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HomeMy Public PortalAbout6146 LOMA AVE_Building__ 76A638A DISH-3 3-86 .;` APPLICATION FOR BUILDING PERMIT 1 1 DIVISION OF BUILDING AND ADDRESS27 , SAFETY BUILDING [� Depa, ent of County Engineer County of Los,Angeles LOCALITY WM.J. FOX, COUNTY ENGINEER NEAREST CASSATT D.GRIFFIN, SUPT OF BUILDING CROSS ST. DISTRICT NO. GRCj,(ZP ,SPE SEWBER MAPPG FOR APPLICANT TO IN CONST. BUILDING MAP; -n ,( f,-3 STATE ADDRESS / J i NUMBER OC !/ YES NO HWY LOT NO. V BLOCK USE ZONE SPECIAL ,yL CONDITIONS TRACTNO. OF BLDG SIZE OF LOT I NOW ON LOTS BUILDING YARD HWY STREET NAME EXIST. SETBACK WIDTH USE FRONT iJ EXISTING BLDG. P.L. ✓`TJ OWNER SIDE -P.L. MAIL / O TRACT DWELL. 1 UNIT ADDRESS' ` 5 INDUSTRIAL TEL. 1 DWELL. 1 UNIT '- CITY NO. 0 `L 6 PUBLIC BLDG. ARCHITECT OR/ TEL. 2 DUPLEX g 1 UNIT 7 P.DDN.,ALT., ETC. ENGINEER v NO. 3 APT. UNITS S MISCEL. ADDRESS 4 I'COMMERCIAL TEL. CONTRACTOINSPECTION RECORD R NO. ADDRESS a DESCRIPTION OF WORK NEW ADD ALTER REPAIR DEMOLISH Sq. FT. NO.,OF NO. OF SIZE STORIES FAMILIES - USE OF STRUCTURE - SIGNATURE Ot ' -APPLICANT APPROVALS ADDRESS DATE INSPECTOR'S SIGNATURE $ FOUNDATION: LOCATION P.C., IIIt FORMS, MATERIALS ' cZ/7� VZJ FEE FRAME: FIRE STOPS, VALUATION t $ ^ BRACING, BOLTS FEE O(•• FURNACE: LOCATION. 1 HEREBY" ACKNOWLEDGE THAT I HAVE READ THIS GAS VENT. DUCTS APPLICATION AND STATE THAT THE ABOVE IS CORRECT f AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES LATH. INT. AND STATE LAWS REGULATI G B ILDING C NSTRUC- TION. f LATH. EXT. SIGNATURE O HOUSE NUMBER COR- PERMITT A, RECT AND POSTED T!/' ADDRESS FINAL WM.J. FOX,COUNTY ENGINEERVALIDATION C. N.DIRLAM, CHIEF t3LDG. INSPECTOR L 2,2 6 7Z0 VOY 13 1 2.0 0 _ r _ 1' A ROAD DEPT -PERMIT IS REQUIRED FOR ANY MATERIAL S ORA:;E OR WORK DONE IN -THE•ROAD ',RIGrJT OF WY 7eweaewcedeme-aaA►PPLICATIOIll ' FOR BUILD[-K�" -PE.RMIT- COUNTY OF-LOS ANGELES . ' BUILDING ADDRESS DEPARTMENT.OF.COUNTY^ENGINEER . , -BUILDING AND SAFETY'DIVISION LOCALI f ' JOHN A. LAMBIE, COUNTY ENGINEER NEAREST• 'CASSATT D GRIFFIN SUPT OF BUILDING - CROSS DISTR T NO GROUP T� :PRO ESSED BY FOR APPLICANT O FII.L`,IN, CON 'BUILDING STATISTICAL C ASSIFICATION EWER'MAP ADDRESS- BFC CLASS.NO _DWELL''UNITS.S� LOT NO -`�" �" - ..BLOCK MAPSTAT NUM ER 6 V - - HWYE YES NO TRACT - - 1 - USE ZONE SPECIAL - -- `• - - - - _ _ _ NO OF.BLDGS CONDITIONS - SIZE OF LOT O V ��.3 'I NOW ON LOT - / • r- - - •USE OF EXISTING fiLLDG - BUILDING EXIST SETBACK YARD HWY .STREET NAME WIDTH 'OWNER FRONT- MAIL j P L ; ADDRESS ./ /(. SIDE - - TEL. P L Y' - CITY N'O J 7 INSPECTION RECORD ARCHITECT TEL° ENGINEER NO ADDRESS d -TEL. - CONTRACTOR NO• ADDRESS DESCRIPTION OF WORE, _T�f/S �S©Mfeli�},+�T D/ffl�ll�T NEW ADD,_, .ALTER' . ,REPAIR DEMOLISH - - - - SQ FT. NO -OF - —NO OF, SIZE - - STORIES FAMILIES USE OF STRUCTURE _ SIGNATURE O 1 _ APPLICANT J 2!2,00r ]! APPROVALS - DATE INSPECTOR'S SIGNATURE ADDRESS /• - FOUNDATION LOCATION FORMS, MATERIALS • '�S ••//�� VALUATION FRAME FIRE STOPS, BRACING, BOLTS PC - ,PMT I -FURNACE LOCATION, FEE S FEE GAS VENT,DUCTS I-HEREBY ACKNOWLEDGE THAT I HAVE READ THIS AP- LATH, INT ' PLICATION AND STATE THAT THE ABOVE IS=CORRECT AND - - _ AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWSEG T G BUILDI C TRU TION LATH, EXT SIGNATURE O HOUSE NUMBER COR- PERM ITTE OR-PERMITTE RECT AND POSTED - ADDRESS FINAL , -zd"V'b a CLYDE N DIRLAM, PRINCIPAL STRUCTURAL R PLAN CHECK.VALIDATION CK. M.O. CASH — 'PERMT VALIDATION a CK. 'M O. CASH lro 8 8 2 4 ASR 5 1 ''A -2.0-0'. ®: 76A9998A DBS-3 APPLICATION FOR 'BUILDING - PERMIT 11.0 DIVISION OF BUILDING AND SAFETY BUILDING Depar ent of County Engineer ADDRESS County of Los.Angeles LOCALITY• r JOHN A. LAMBIE, COUNTY ENGINEER NEAREST CASSATT D.GRIFFIN, SUPT OF BUILDING CROSS-ST. FOR APPLICANT O FILL IN DISTRICT NO: GTI TYPE SEWER MAP I PG CONST.•-� - �I BUILDING MAP ADDRESS NUMBER ,D� SHWY YES- O LOT NO. 2L BLOCK USE ZONE SPECIAL CONDITIONS , TRACTNO OF SIZE OF LOT ffj V /"Oy J I NOW ON L TS• �BUILDING EXIST. USE OF SETBACK YARD HWY STREET NAME WIDTH EXISTING BLDG. FRONT j-0 P.L. (G J SSV OWNER SIDE , J P L. MAIL ADDRESS �/ O TRACT DWEL 1 UNIT - r� �� 5 INDUSTRIAL CITY p 1 DWELL. 1 UNIT 6 PUBLIC BLDG, ARCHITECT O TEL. 2 DUPLEX 2 UNITS 7 ADDN.ALT., ETC. ENGINEER v NO. 3; APT. D UNITS • 8 MISCEL. ADDRESS, 4 COMMERCIAL I ' CONTRACTOR �/T' /L NO. INSPECTION, RECORD ADDRESS DESCRIPTION OF WORK NEW ADD .ITER • REPAIR DEMOLISH SO FT. NO. OF NO OF SIZE STORIES FAMILIES USE OF STRUCTURE SIGNATURE OF - / APPLICANT APPROVALS , ADDRESS s(�['� ,DATE .INSPECTOR'S SIGNATURE FOUNDATION' LOCATION $ / (-7j P.C. S FORMS,MATERIALS !J (N FEE FRAME: FIRE STOPS. VALUATION $� Q C BRACING. BOLTS FEE FURNACE *LOCATION, I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS GAS VENT, DUCTS ' APPLICATION AND STATE THAT THE ABOVE I'S CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES LATH, INT. AND STATE LAWS REGULATING BUILDING CONSTRUC- TION. - LATH. EXT. SIGNATURE OF.R / HOUSE NUMBER COR- PERMITTEE :)POSTED / ADDRESS FINAL JOHN A.LAMBIE. COUNTY ENGINEER VALIDAT= CLYDE N. DIRLAM. CHIEF BLDG. INSPECTOR CK MO/CASH ' 5 3 4 3 -JUL 1 P 1 2.0 0 '� 76A888A Des-9 3.88 - - APPLICATION FOR BUILDING PERMIT DIVISION OF BUILDING AND SAFETY BUILDING ADDRESS Depa=tment of County Engineer County of Los Angeles LOCALITY WM.J. FOX, COUNTY ENGINEER NEAREST < < CASSATT D. GRIFFIN, SUPT OF BUILDING CROSS ST. DISTRICT NO. GROUP �\'/7+ SEWER MAP FOR APPLICANT TO FILL IN S U C NST�"� 9 yp BUILDING // `— STATE ADDRESS //IBJ 14 CQ `7LNUMB ER cD 0 'WY YES NO_ LOT NO. fJ-t�n BLOCK USE ZONE SPECIAL CONDITIONS TRACT O R J _" NO. OF BLDGS. BUILDING EXIST. Sl'ZE OF LOT J\ �> NOW ON LOT SETBACK YARD HWY STREET NAME WIDTH USE OF / _ EXISTING DG. !r FRONT . P. L. OWNER SIDE P.L. MAIL 17" ADDRESS �p O _TRACT DWELL. 1 UNIT 5 INDUSTRIAL TEL.8 r'l �/ 1 I DWELL. I UNIT CITY NO. // {„Bd. 6 PUBLIC BLDG. ARCHITECT ORTEL. 2 DUPLEX I,UNIT ENGINEER TEL 7 ADDN.,ALT.. ET 3 APT. UNITS 8 MISCEL. ADDRESS 4 'COMMERCIAL TEO.L• NEO.- INSPECTION RECORD ADDRESS DESCRIPTION OF WORD NEW DD ALTER REPAIR DEMOLISH SO. FT. NO.OF NO.OF SIZE, STORI SFAMILIES USE S U RE-,;t LI�CJG.C. fff��tl -- �.' �/J���.�-c [i SIGNATUREOF APP)_ICANT APPROVALS ADDRE89 DATE INSPECTOR'S SIGNATURE 7� FOUNDATION: LOCATION P $ .C. $ FORMS, MATERIALS /��/nlPA/ '�QaEfTE,O-�VTGY FEE / 'FR�ME: FIRE BRACING,BOLTTSS. V / y0�j �/ 1 VALUATION $ FEE YJ FURNACE: LOCATION. I 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 BUILDING CONSTRUC- TION. LATH, EXT. " - y SIGNATURE OF R BER COR- PERMITTEERECT AND POSTED ADDRESS FINAL .7 ,WM.J.FOX.COUNTY ENGINzs* VALIDATION C. N. DIRLAM.CHIEF BLDG. INSPECTOR LACp 4 1 9 1 un MAR 16 1 6,0 0 In DEPARTMENT OF BUILDING AND SAFETY f APPLICATION FOR PERMIT COUNTY OF LOS ANGELES I p I N " to ww" WM. J. FOX. CHIEF ENGINEER �o ®� FOR APPLICANT TO FILL IN l FOR OFFICE USE ONLY �•--y DISTRICT NO. PLAN CK.NO. t /P_ERMIT NO. BUILDNG ADD EI98 4/n pl.�.�i�f�{.,,s+ b S eo LOCALITYRECEEI,VED BY DATE OF APPL. /DATE ISSUED NEAREST ...11 ' 'FY CO- t - .5� `• Y ]'-. CROSS ST. (7/ __ BUILDING OWNER UR f1..�1- _�..ft. �✓yYD'I t.4 ADDRESS - __6 A4 A !!Z c , MAIL _ � � LOCALITY ADDRESS NEAREST �(� •/6 L�J //pp TEL. CROSS ST. [� AJ /'j CITY _ O NO. FIRE NO. TYPE GROUP ARCHITECT OR TEL ZONE PLANS NB - ENGINEER NO. BLDG. ^�• ORD.NO., ADDRESS SETBACK LINE , 1 E APPROVED / J -1 TEL. CONTRACTOR /V r NO. BY DATE - USEL^ APPROVED ADDRESS ZONE F4 BY' DATE LEGAL �y DESCRIPTION I LOT NO..2(n BLOCK CORRECTIONS TRACT e a _ NO.OF BLOBS. SIZE OF LOT f�Fs� o I NOW ON LOT ' USE OF / e NO.OF NO.OF I D ' EXISTING BL . 121-A DESCRIPTION �+Or�.AMILIEB I ROOMS !� '•' '- - - C ON WORK j NEW ALTERATION ADDITION 41 " A REPAIR MOVING DEMOLISH - GI Sq FT. ��qq �qNO OF SIZE b &0 ROOMS r -STORIES D WALL ROOF /� n �+ �• '' - f' COVERING �M.�I COVERING L;,Ef yN1r19s �17•�j'�,' USE OF NEV; I 7-V• /� BUILDING _ TO ,EX'/ .5 / •/A`l, ' /A ) r;2- MJLv CS . 1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPROVALS , o- APPLICATION AND STATE THAT THE ABOVE IS CORRECT FOUNDATIOW LOCATIO I SPECTOR• AT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES FORMS,MATERIALS- n AND STATE LAWS REGULATING BUILDING CONSTRUCTION. } �1` FRAME: FIRE STOPSr l BRACING,BOLTS SIGNATURE OF AiLiC/�J .�✓Y�' PERMITTEE LATH, INT. AUTHORIZED AGT LATH, EXT. 76A63BA 9-4B DBS-3 SOM SETS $ G0 P.C.$ PLASTER, INT. FEE PLASTER,EXT. f+ !11 .. // VALUATION FEE FINAL l�� 1 A638A CE t803 -56 APPLICATION FOR BUILDING PERMIT BUILDING AND SAFETY DIVISION BUILDING Department of County Engineer ADDRESS County of Los Angeles LOCALITY JOHN A. LAMBIE, COUNTY ENGINEER NEAREST CASSATT D.GRIFFIN, SUPT OF BUILDING CROSS ST. FOR APPLICANT TO FILL IN DISTRICT NO. I GROUP ITYPE SEWER MAP:` - BK PG CONST. "r BUILDINGF,J'" r, r .ti ADDRESS ��� J W� %`^g ✓� ;:,1�+� .a+� ,� t '. STATISTICAL CLASSIFICATION LOT NO. •� BLOCK CLASS. NO. '•- DWELL. UNITS MAP STATE YES NO V NUMBER -i- ,-.. HWY TRACT ,_ e � USE ZONE SPECIAL` - r _ NO OF DGS. CONDITIONS > I SIZE OF LOT NOW ON LOT �_�eL,,,_ USE OF EXISTING BLDG. ,dJ'4'1r'f .e" _ , a,IF". BUILDING YARD HWY STREET NAME EXIST. _ SETBACK WIDTH OWNER i'; ''t�'T� ,/�`",. f.+/ _�1J` ,•..' FRONT �- MAIL f �. ^a.I �� P. L. 4 ADDRESS , d ,t�. "4 ,rt jam, � SIDE .• • TEL P. L. CITY f ° p NO• ` ' ` INSPECTION RECORD ARCHITECT OR TEL. ENGINEER NO. TEL ADDRESS CONTRACTOR / ADDRESS,." DESCRIPTION OF WORK f....n 3! NEW ADD r ALTER REPAIR DEMOLISH SQ. FT. NO. OF NO. OF SIZE STORIES FAMILIES L STRTURE APPROVALS RE OFtiDATE INSPECTORS SIGNATURE ANT '^ FOUNDATION: LOCATION S ` F - r.".r "` FORMS. MATERIALS P. C. $ FRAME: FIRE STOPS, FEE BRACING. BOLTS $ r,ti� FURNACE: LOCATION, ON FEE GAS VENT, DUCTS """'" 1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS AP- LATH, INT. PLICATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL C LINTY ORDINANCES AND STATE LAWS R LATING BU�ING CONSTRUCTION. LATH, EXT. SIGNATURE OF HOUSE NUMBER COR- PERMITTEE y, -,4"�v RECT AND POSTED ADDRESS '' ' " a ^.es"' FINAL �� JOHN A.LAMBIE, COUNTY ENGINEER, CLYDE N. DIRLAM, PRINCIPAL STRUCTURAL ENGINEER PLAN CHECK VALIDATION CK. M.O. CASH PERMIT VALIDATION rCK.'+ M.O. CASH DIVISION BUILDING IN�NT OF COUNTY E[SGII�E ' DN OF BUDING AND SAFETY COUNTY OF LOS ANGETM WILLIAM J. FOX, COUNTY ENGINEER APPLICATION CASSATT D. GRIFFIN, SUP'T OF BUILDING FOR APPLICANT TO ML IN FOR OFFICE USE ONLY BUILDING DISTRICT NO. PLAN-CK..OR REc.No. PERMIT NO. ADDRESS Q LOCALITY R EIVE BY DATE OF APPL. -tD TE ISSUED NEAREST CROSS ST a BUILDING OWNER Ov, tj *DDRESS. , MAIL LOCALITY ADDRESS - NEAREST CITY NO 1 - ' TEL. - a CROSS ST. ARCHITECTO I TEL. FIRE NO. OF ir,I TYPE "I GROUP ENGINEER NO. ZONE - PLANS 1 ADDRESS BLDG.- SETBACK LINE Y i USE APPROVED CONTRALTO - ZONE BY DAT ADDRESS ,- HOUSE NUMBERING r D. LEGAL - ,MAP NUMBER y� NO. ASSIGNED BY DESCRIPTION I LOT NO. BLOCK CORRECTIONS- - TRACT ­ckolat9 .41 NO. OF BLOGS. SIZE OF LOT 9 I NOW ON LOT _ USE OF r.7%10 • 0 O. OF EXISTING BLDG. 41 IL DESCRIPTI(N& 0FWORK kNEWALTERATIONADDITION HDEMOLITION V6R ADD A145 - /W(-✓l&W/5GTIGJ�/y NO. OF /T 7j/iil ��IfJ, P • ROOMS STORIES ALLROOF ING A COVERING ST •U fi jol APPROVALS INSPECTOR'S SIGNATURE DATEFOUNDATION: LOCATION ' rFORMS, MATERIALS REBY ACKNOWLEDGE THAT 1 HAVE RGAD THIS AP- d FRAME: FIRE STOPS, PLICATION AND STATE THAT THE,INFORMATyON GIVEN IS BRACING, BOLTS CORRECT. _ FURNACE. LOCATION, I AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS EGULATING BUILDING CONSTRUCTION GAS VENT, DUCTS SIGNATURE OAM a4"1.4LATH, INT. PERMITTE A r „ LATH. EXT. ADDRES � a PLASTER, INT. AUTHORIZED AGT. PLASTER, EXT. / �1FEE' S HOUSE NUMBER COR- Q V RECT AND POSTED VALUATION FEE $( ® FINAL 78A888A 1286 3 8-ba APPUCAMON FO COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION'DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS I hereby affirm that I have a certificate of consent to self Insure, 13 LDINLG ADDRES or a certificate of Workers' Compensation Insurance,or a certified CITY copy thereof(Sec 3800,Lab C) zip LOCALITY *Policy NO Company SIZ F LOT t / O OF BLDGS NOW ON LO7 , , ❑ Certified copy Is hereby furnished 0 NEAREST CROSS ST ❑ Certified copy is filed with the county budding Inspection TRACTBLOCK LOT NO department - I. USE ZONE MAP NO Date Applicant ASSESSOR MAP BOOK PAGE PARCEL ' SPECIAL CONDITIONS CERTIFICATE.OF EXEMPTION FROM WORKERS' OAR TEL NO COMPENSATION INSURANCE - C WITHIN 1000 FT OF SCHOOLS ' YES NO A PRESS _ ' (This section need'not be completed if the permit is for one hundred DISTRICT GROUP TYPE CONST FIRE ZONE PROCESSED BY- dollars($100)or less) CITY�� I certify that In the performance of the work for which this permit (� Is Issued, I shall not employ any person m /any manner so as to GI f 2 become subject to the Workers'Compensation Laws ARCHITECT OR ENGINEER TEL NO STATISTICAL CLASSIFICATION APT CONDO Date Applicant ADDRESS CLASS NO DWELL UNITS NOTICE TO APPLICANT If, after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST Exemption, , you should become`-'subject t0 the Workers' CONTRACTOR // TEL NO SET BACK YARD HWY PROP LINE _ WIDTH Compensation provisions of the Labor Code, you must forthwith I FRONT comply with such provisions or this permit shall be deemed revoked ADDRESS - LIC NO PL LICENSED CONTRACTORS DECLARATIONSIDE CITY LIC CLASS - P,L _ I hereby afflrm that I am licensed underprovisions of Chapter 9 >_ (commencing with Section 7000)of Division 3 of the Business and SO FT SIZE NO OF STORIES NO OF FAMILIES SEWER MAP a Professions Code,and my license Is In full force and effect NEW El BK PG — U License Number LIC Class RIPTI OF WORK ADD ❑ VALUATION Cr O I Contractor Date W ALTE nELea ❑ I'am exempt under Sec EPAI4 $ /✓ B'&PC for this reason DEMOL ❑ LDMA P/C# Date USE OF EXISTING BLDG URM ❑ Signature _ „6PP�LICANT(PRN _ --_ _TEL1J0 _ LDMA Perm#_ _ _ _ _ _ _ _,_ - j, a _--• _ _ _ _ _ t_ as owner of the property, or,my employees with wages as ��1 — Z their sole compensation, well do the work and the structure Is ADDRESS O not intended or offered for sale (Section 7044, Business and FINAL DATE Q>77 Professions Code WILL THE APPUCANT OR FUTURE BUILDING OCCUPANT,HANDLE A HAZARDOUS ) O — _ licensed contractors to construct the project (Section 704444,, MATERIAL , ❑ 1, as Owner of ,the OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE J $ F ' property, am exclusively contracting AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE' FINA > L I F r YES 11NO� - Tf-I f�fL. 1 0_5 0 Business and Profession§Code) -WILL THE INTENDED USE OF'THE BUGLING BY THE APPLICANT OR FUTURE BUILDING' OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH _ - (,E C. - 'D5. -. n CONSTRUCTION LENDING AGENCY COAST AIR QUAUTY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FOR f GUIDEUNES ' I hereby affirm that there Is a construction lending agency for ves❑ ryo❑ rn the performance of the work for which this permit Is Issued(Sec IHAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE ANDTHE SCAOMD PERMITTING w 3097,Civ C) 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 HAZARDOUS y '( 1 IS)i{^j.—I�j}, �';ia•i't`* Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD Lender's Address ia( ONNER OR AGENT 0 1 certify that I have read this application and state under penalty G of perjury that the above Information Is correct I agree to comply PC FEE PERMIT FEE -/ cw with all county ordinances and State laws relating to budding co hereby co and hereby authorize representatives of this County hSSUANCE FEE �� O co enter u e bove-m coned property for inspection purposes, a / INVESTIGATION FEE TOTAL FEE /D -2 ^ a oa° SEE REVERSE FOR EXPLANATORY LANGUAGE �. APPUCAMON FOGS BULONG PERMIT � COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN u 77-d X ss ' I hereby affirm that I have a certificate of consent to self Insure, B LD D ESS or a certificate of Workers' Compensation Insurance, or a certified a�= copy thereof(Sec 3800,Lab C) it � i ZI �/� \ V Policy No Company SIZE OF L N¢�OF BLD SNOW ON LOT ' El Certified copy Is hereby furnished :L� NEAREST CR SS ST_ ❑ Certified copy Is filed with the county building Inspection TACT BLOCK LOT NO department rUSEONE MAP NQDate Applicant ASSESSOR MAP B O PAGE/ 'PARCE� SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' ERCOMPENSATION•INSURANCE � N 1000 FT OF SCHOOL? S NO (This section need not be completed If the permit Is for one hundred ADDRESS p �J - - /.,� //• v DISTRICT GROUP E C = ONE PROCESSED BY dollars($100)or less) CITY ZIP I certify that In the performance of the work for which this permit Is Issued, I shall not employ any person'In,any manner so as t0 ARCHITECT O ENGINEER TEL NO become subject to the Workers'Compensation Laws STATISTICAL CLASSIFI ATION APT CONDO Date Applicant. ADDRESS CLASS I DWELL UNITS , NOTICE TO APPLICANT If, after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST Exemption, you• Should become subject to the Workers' CONTRACTOR �� TEL NO" SET BACK ' 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 PILE CITY LIC CLASS P L I hereby affirm that I am licensed underprovisions of Chapter 9 SEWER MAP (commencing with Section 7000)of DIVISIOn 3 of the Business and I SQ FT•S� NO OF STORIES NO OF FAMILIES - Professions Code,and my license Is In full force and effect { d NEW BK PG D a License Number Llc-Class DESCF7IPTION OF WORK ADD• E] 'VALUATION _ 0 Contractor Date I ALTER ❑ E1.1 aim exempt under Sec REPAIR El $ F_ B&PC'for this reason DEMOL ❑ LDMA P/c# 0 Date ' USE OF EXISTING BLDG URM ❑ d ) Signature /' APPLICANT(PRINT) TEL NO LDMA Perm# ] Z p� I, as owner of the property, or my employees with,wages as O t�•'{'.g _ their sole compensation, will do the work and the structure is ADDRESS not Intended or offered for sale (Section 7044, Business and - FINAL DATE 0 �3307p �7 __,iEI Professions Code) - WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL ,•%/� J i ❑ I, as owner of the property, am exclusive) contracting With OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE - j ITEMS EM Y g AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDES FINAL BY - 1. < licensed contractors to construct-the project (Section 7044, Business and Professions Code) VES❑ NO❑ 4 TI jTAL rm WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING / { (� - 86.70 .i 86 j OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH ��/ C-AcH .7] CONSTRUCTION LENDING AGENCY COAST AIR QUALITY,MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKUST FOR �- CCCYYYIN • GUIDELINES - � (' ' ('1 I hereby affirm that there Is a construction lending agency for YES 11 No El /'M �G� .011, w the performance of the work for which this permit Is issued(Sec I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING T 3097,CIV C) CHECKLIST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, _ N TITLE 2 CHAPTER 2 20 SECTIONS 2 20 100 THROUGH 2 20 140 CONCERNING HAZARDOUS i 'i�'y �'y { --' Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD 13000-IIOIJ 1 •4.'�2 C3 Lender's Address932 1 AM S:0 O O`MJER OR AGENT ' 0 1 certify that I have read this application and state under penalty 0 of perjury that the above Information IS correct I agree to comply PC FEE PERMIT FEE `D _ with all county ordinances and State laws relating to building / con 10 nit hereby authorize representativeS of this County ISSUANCE FEEco ID e to p above-mentione r y or Inspe Ion purposes �d' (O� < INVESTIGATION FEE TOTAL FEE - 0 co - SEE REVERSE FOR EXPLANATORY LANGUAGE