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76A838A CE#803,11-57APPLICATION TION FOR -BUILDING PERMIT'
COUNTY OF LOS ANGELES ADDRESS / �✓
DEPARTMENT OF COUNTY ENGINEER.
BUILDING AND SAFETY DIVISION LOCALI -/} L E e--1-7.
JOHN A. LAMBIE.COUNTY ENGINEER NEAREST
CASSATT D.GRIFFIN,SUPT OF BUILDING CROSS ST. e - - 4✓' -
DISTRICT NO. GROUP fTypE SEWER ,MAP.
FOR APPLICANT O FILL IN-
0' ZSy�
NG BUIL - STAT3IST'ICAL CLASSIFICATION
CLASS.NO. % 'DWELL.UNITS - -
LOT NO. ZC2 4z BLOCK MAP STATE
NUMBER D HWY. YE5 NO
-TRACT USE ZONE SPECIAL
NO.OF BLDGS. CONDITIONS_ _
SIZE OF LOT So XI 79 I NOW ON LOT v� -
USE OF
EXISTING BLDG. C G BUILDIN - EXIST.
` YARD HWY STREET ME
SETBACK _ WIDTH,
OWNER GST mac/`�, FRONT
MAIL P L. '
ADDRESS GC L SIDE - -
TEL. P L. _
CITY z 4 NO• INSPECTION .RECORD
ARCHITECT OR TEL. _
ENGINEER 'NO. '`• -- -
_ ADDRESS.- - - - /'/ IAV //1"� /r �O//A-�.•
TE
CONTRACTOR /1f - L' - N
' '� �'`>�J.� `Tip 7l��•._�,r�',�7`` _
ADDRESS �df V149A J P 0�l _
DESCRIPTION OF WORK '
�D ���n/!�� 2 �i�1h_mmJ'
NEW ""ADD - ALTER REPAIR DEMOLISH
-SQ.FT. NO.OF NO.OF
SIZE STORIES FAMILIES
USE OF STRUCTURE }
SIGNATURE Of - APPROVALS
APPLICANT - •-
400,
DATE, J INSPECTOR'S SIGNATURE
ADDRESS `FION
FORMS.MATERIALS
$ 2 oa P.C. S FRAME: FIRE STOPS.
VALUATION �{J ^
FEE ' :BRACING.BOLTS -e� •����% /�� �A �Q� -
S co FURNACE:GAS VENT, UCTS N.
FEE
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS AP-
PL ICATION
P-PLICATION AND STATE THAT.THE ABOVE IS CORRECT AND LATH,INT.
AGREE TO COITH LL COUNTY ORDINA ES AND
STATE LAWS EG LAT G B - / ,�/-
UIL IN C N U_TION. LATH,EXT. / :/
'SIGNATURE O - HOUSE NUMBER COR- . ' --
PERMITTE RECT AND POSTED ✓ -
ADDRESS FINAL Z5�
CLYDE N. DIRLAM, PRINCIPAL STRUCTURAL ENGINEER,
PLAN CHECK VALIDATION CK. M.O. CASH :PERMIT VALIDATION. c M.O.: CASH'
�nco 7 9 3 .3 °;' Jl 1� 1.5. 1 A ,, .18,.00 . -
APPLICATION FOR, BI ILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS
BUILDING DD ESS _ ���
U
I hereby affirm that I have a certificate of consent to self insure, _ S QAle—
copy
O
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.) 11,
.) zIP QO LOCALITv—.
Policy No. Company SIZE OF OTS NO.OF BL .NOWONLOT
llCertified copy is hereby furnished. NEAREST CROSS ST.
❑ Certified copy is filed with the county building inspection TRACT BLOCK LOT NO. �7
department. .6E( / S 9 0o G. USE ZONE MAP NO.
Data Applicant ASSESSOR MAPBOOK S S7_ pAGE0Z® 06 SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' �If1ER 7.TEL.NO. YES NO
COMPENSATION INSURANCE L WITHIN 1000 Fr.OF SCHOOL?
D REss
(This section need not be completed if the permit is for one hundred 4nde. DISTRICT GROUP TYPE CONST.' FIRE ZONE P CESSE{D BY
dolls $hat or less.) F CI ZIP G OY �� , / 3 -Y
I certifythat in the performance of the work for which this permit /C. I�i 9170 0 `JI/�' /T"
is issued, I shall not employ any person in any manner so as to ARCHITECT OR ENGINE L.NO.
become
subject to the Workers' O pensation Law ) STATISTICAL CLASSIFICATION APT CONDO
Date .� Applicant 7AA&11&& %P,/, od. ADDRESS CLASS NO. DWELL UNITS
NOTICE TO APPLICANT. if, after making this Certificate Of CONTRACTOR TEL.NO. REQUIRED TOTAL SETBACK FROM EXIST
Exemption, you should become subject to the Workers' SETBACK YARD HWY PROP LINE WIDTH
Compensation provisions of the Labor Code, you must forthwith FRONT
comply,with such provisions or this permit shall be deemed revoked. ADDRESS LIC.NO. ,P L
LICENSED CONTRACTORS DECLARATION CITY LIC.CLASS
FIDE
CD
0
I hereby affirm that I am licensed under provisions of Chapter 9 SEWER MAP
U
(commencing with Section 7000)of Division 3 of the Business and SQ.FT,,SIZE NO.OF STORES NO. FAMILIES O
Professions Code,and my license is in full force and effect. NEW ❑ BK PG 15
DESCRIPTION OF K d ADD ❑ VALUATION 0 ® , a
License Number Lic.Class old 400.00
�
Contractor Date `� ALTER ❑ $ v ° _Z
(A iNd IO eq*r REPAIR
❑ 1 am exempt under Sec. �!�
B.BP.C.for this reason L K q Cj- Ct I.5° DEMO ❑ LOMA P/C#
Date. US OF EXISTING L URM ❑
5
Signature A�ICANT(PRINT) �/ TEL.NO. LDMA Perm#
❑ I, as owner of the property, or my employees with wages as CI' - 4_2 /�/ — p a +, s
ADDRESS �� A'''.j °
their sole compensation,will do the work and the structure is H
/f / FINAL DATE Q
not intended or offered for sale (Section 7044, Business and ZS Q Q /z�c• t 6 a 330; &.3.:,F
rofessions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HAN LEA HAZARDOUS MATERIAL' �� (/ r 1 J rr•
as o ' OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN Q 1 Ir€E 3i-
wner of the property, am exclusively contracting with THE AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINA"Y �'% 1 )�V
II ensed contractors to construct the project.(Section 7044, YES❑ NO❑ �� I��v TOTAL
1.11�� ,
Business and Professions Code.)
WILL THE INTENDED USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING �{ 'Iiy -75
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH 1 ' �.•E-E .:. 4j,
CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST �, I ) �� _
FOR GUIDELINES. I �� ( •' I�_ i f
I hereby affirm that there is a construction lending agency for YES❑ NO❑ { �r
the performance of the work for which this permit is issued(Sec. J~ ``
I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD
3097,CIV.C.). PERMITTING CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES +
�. COUNTY CODE,TITLE 2,CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING III —I 3 3 I' {.i 6 1
Lender's Name HAZARDOUS MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD. •-- f. t
Lender's Address armsaonAcolT +=#-159 1 f 7'33
o I certify that I have read this application and state that the above RC.FEE PERMIT FEE
information is correct. 1 agree to comply with all county
QTX� ordinances and State laws relating to building construction,and
¢. hereby authorize representatives of this County to enter upon ISSUANCE FEE
the ab ve mentioned prop for inspection purposes. �i
7-Z9-90 INVESTIGATION FEE TOTAL FEE
i sq,eare m Appllonl or A� om. �
SEE REVERSE FOR EXPLANATORY LANGUAGE,