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HomeMy Public PortalAbout5314 LOMA AVE_Building__ 76AGSBA DBS-3 3-55 APPLICATION FOR BUILDING PERMIT 1 DIVISION OF BUILDING AND SAFETY BUILDING Depa7 ent of County Engineer ADDRESS County of Los Angeles Ltt LOCALITY WM.J. FOX. COUNTY ENGINEER NEAREST' r CASSATT D. GRIFFIN, SUPT OF BUILDING CROSS ST. DIBTRIC GR I TYPE I ®ESR MAPPG ' - FOR APPLICANT TO FILL IN _ _ CONST. BUILDING S3 L p,��. MAP STATE ADDRESS 'NUMBER HWY YES O LOT NOIAAAV tadjBLOCK USE ZONE BPECI L f CONDITIONS TRACT r f` / NO. OF BLDGS. SIZE OF LOT ('A /s"D NOW ON LOT BUILDING YARD HWY STREET NAME EXIST' SETBACK WIDTH USE OF EXISTING BLDG. FRONT P. L. OWNER (� �-- 0 ! G-. y ING SIDE P. L. MAIL L/ A ADDRESS / / L 0,11A 9 O TRACT DWELL. I UNIT 5 INDUSTRIAL r�,► //_+ TEL./� I DWELL. I UNIT CITY / r r!-PL `� T�NO. ' I 6 PUBLIC BLDG. ARCHITECT OR TEL 2 DUPLEX I UNIT 7 ADDN.. A ETC. ENGINEER NO. 3 APT. UNITS S MISCEL ADDRESS 4 COMMERCIAL VA44-114-1CONTRACTOR / TEL NO.A�75033 INSPECTION,RECORb ADDRESS Z� N`L�' / 6 . ��- '�'S� fI�- LAA ••i,�IGt. . DESCRIPTION OF WORK �� ��� 1;oQ- NEW ADD ALTER REPAIR DEMOLISH ry SO. FT. NO.OF NO. OF A SIZE STORIES FAMILIES en USE OF STRUCTURE Y� SIGNATURE OF APPLICANT APPROVALS ADDRESS DATE INSPECTOR'S SIGNATURE z:1P. $ FOUNDATION: FORMS, MATERIALS ION - FEEE FRAME: FIRE STOPS, VALUATION/ 8 I.D BRACING, BOLTS - FEE FURNACE: LOCATION, 1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS GAS VENT, DUCTS APPLICATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES LATH, INT. AND STATE LAWS REGULATING BUILp4C> CONSTRUC- TION. LATH. EXT. r SIGNATURE OF �, HOUSE NUMBER COR- PERMITTEE RECT AND POSTED ADDRESS FINAL - WM.J. FOX,COUNTY ENGINEER VALIDATION C. N. DIRL4M.CHIEF BLDG. INSPECTOR 2.0 0 In TEMPLE CITY f41Aa3eACE$e01- +-61 APPLICATRON FOR BURLDNG PERMIT" lJ COUNTY OF LOS ANGELES BUILDING DEPARTMENT OF COUNTY ENGINEER SDDRESS BUILDING AND SAFETY DMSION LOCALITY 01 JOHN A. LAMBIE, COUNTY ENGINEER NEAREST WILLIAM A. JENSEN SUPT OF BUILDING CROSS ST DISTRICT NO. GROUP TYPE . P SSED BY FOR APPLICANT TO FILL IN � CONST BUILDING STATISTICAL CLASSIFICATION SE ER MAP ADDRESS 5314 No. Loma CLASS NODWELL UNITS K / P LOT NO. BLOCK WATER (D CERTIFICATE NOT REQUIRED RECEIVED TRACT — /-L7 3 MAP HIGHWAY NO OF BLDGS. NO (CIRCLEI STATE MAJOR SECOND, OC LI SIZE OF LOT I NOW ON LOT USE ZONE SPECIAL USE OF 0? CONDITIONS EXISTING BLDG. - TEL. ` OWNERGeD. C. Levine NO BUILDING EXIST SETBACK YARD HWY S REET NAME WIDTH ADDRESS 5314 N & T �+ FRONT 1+i� ARCHITECT OR TEL P L ✓ J ENGINEER NO SIDE P L ADDRESS CONTRACTOR Virgin Roof COT EoLA T7050 INSPECTION RECORD Q V ADDRESS 600 S, San Gabriel Blvd. O DESCRIPTION OF WORK S. G. v W CL NEW ADD ALTER REPAIR DEMOLISH N SQ FT. NO OF ? IZE STORIES FAMILIES USE OF STRUCTURE , Re-roof Rouse & Gara e SIGNATURE OF APPLICANT VALUATION$216.00 - APPROVALS DATE INSPECTOR'S SIGNATURE PC PMT, FOUNDATION* LOCATION FEE $ FEE $ FORMS,MATERIALS FRAME FIRE STOPS, IHEREBY ACKNOWLEDGE THAT I 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 GASVENT DUCTS BUILDING CONSTRUCTION I CERTIFY THAT IN DOING THE WORK AUTHORIZED HEREBY I WILL NOT EMPLOY ANY PERSON IN VIOLA. LATH, INT. TION OF THE LABOR CODE OF THE STATE OF CALIFORNIA RELAT- ING TO WORKMEN'S PENSATION�URAN�CE, LATH,EXT � SIGNATURE O HOUSE NUMBER COR- PERMITTEE RECT AND POSTED I pa,r�pyJj ADDRESS 600 S. San Gabriel Blve., FINAL i San Gabriel CLYDE N DIRLAM, PRINCIPAL STR RAL ENGINEER• PLAN CHECK VALIDATION CK. M.O. CASH PERMQT VALIDATION cK m.o. CASH LACo 4 45 7N(-0 SEP 18 1 •D 6.00- .V �. WORKERS' COMPENSATION DECLARATION } insure,or afc'ertificatethat lhave a certificate of Workers'Compensotf nconsent lnsurance, or self A P IPU CAU P O lJ V FO o O a certified copy thereofSec 3800, Lab C ) COUNTY OF LOS ANGE'ES- BUILDING APUD SAFETY �o- 397to I 5-rn-M r-Amfl Policy No Company Certified copy is hereby'furnishedle �� _�` FOR APPLICANT TO FILL IN BUILDING ADDRESS (✓)� Certified copy is filed with the county building inspec- BUILDING �3 ��U tion department -WilLt>Wr�+ 13'7 ADDRESS LOCALITY 1 JS (�SC1�l,��-�.---� NEAREST _ u Dote -7Is 8 ApplicantQ 7_ - CITY HPI- G� ZIP CROSSST CERTIFICATE OF EXEMPTION FROM WORKERS' NO OF BLDGS ASSESSOR f COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL (This section need not be completed if the permit is for one USE ZONE MAP TRACT BLOCK LOT NO NO hundred dollars ($100)or less ) /J > OWNER jo*ycW rzsrFD TEL �j/ SPECIAL O I certify that in the performance of the work for which this NO CONDITIONS permit is issued, I shall not employan GROUP TYPE FIRE P SED BY U ONST Z IM y 'S�« ��� ���'manner DISTRICT ADDRESS [,eC so as to become subject to the Workers'Compensation Laws , CITY T�rtt��� GI 1 ZIP 2 i��S IGP Date Applicant STATISTICAL CLASSIFICATION APT - CONDO U NOTICE TO''APPLICANT If, after making this Certificate of ARCHITECT OR _ TEL U ENGINEER NO CLASS NO DWELL UNITS 0. Exemption,''you should become 'subject 'to the Workers' W Compensation provisions of the Labor Code, you must forth- ADDRESS SEWER MAP Z with comply with such provisions or this permit shall be deemed revoked CONTRACTOR Rh It"r-)W 8\)ILD 33 SOS4� -BK PG, VALIDATION LICENSED CONTRACTORS DECLARATION - L ^COs AVi✓ LIC q I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS 5'30 NO -2 f 15w VALUATION (commencing with Section 7000 of Division 3 of the Business andLIC �y Professions Code, and my license is in full force and effect CITY �� N ��� G�L�F CLASS $ I O} L-I `lSS' g SIZE FT ¢ NO OF ) NO OF CHECK License Number Lic Class F 6 STORIES 1 FAMILIES ONE FAi It4BVW- RV ILD�11r5 7` �S'(>�� DESCRIPTIONOFWORK RIUIL.A I6 'x! NEW ❑ $ Contractor Date• fff �O Y1 /i1V i�ID I am exempt from the licensing requirements as I am a ,C. ADD licensed architect or a registered professional engineer ALTER E] FINAL acting in my professional capacity (Section 7051, L1� Rood REPAIR ❑ DATE Business•and Professions Code) USE OF , EXISTING BLDG P�I�L�L I��7 DEMOL' ❑ 1 FINAL Lic or Reg No _Date APPLICANT �aD�� L � tEL Sa BY OWNER-BUILDER DECLARATION (PRINT) ,\ FtGO / (�21 I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section.7031 5, Business and ADDRESS 203'S7A Professions Code) PRESENT ING j, as owner of the property, or my employees with ADIDRESS #'o'oto 0 0'1 wages as their sole compensation,will do the work and the structure is not intended or offered for sale(Section LOCALITY 0 /f 210 1 V&0 0 7044, Business and Professions Code MOVING TEL Q !/ U' I, as owner of the property, am exclusively contracting CONTRACTOR NO �r o 0 1 060 02 C) with licensed contractors to-construct the project (Sec- ADDRESS r tion 7044, Business and Professions Code) 0 7'1 5—'8 1 REQUIRED TOTAL SETBACK FROM EXIST vv CONSTRUCTION LENDING AGENCY SET BACK YARD. HWY PROP LINE WIDTH t 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 Lender's Name ' P C Fee$ - Permit Fee - Lender's Address w I certify that I have read this application and state that the Issuance Fee above information is correct I agree to comply with all County Investigation Fee ordinances and State laws relating to building construction Total Fe and hereby authorize representatives of this County to-enter - (_upon the above- entici ro erty for inspection purposes "il�tl�}gev.� lA i3-y/ a ��11�,_� _ � �5 ✓ejI SEE REVERSE FOR EXPLANATORY LANGUAGE ' '•'� Signature of Applicant or Agent Dote l s� 'VNRKERS' COMPENSATION DECLARATION _ ' -� - • affirm that I have.a certificate of'consent to self 31.51 .. O a cert ctor'sificate of Workers'Compenstion Insurance, or Q p p L p C�QI p O�1 i copy thereof (Sec 3800, Lab C ) r! hich� .r .✓ COUNTY'OF LOS ANGELES BUILDING,AND SAFETY fish Com an us entified copy is herebypfurni�ed FOR APPLICANT TO FILL IN', BUILDING 3 (a ' /V' t! ADDRESS men rtified copy is filed with the county building inspec- BUILDING �l r� Conn department ADDRESS �� /'� /y LOCALITY Sec �j y NEAREST aC Applicont�/Cf,Ry, ""'r/�/ CITY 2W i Cl)` ZIP CROSS ST !V,G rth4ERTACATE OF EXEMPTION FROM WORKERS' NO OF BLDGS 2 ASSESSOR S COMPENSATION INSURANCE SIZE OF LOT 3TU NOW ON LOT MAP BOOK PAGE PARCEL cl,iclion need not be,completed if the permit is'for one USE ZONE MAP TRACT BLOCK LOT NO NO O J,�;I Ile dollars ($100)or less ) TEL �7♦fie-rte, 1,K1r SPECIALCL wt} h OWNER NO /"IJV V� CONDITIONS O q ,that in the performance of the work for which this _ L{ / ,, DISTRICT GROUP TYPE FIRE PROCESSED BY 0441is issued, 1 shall not employ any person in any manner ADDRESS ` / �� —CJ�'!� u o become subject to the Workers'Compensation Laws �J CONST ZONE I CITY 5 '✓f I I k4 Applicant �/l ZIP STATICAL CLASSIFICATION APT CONDO 0 aAE TO APPLICANT If, after making thin Certificate of ARCHITECT OR TEL / UJI e ENGINEER NO _ CLASS NO [_DWELL UNITS a imotion, you should become subject to the Workers' y jffensation provisions of the Labor Code, you must forth- ADDRESS 1 SEWER MAP Z Qcomply with such provisions or this permit shall be TEL�� {�'e tb led revoked CONTRACTOR V�/��!SAA NO ��/ BK PG, VALIDATION o LICENSED CONTRACTORS DECLARATION LIC eby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO 29 � VALUATION Imenang with Section 7000)of Division 3 of the Business'and ..r / cessions Code, and my license is in full force and effect CITY L) CLASS 13 $ J cc) SQ FT NO Oq NO OF CHECK h�nseNum/'bber�7 Lys' Lic Class —1-12"tSIZE r STORIE6 FAMILIES ONE c tractor tC1JSIV; �i�nr Date / DESCRIPTION OF WORK NEW ❑ nsing requirements ADD I am exempt from the liceas I am a L r9/Ki b licensed architect or a registered professional engineer ALTER ❑ DATE t acting- in my professional capacity (Section 7051, REPAIR ❑ Business and Professions Code) USE OF _ EXISTING BLDG k9� D�EsMrOFINAL �L' ❑ t'c or Reg No Date APPLICANTv lC���TNO z 7/ By 'OWNER-BUILDER DECLARATION PRINT) I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031 5,-Business and" ADDRESS !3V �' '�z.0 1 90 6;6 8 A Professions'Code) PRESENTa DING 'EJ 1, as owner of the property, or my employees with ADIDRESS #,o:o 0 0 0 wages as their sole compensation,will do the work and LOCALITY 2 0'1 '5 1.00 the-structure is not intended or offered for sale(Section 7044, Business and Professions Code) MOVING TEL �o a 1 5 1,0.0 1, as owner of the property, am exclusively contracting A CONTRACTOR NO with licensed contractors to construct the project (Sec- ADDRESS 8 0,7_8 1 ' tion 7044, Business and Professions Code) REQUIREDYARD TOTAL SETBACK FROM EXIST - - CONSTRUCTION LENDING AGENCY SET BACK PROP,LINE WIDTH I herebyaffirm 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• PL HWY Lender's Name P C Fee$ Permit Fee Lender's Address I certify that I have read this application and state that the Issuance Fee • above information is correct I agree to comply with all County Investigation Fee ) O ordinances and State laws relating to building-construction, Total Fee ! „ �r and hereby authorize representatives of this County to enter upon the .+ tioned property for inspection purposes 7 9/ SEE REVERSE FOR EXPLANATORY LANGUAGE S e of Applicant or Agent Date - ©s WORKERS' MPEN•S�'4TION DECLARATION • insurebona certif catte of WorkersrtCompensation ificcite of eInsuran ent to lf or d certified copy thereof'(Sec 3800, Lb6~C )_ COUNTY OF LOS'ANGELES t _ BUILDING AND SAFETY Policy No Company , ` , ❑ BUILDING Certified co is ' FOR APPLICANT TO FILL IN'PY here'b'y furnished - ,. ADDRESS 5 3 � 1..n m c- Are. . . ❑ Certified copy is filed with the county building mspec BUILDING tion department ADDRESS 9/7 D Date Applicant CITY ZIP LOCALITY PP / / O OF BLDGS NEAREST IO CERTIFICATE OF EXEMPTION 40M WORKERS' SIZE OF LOT Sa )QSO NOWONLOT CROSS ST J COMPENSATION INSURANCE ; _ ASSESSOR /� (This section need not be completed if the permit is for one TRACT BLOCK LOT NO MAP BOOK 53 8 PAGE DO O PARCEL 2 hundred dollars ($100) or less ) ' TEL / OWNER u e �50 NO (� USE-ZONE MAP I certify that in the performance of the'work for which this NO SPECIAL permit is issued,•1 shal I not employ any,person in any manner ADDRESS — CONDITIONS i1 so as to become subject to the Workers'Compensation.Laws I _.. , - I 1 O CITY ZIP Date `1Apphcant ARCHITECT OR, L TEL Gn O NOTICE•TO APPLICANT.-If, after akt g this Certificate of ENGINEER (�r\(1 } NO -G 3 J� DISTRICT GROUP CONS ZEE CESSED BY Exemption, you should become subject to the ,Workers /Ylo tl fC U Compensation'provisions of the Labor Code, you must forth- ADDRESS. SZ2 S• 6 el(A �O P.3 � "' .a with-comply with such provisions or this permit shall be TEL STATISTICAL,CLASSIFICATION - APT CONDO Z deemed revoked _ CONTRACTOR NO — 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 Professions Code,and my license is in full,force and effect CITY CLASS + BK VALIDATION SQ FT NO OFNO OF CHECK PG License Number Lic Class SIZE STORIES FAMILIES, ONE z VALUATION Contractor Date -• DESCRIPTION,OF WORK NEW , $ ❑I am exempt under Sec / - Ic ADD ❑ _ T ALTER .❑ B&P C for this reason REPAIR ❑ $ ' USE OF Date EXISTING BLDG j ~ DEMOL `Signature APPLICANT _TEL C FINA 1 s } OWNER-BUILDER DECLARATION (PRINT) e NO / 65 _DAT I hereby affirm that I am exempt from the Contractor's License ADDRESS �3� V �•v ? Law for the following,reason (Section 7031 5,, Business and FIN 1 Professions Code) PRESENT - BY 1 �e'ACCT. s ❑ I, as owner of theproperty, or m em Io ees.with BUILDING r T 04.- Y P Y ADDRESS wages•as their sole compensation,will do the work and � b�.•`�I the structure is not intended or offered for sale(Section LOCALITY 7044, Business and Professions Code ) MOVING TEL j �'' 1 ITEMS ❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO TOTAL 60.50 with licensed contractors to construct the project-(Sec- ADDRESS` x , tion 7044, Business and Professions Code ) CONSTRUCTION CHECK REQUIRED TOTAL SETBACK FROM,' EXIST,, n-t LENDING AGENCY SET BACK YARD HWY PROP LINE WIDTH1. I hereby'affirm that there is a construction lending agency for FRONT _ ` I MANGE Nie the performance of the work for'which.this permit is issued P C (Sec 3097, Civ 'C ) SIDE ' P < - r ✓ �-���'y�yy LendL er's Name 0000�U01 9/2�09 \ LDMA'Ref # p��y�L i ❑M�+� _ Lender's Address PC Fee$.+ Permit Fee O� 5906 1 PMLo[IL SU I certify ihat•I have read tFiis application and state that the y V Issuance Fee LDMA P/C# above information is correct I agree to comply with all County Investigation Fee„ ordinances'arid State laws relating to building construction, Total Fee ! LDMA Perm # a grid hereby authorize representatives of this County to enter _ ~ upon the above-mentioned property for inspectioh rposes G SEE REVERSE FOR EXPLANATORY LANGUAGE \ SiAnatuFe of,Applic nt o Agent nt Date a Y Ilk WORKERS' COMPENSATION DECLARATION I hereby affirm that have'aicertificdte of consent to self : Qp p i p CQU��N �©.G°3 � M�d D O G p E QM O U insure, o�o.certificate,of Workers' Compensation Insurance, - or dcertified copy thereof (Sec .3800, hob ,C ), COUNTY OF LOS�ANGELES BUILDING,ANID SAFETY Policy No." Company.Company BUILDING ❑„ Certified copy-is hereby furnished = FOR APPLICANT TO FILL',IN ADDRESS 573 f y• �or�ct ❑ 'Certified copy is filed with the,county building inspec- BUILDING ADDRESS ' bo Ci Av e • • .-tion department: � - Q ^7 •�•j-�/� R CITY ZIP l/l60 ioCAUTI . . / L. C Date Applicant' ; r v` NO OF BLDGS "_ NEAREST, o .CERTIFICATE OF EXEMPTION FROM WORKERS" SIZE OF LOT J� I`�SNOW ON LOT : CROSS•5T I v • COMPENSATION INSURANCE ASSESSOR R .(This section need not be completed if the permit"is for'one TRACT-' BLOCK LOT'NO " MAP BOOK 5386 �PAGEwv PARCEL 0 hundred dollars ($100),or less ) TEL 7 OWNER prj NO / -�-'/ USE ZONE. MAP I certify-that in The,performance,"of'.the work for which this • . I - NO SPECIAL permit is issued; I shal I not employ any person in,any manner ADDRESS •5 Q CONDITIONS i1 so as to become subject to the Workers'Compensation Laws S O � }�( CITY -• ZIP IA� 'J Date `Applicant ARCHITECT OR TEL �7�i� c�1 [TYPE0 NOTICE TO APPLICANT, If, after 'maktn this Cerirficai of a ENGINEER Jo Old. NO .G(JIJ,-O37v DISTRICT GROUP. FIRE PROCESSED'BY 9 CONST- ZONE O Exemption, you should become subject•to-the,Workers' Compensation provisions of the Labor Code, you must forth- ADDRESS ZZ S• &ar 5% nW `3 3 with comply with such provisions.or, this permit shall be -1rTEL STATISTICAL CLASSIFICATION APT CONDO Z Q deemed revoked CONTRACTOR W NO - — LICENSED CONTRACTORS DECLARATION LIC CLASS NO DWELL UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADORES NO (commencing with Section 7000)_ Lof Division 3 of,the,Business I, LIC SEWER MAP and Professions Code,and my license is in full force and effect CITY 404 9 CLASS' BK PG VALIDATION SO FT C}-�) NO,OF NO OF CHECK License Number Lic Class SIZE SV STORIES FAMILIES ONE VALUATION ,Contractor Date DESCRIPTION OF WORK NEW $ ❑ Y` a ADD ❑ ✓ ui J D I dm exempt*under Sec - - -• ' ALTER, ❑ ... . B BP.0 for this reason ' $ REPAIR ❑ ` Date USE OF _ _ EXISTING BLDG -DE MOL ❑ ' d Signature APPLICANT TEL FINAL r, ('���y t , �• ' OWNER-BUILDER DECLARATION c.(PRINT)' tt ,�-- -W 7l° DAT I hereby affirm that I am exempt from the Contractor's License ADDRESS S3 f L-CZ Av c` FINAL• �G' 5 `~ Law for the following reason (Section 7031 5, Business and 1 ' Professions Code) PRESENT. By AGGTa4 ❑ I, as owner of the property', 'or my employees with ADDR SSvvv wages,as their sole compensation,.will do the work'and «� - -,�7 2r3 �75 the structure is not intended or offered for,sole(Section LOCALITY 3+ r �l 3•(. ❑ 7044, Business and Professions Code ) - MOVING TEL __ 1 ITUS TOTAL, _ I, as owner of the property, am exclusivelyr contracting CONTRACTOR NO �.9 m d with licensed contractors to construct the project (Sec- ADDRESS y,' ,I[ITAL, 2 tion 7044, Business and Professions Code ) /' -TOTAL SETBACK FROM. EXIST > JCHECK 2n.75 CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP LINE WIDTH I hereby affirm that there is a construction lending agency for FRONT 'v, ; C .I the performance of-the work for which this permit is.issued P L (Sec 3097, Civ C ) [RE6UIRED IDE 1 t r L• tt'�. •r { { Lender's Name---, Q W 1 926/39 �j LDMA Ref # �q ,} ' P C Fee$ Permit Fee / ✓ 5903 .1 PM12:01 Lender's Address a j certify that I have read this application and state that the Issuance Fee 5 LDMA P/C# a 0 8 above information is correct I agree to comply with all County Investigation Fee ordinances and State jaws relating to building construction, Total Fee r LDMA Perm # a and hereby authorize representatives of this County to enter -upon the above-mentioned property for inspection purposes " a SEE REVERSE FOR EXPLANATORY LANGUAGE ign ture of Applica t oil,Agent Date _ r WORKERS' COMPENSATION DECLARATION R' I hereby affirm'tha'fiat I have r certificate of consent t c self /�\P p�D C/O\ I I D O S RSI _ F O D O M.D d D D f�]C� p C G3G�iv D insure, or c+certrficate of Workers'-Com pensation Insurance, [Tuu u u u V or a certified copy thereof (Sec 3800, Lab C ) COUNTY,OF LOS ANGELES• BUILDING AND SAFETY Policy No Company BUILDING: ❑ Certified copy is hereby furnished . FOR APPLICANT TO FILL IN ADDRESS �J`'3( �} (_C�i�4 U s `.❑ Certified copy-is filed with the.county building inspec- BUILDING q�( tion department.- ADDRESS 1�t r CITY LI (' ZIP 1I�S0 LOCALITY Date Applicant l y NO OF BLDGS NEAREST CERTIFICATE OF.EXEMPTION FROM WORKERS` SIZE OF LOT �d ��� NOW ON LOT 2 CROSS ST (,L 1 Vit -COMPENSATION INSURANCEASSESSOR' 2 �1 (This section need'not be'completed if the permit is for one TRACT BLOCK LOT NO MAP BOOK 538 PAGE 00 PARCEL v ZZ 'hundred dollars ($100) or less ) TELf cS AP OWNER Z5j& NO c S70 _ S USE ZONE I certify NO that in the performance of-the work for which this permit is issued, I shall not employ any person in any manner ADDRESS S CONDITIONS a- so,as to,becorrie subject,to the,Workers' Compensation Laws O CITY ZIP U Date Applicant ARCHITECT OR ( TEL NOTICE TO APPLICANT- If, after makingthis Certificate of ENGINEER VOl�Ja0 _ NO2��'�� DISTRICT,. GROUP TYPE FIRE PROCESSED BY c 5 (� CONST Y ZONE Exemption, you should become"subject to the Workers' OtJ'( UX Compensation provisions of the Labor Code,-you must forth- ADDRESS 22 S. Gil ,� r U.1 with comply with such provisionsror this permit shall be TEL STATISTICAL CLASSIFICATION _ A_PT CONDO N deemed revoked CONTRACTOR l 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 'CLASS and Professions.Code, m and my license is full force arid'effect CITY _ _ BK pG "VALIDATION , SQ FT p NO OF n NO"OF / CHECK, License Number Lic Class SIZE 5 1 I STORIES ` FAMILIES 7 ONE " VALUATION Contractor Date DESCRIPTION OF WORK ��ti0 " ❑I am exempt under Sec S �� ADD El L B'&P C for this reason' k� Ls ALTER 1:1 $ `j (EM, —g REPAIR ❑ 13 t RL. A Date U E OF - _ EXISTING BLDG + DEMOL CHECK Signature APPLICANT TEL FINAL (PRINT)` L� y NO l € s OWNER-BUILDER DECLARATION DATE =00 I hereby affirm that I am exempt from the Contractor's License 'Law for the following reason•(Section 7031 5, Business and- ADDRESS FINAL Professions Code) , PRESENT _ By 4��0 89 ❑ BUILDING- �I, as owner of the property, or my employees with ADDRESS `- j Art 8-'-1312 yr- __t "wages as their sole compensation,will do the work and LOCALITY the structure is not intended or offered for sale(Section 7044, Business and Professions Code ) = MOVING STEL _ ❑ 1, as owner of the property, am exclusively contracting CONTRACTOR. NO with licensed contrdctors to construct the project (Sec- ADDRESS tion 7044,'Bdsmess and Professions Code ) , REQUIRED EXIST CONSTRUCTION LENDING AGENCY- K SETT BACK YARD HWY TOTAPROPALINEFROM 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 PL Lender's Name $, LDMA Ref # Lender's Address PC Fee$ Permrt Fee + 1 certify that I have read this application and state that the lssuance Fee LDMA P/C# ' above information is correct I agree to comply with all County Investigation Fee ordinances and State"laws relating to building construction, Total Fee LDMA Perm # a and hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date WORKERS'COMPENSAON DECLARATION I hereby affirm that 11 have a czrtificate of,� p consent to self IPP D D O O t insure,:oracertificate'of'Worken rs' Compesation Insurance, Pd Q%U�(01M,' or a certified copK,'thereof (Ser 3800, Lab C ) COUNTY OF LOS ANGELES` BUILDING AND SAFETY t Policy No Company__ ❑ BUILDING ' Certified copy is hereby furnished 1. FOR APPLICANT TO FILL IN ADDRESS Certified copy is filed with the county'b'uildmg``nspec- BUILDING 1 tion deportment' "' ADDRESS s3% a C: Date +'•' Applicant CITY g C —4rr ZIP )Akf, LOCALITY ' CERTIFICATE OF EXEMPTION FROM'WORKERS' NO OF-BLDGS - NEAREST- t" 'COMPENSATION•INSURANCE SIZE OF LOT J C)X• J-6 NOW ON LOT CROSS,ST d L /a (Thislsection need,not be completed if the permit is for one - - • ASSESSOR- hundred . hundred dollars ($100)ort less ), TRACT BLOCK LOT NO - MAP BOOK, PAGE PARCEL TEL - /G' I certify m .that in the performance of the work for'whii:K this OWNER % N rC' T��NO USE ZONE ? ; permit 1s issued, I'sHall not employ any pe on in any mariner SPECIAL-- -•- -- IL 1 o-= -ADDRESS Lv''YJ �� CONDITIONS O so'ds'to b' 'o •'sublect t, the W rs ns V s CITY. _ C i cA-. ZIP Date Applica ARCHITECT OR' TEL O NOTICE T APPLICANT .If, after akmg is Certificate of DISTRICT GROUP TYPE_-_ FIRE PR CESSED BY.. <_ F. ENGINEER v 1�L F NO CONST ,� ZONE U Exemption, 'you••should beco suble to the Workers' / /�C/ ®�� V Compensation provisions of.the Labor Code, you must forth- (/d n CL ADDRESS with comply.with such provisions or this permit shall be H deemed revoked TEL STATISTICAL CLASSIF CATION APT CONDO CONTRACTOR NO /1_ h LICENSED CONTRACTORS DECLARATION LIC - - CLASS NO J DWELL UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO (commencing with Section 7000)of Division 3'61`the Business and ._ _.. -_ - LIC-- SEWER MAP Professions Code, and my license is,m full force and.effect CITY CLASS w BK PG` VALIDATION - t SQ FT NO OF _ _ j NO OF CHECK - 5 L cense Number' Lic Class SIZE STORIES `( FAMILIES ONE ; . _ r. • ,1 ♦. �' NEW VAL-DATION ^ '• • . DESCRIPTION OF WORK . ❑ - fJ Contractor _ Date ADD s -7� I am exempt under Sec - ®❑ " t, I1, ALTER B&P C for this reason ❑ -S - - - - REPAIR USE GING BLDG DEMOL ❑ - _ ' _ 2.4 3,9.2 A Signature + ` ' APPLICANT � TEL ' - "" -- _ - _ OWNER-BUILDER'DECLARATION PRINT) dp't/ /L/ NOS y �G DAT FINALU. »- -- # 0 0 0 0,0 I hereby affirm,that.I am exempt from the Contractor's License y - `� Law for the following reason (Section 7031 5, Business andADDRESS FI = �3`' ° ° Ta Professions Codd)'-- ..._ - PRESENT- - - B - e o 0 7 8, O�T BUILDING i I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work`and ' - •1 � � 4,08=$(� the structure'is not intended or offered for sale(Section LOCALITY L 1 "n -7044, Business and Professions_Code) MOVING'' 'TEL w - ❑ CONTRACTOR _ - NO - I, as owner of the property, am exclusively contracting with'Iicensed-contractors to`construct the'prolect (Sec- - - - tion 7044, Business and Professions Code) ADDRESS _REQUIRED TOTAL SETBACK F CONSTRUCTION LENDING AGENCY` SET BACK YARD HWY PROP LINE WIDTH ` I herebyaffirm that there is a construction lending agency for 9 9 Y FRONT \ ",' •�;' `� , . the performance-of the-work for which-this permit is issued - PL' - - - - r '= `_ = -"• _ (Sec 3097, Civ C ) SIDE :n PL Lender's Name LDMA Ref #y 1 _ �• P C Fee$ •- Permit Fee - 7,50-! -^ -- - - - - -• Lender's Address _ - ''11 " ,r _.I.certify.that I have read.this application•and-state that the Issuance Fee -- 0V's• V LDMA P)C# �•^ - a above information is correct I agree to comply with all County Investigation Fee S ordinances and State laws_relating to building construction, _� u and hereby authorize-representatives of this County to enter Total Fee• LDMA Perm• # �� on th b -eenTion pr rt for inspection urp ses � ; � r v, - v ; SEE REVERSE FOR EXPLANATORY LANGUAGE Signal of App cant or Agent- Dat