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APPLICATION-TOR Y;6U'ILDI NG PERMIT
3
COUNTY OF,LOS ANGELES BUIL
u aiiNG
DEPARTMENT OF COUNTY ENGIIQEER n°DREss.
BMLDING AND SAFETY DMSION cocwurY
JOHN A.•LAMBIE, COUNTY ENGINEER L"NEAREST
WILLIAM•A:JENSEN SUP•TOFBUILOIND - LCROSSST. -
DISTRICTIgO. GOUP TYPE- PR 'SSED BY ,
.FOR APPLICANT TO FHELL IN �'.p . coN ST.
//]]/J` s� /� / / STATISTICAL CLASS ,KATION- SEWER MAP
BUILDING `�/._/.J V G'• L /a ;F,95 � P%Z ' ,. �_HK,.
ADDRESS. / J
/ - CLASS. NO. • DW ELL.•UNIT9
'LOT NO. Vii S OF--I FS -A-2-1'.23 BLOCK WATER NOT REQUIRED - RECEIVED '
CERTIFICATE:
TRACT MAP HIGNwnv.. '- •.
N O.OF BLDGS. 99
'NO. - (CIRCLE)
: STATE;MAJOR.SECON SECOND,-LOCAL
SIZE OF LOL.,SOX /7 ' KNOW ON LOT J. USE ZONE' SPECIAL „
'USEOF "- - -� CONDITIONS ;
EXISTING BLDGL•' ,! �5 -
OWNER I%/- /U�./ CY�•/✓nT _TEL
NO/I'T�'J JL BUILDING - ' 'EXIST.. '
SETBACK YARDS HWY TREET,NAME .WIDTH'
ADDRESS. ..�G.SD' C- I''' L/a��O S�1- FRONT ,
ARCHITECT OR 'TEL. ! P. L. VV
ENGINEER "' NO. SIDE -
P.L. }
ADDREss- q INSPECTION RECORD s
CONTRACTOR /I.T /�'�//✓BOAT NO AT J'G1iS �-'
ADDRESS J�'.3Z7 CLO VE,fl ty " T' C r
DESCRIPTION OF WORK rycN,.;/ t� t �IrTS *j
Lt/W Ak �ff s 7!I �.yfG l4la'J/ Fry. :N7
NEW ADD ALTER REPAIR DEMOLISH �n ry - ! / I ,Z
SO:FT. NO.OF 'NO.OF C I i'JS ••���ITI. �Q"LM k�A J.Y.r.9 Y.�°'S'A f
IZE �+/f1 o STORIES FAMILIES
USE OF-
STRUCTURE' , . C'S •T - `` ,I _
SIGNATURE OF. C' .� �L ' /1/ �/ JYJ✓%A /!rl LS�iI/. /..N �Lr• S' �•ZYetY. S4bL.+'
APPLICANT �'• ,;_.` �r�.�
✓ALU ATION'$ -. , ..
APPROVALS .DATE ' INSPECTDR'SrSIGNATURE
''FEE $' �� FEE $� O `FOUNDATION: LOCATION
_ FORMS, MATERIALS �I•`F. Ls C •'Z•✓ _
FRAME: FIRE STOPS;` 1l
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION. � .BRACING.BOLTS
AND STATE THATJHE ABOVE•I5 CORRECT AND AGREE TO COMPLY FURNACE: LOCATION,
WITH ACE COUNTY ORDINANCES AND STATE LAWS REGULATING' '.GAS VENT DUCTS' / V/
BUILDING CONSTRUCTION.'1 CERTIFYlTHAT IN DOING THE WORN - - �.//�� / / may@.yam r•/
AUTHORIZED HEREBY I WILL,NOT EMPLOY ANY PERSON Iry VIOLA=, ' LATH,,I NT.
TION OF.THE LABOR�CODE,Or THE STATC OF CALIFORNIA RELAT� "-
INDTO WORKMEWS COMPENSATION INSURANCE. I ~ -
�. LATH,EXT.
SIGNATURE OF, '�rL,pv✓ HOUSE NUMBER COR- ,.,,; ;,,_ '_• r
(PERMITTEE - '. R ECT AND POSTED A
ADDREss 'FINAL
• CLYDE N. DIRLAM:PR"INCIPAL sTRyCTDftALlENGINEER
PLM,CHECK VALIDATION CK. M.O. CASH PERIM VALIDATION CK, M.D. GSH
��uv1 4 1 6 4.00 °
APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS 5 , D D�.
I hereby affirm that I have a certificate of consent to self insure, BUILDING ADDRESS �+ls� �� Ave—
ve—
or a certificate of Workers' Compensation Insurance,or a certified j
copy thereof(Sec.3800,Lab.C.) CITY 7 ' 1 ZIP
LOCALITY
Policy No. Company SIZE OF LOT NO.OF BLDGS.NOW ON LOT
❑ Certified copy is hereby furnished. NEAREST CROSS ST.
❑ Certified copy is filed with the county building inspection TRACT BLOCK LOT NO.
department. USE ZONE MAP NO.
Date Applicant ASSESSOR MAP BOOK PAGE PARCEL
SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER �+�r TEL N
COMPENSATION INSURANCE iC� �Gnl WITHIN 1000 FT.OF SCHOOL? Yes No
(This section need not be completed if the permit is for one hundred ADDRESS G
dollars IS 100)or less.) DISTRICT GROUP TVP CONST. FIRE ZONE PROCESLBY
CITY � -�---- 21P �� _�
certify that in the performance of the work for which this permit CM2 J
is issued, I shall not employ any person in any manner so as to ARCHITECT O NGINEER TEL NO.
beeo a suIS ect to the Workers'Compensation Laws T STATISTICAL C/LAn/�S/�S�IFICATION APT CONDO
Da�PPIiCant��'> ADDRESS CLASS NO. T DWELL UNITB
NOTICE TO APPLICANT.. If, after making
this Certificate of + REQUIREDTOTAL SETBACK FROM EXIST
Exemption, you should become subject t0 the Workers' CONTRACTOSET BACK YARD MY PROP LINE WIDTH
Compensation provisions of the Labor Code, you must forthwith -� �b FRONT
comply with such provisions or this permit shall he deemed revoked. ADDRESS ? IC.NO. P L
CIT LICENSED CONTRACTORS DECLARATION 7 'r'S -x �uc.c ss 91 SIDE
� P L
I hereby affirm that I am licensed underprovisions of Chapter 9 f'� SEWER MAP
(commencing with Section 7000)of Division 3 of the Business and SO.Ft.SIZE NO,OF ST NO.OF FAMILIES }
Professions Code,and nnlicense 9 in full force and ct NEW ❑ BK PG d
License Number Lic.Class D� IPTIO OF WOR U
ADD ❑ VALUATION f V , O
t /��
Contract , I Date ALTER ❑
I �j
❑ lam exem un -Se � PAIR ❑ $ 0
BAP.C. for this reason I LI ❑ LOMA we.. W
Date: SE OF EXISTING BLDG. - U 55
Signature APPLICANT(PRINT) TEL NO. LDMA Perm A 1 Z
❑ I, as owner of the property, or my employees with wages as ZO
their sole compensation, will do the work and the structure is ADDRESS {{
not intended Or offered for sale (Section 7044, Business and FINAL DATE Q _GI]j �,iy N._'. 1
Professions Code.) J7' 23.P(�Y O
WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL
❑ 1, as Owner Of the property, am exclusively contracting With OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER iNAN THE Q 1 I 1
AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL B >
licensed contractors to construct the project (Section 7044,
Business and Professions Code.) vas❑ No❑ le I L I-TAL 121 - 35
WILL THE INTENDED USE OF THE BUIDUNG BY THE APPLICANT OR FUTURE BNLOING �.(�tl.f'.
L C(K �C
CCCUFANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH .LZ i.J'
CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMDI SEE PERMITTING CHECKLIST FOR
GUIDEUNEs. CHAT ill .03
I hereby affirm that there is a construction lending agency for YES No El
the performance Of the Work for which 1(115 permit 15issued(SCG I HAVE READ THE HAZARDOUSMATERIALS INFORMATIONGUIDE AND THE SCAOMD PERMITTING
3097,Civ.C.) CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, r f iq
W TITLE 2,CHAPTER 220 SECTIONS 2.20.100 THROUGH 2,20.140 CONCERNING HAZARDOUS 1_II k�l(I—[I(I[.I i 7/y�7)._+t'
Lenders Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCACMD.
$ Lender's Address +-f' 1 PIN
o COMER CR.ENT
o I certify that I have read this application and state under penalty
o of perjury that the above information is correct.I agree to comply PC.FEE PERMIT FEE
o
with all county ordinances and State laws relating to building
w construction, and hereby authorize represe Gives of this County ISSUANCE FEE
m ito nt rupon1.nwm hove-m¢ptio rort c(insp0ectio_ npu[posesr� SI
INVESTIGATION FEE TOTAL FEE
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SEE REVERSE FOR EXPLANATORY LANGUAGE