATION -LOCATION /'� p I
FEE $ FEE V v FORMS, MATERIALS S1//f� '
FRAME FIRE STOPS.:,, ��I�/rte
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION 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 I WILL NOT EMPLOY ANY PERSON IN VIOLA-, .LATHINT
TION OF THE LABOR CODE OF THE STATE OF CALIFORNIA RELAT- r ,
ING TO WORKMEN'S COMPENSATION INSURANCE
LATH, EXT -
SIGNATURE OF T d � HOUSE NUMBER COR--
' PERMITTEE RECT AND POSTED '
ADDRESS a ' _ FINAL
JOHN F LEWIS. RINCIPAL�ST URAL ENGINEER
PLAN CHECK VALIDATION, CK ' M O CASH. _t PERMIT VALIDATION cK M,O: ckS'H
2'Z14='6Z AUG 5 1' 0 6-.G0-
WORKERS' COMPENSATION DECLARATION
;Thereby affirm that I;have'a certificate�of consent to "self
insure, or a certificate of•Workers'Compenstion Insurance;or APPLICATIONFOR B U I L D I-N G PERMIT
a certified copy thereof (Sec 3800, Lab C ) _ COUNTY OF LOS ANGELES " BUILDING AND SAFETY
Policy No, • • 'Company - " 1
❑'
Certified copy is'h'ereby furnished '',FOR APPLICANT'TO FILL•IN . ADDRESS,
aCertified copy ris filed with the county building'mspec- BUILDING
'tion department ADDRESS a Z /V 1�;f7.0-t �I 'fYI� �.l LOCALITY —�
•-� -yam Q NEAREST _
Date Applicant" CITY 1 �� / ZIP / 7 � CROSS ST G
.- / •F / .NO OF BLDGS ASSESSOR
-"CERTIFICATE'OF EXEMPTION FROM WORKERS'
SIZE OF-LOT tJ `` ad NOW-ON LOT MAP BOOK PAGE PARCEL
- - ''- •` ''`� COMPENSATION INSURANCE - :� i q
-(This section need'nof be completed'if the permit is for one'" C //�,) p USE ZONE" MAP }. .
hundred dollarsE($100)or less:)` j, TRACT � t4-h BLOCK' . LOT NO !�_ NO >
TEL yy / SPECIAL• O
1. r . : ,, OWNER •'•L�: �� �: N04• T'�AA RY CONDITIONS
I certify that in the performance of the work for which this
C %/ DISTRICT_ GROUP TYPE R FIRE PROCESSED•BY V
` permit Ls issued„I shall not employ any person.m any manner ADDRESS 7 C• L /�+ • (,?�'(f M/!•� /' CON ZONE: 0
so cis to become subject to the Workers'Compensation Laws
Tro
Date' Applicant CITY �-^ ZIP - STATISTICAL CLASSIFICATION APT CONDO V
"NOTICETO'APPLICANT- If,':after'.making this Certificate of ARCHITECTOR-
EL W
Exemption; `you should become• subject to The Workers'
ENGINEER NO CLASS NO DWELL UNITS N'
Compensation provisions of the Labor Code, you'must forth- ADDRESS SEWER MAP Z
withi.comply with such provisions or this, permit shall be _
deemed're'voked TEL
CONTRACTOR NO BK G, VALIDATION
LICENSED CONTRACTORS DECLARATION - - LIC
I hereby affirm that I am licensed under provisions of Chaptec9 ADDRESS NO - VALUATION
(commenting-with Section 7000),of Division Sof the Business and =” LIC
Profeasio_ns Codea
, ndymy license is in full force and effect CITY CLASS $
SO FT NO .OF NO OF CHECK
License Number - Lic.Class SIZE STORIES FAMILIES' ONE
DESCRIPTION OF WORK (. R C NEW
,Contractor Date ADD -
❑ I am exempT from the licensing requirements as I am a —( ,
licensed architect or a registered professional engineer ALTER 'FINAL
acting in my professional, capa_City (Section 7051, REPAIR DATE
Business acid P,rofessions,Code)., USE OF '� ., DEMOL "❑ FINAL
EXISTING BLDG B
MLic or Reg. No'
Date APPLICANT'// �'�j TEL c Y
OWNER-BUILDER DECLARATION PRINT)( S"19W V/-'/'� NO.a -� Q
,,JJ(� /►per 1 8&4A
I"hereby affirm that I am exempt from the'Contractor's License ADDRESS ��7 '�� IR�C �I�/"'
Law4.for the following reason (Section 7031 5, Business-and, # e o 0 0,0
Prof Bions Code)- '• PRESENT
BUILDING • 2'0 • 2 s o a
I as owner of.ih`e'property, or my employees with , ADDRESS
wages as their sole compensation, will do the work and io o.o _
the structure is not intended or offefed for sale,(Section LOCALITY 2 5 O O r,
7044;Business and;Professions Code) MOVING. TEL,
❑ ';,I,'as owner of the property, am exclusively cgntracting CONTRACTOR NO 0'a 2 6,-,8 O''
witji licensed contrcictors to construct-the project (Sec- ADDRESS
tion 7044,--,Business and Professions Code) '
-REQUIRED TOTAL SETBACK FROM EXIST'
CONSTRUCTION LENDING AGENCY SET BACK, YARD TOTAL PROP LINE -WIDTH
I'kereby affirm that there is a construction lending agency,for FRONT
the performance of.the work for which this permit.is issued p LIf
ID
'(Sec 3097, Civ•C ) ' SIDE '
Lender's Name
P C Fee$• - Permit Fee -
Lender's Address
w j certify:that I have read this"application grid state that the ssuanceFee 09
above information is correct I agree to comply with,all County Investigatiori Fee
ord{nances-and State laws'relatmg to building construction, !t
O'
and'hereby-authorize representatives of this County to enter Total Fee
upoet e-m
abovent e property for inspection purposes '
r'
aSEE REVERSE FOR EXPLANATORY LANGUAGE
Signa e'of Applicant or Age Date ®s