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76A638A CE#8035-6I APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING '
DEPARTMENT OF COUNTY ENGINEER ADDRESS
BUILDING AND SAFETY DIVISION LOCALITY f
OOHN A. LAMBIE, COUNTY ENGINEER NEAREST
WILLIAM A. JENSEN SUp'T or BUILDING CROSS ST.
mommmolaw DISTRICT O. GROU TYpE ESSED BY
1 .
FOR APPLICANT TO FILL IN �" coNsr. - �Z_
BUILDING (' STATISTICAL CLASSIFICATION I
r'lWER MAP
ADD SS I I3 k' 0^ K 7
r' _ .s� V,;i �13� _ CLASS. NO. DWELL. UNITS C"
LOT O. / BLOCK - WATER NOT REQUIRED RECEIVED
_ CERTIFICATE:
TRACT '� M't IGS MAP HIGHWAY STATE MAJOR SECOND(LO AL
NO.OF DG . N )I (CIRCLE)
SIZE OF LOT /0 1:�fT 4 ' I NOW ON LOT USE ZONE SPECIAL
USE TI /'hA-
CONDITIONS
EXISTING BLDG.
f.` - TEL.
OWNER x.� NO. 'BUILDING EX13T.
/ y '� SETBACK YARD HWY BET NAME IF WIDTH
ADDRESS a D! pw `Q f✓ FRONT
AR C HsITECTOR TEL. P. L. d
ENGINEER NO. SIDE O
P. L.
ADDRESS V
TEL. / INSPECTION RECORD
CONTRACTOR 4�" vIf NO. �- 'Y:. Q
ADDRESS W
DESCRIPTION OF" ORB CA
z
NE� ADD ALTEJR, ,WAIR DEMOLISH
. FT. I F NO.OF
IZE RIES F MILT
USE OF -
^
STRUC E 4
i
SIGNATURE OF
APPLICANT /yp
VALUATION$ -
APPROVALS DATE INSPECTOR'S SIGNATURE
FEE $ .' �, FPMT.EE $ GZT FOUNDATION: LOCATION
FORMS, MATERIALS
FRAME: FIRE STOP;:.
IHEREBY 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. LATH, INT.
TION OF THE LABOR CODE OF THE STATE OF CALIFORNIA RELAT.
ING TO //)'/A WORKMEN'S TION INSURANCE.
e' LATH,EXT.
'//► //J
SIGNATURE OF ENS /r✓ ' // HOUSE NUMBER COR-
PERMITTEE RECT AND POSTED
ADDRESS (c-Sr 4• C�.1 �' INAL
CLYDE N. DIRLAM, PRINCIPAL ST RAL ENGINEER
PLAN CHECK VALIDATION CK. M.O. cwBH PERMIT VALIDATION CK. M.O. CASH
L j-
�' J U 6 3 r
WORKERS"COMPENSATION DECLARATION _
I hereby`affirm •that, I have•a certificate of*con'sent to self
AP 4
insure, or a'certificate of;Workers%.Compehsation Insurance, ��� ��`' �- ����''
or a certified copy thereof-(Sec _3800, Lab'C ) ' Y, al= „
'COUNTY'O
Policy No 4_ Compd'nyvCT'�fiE F=LOS ANGELES SAFETY
- :a BUILDING AND
�-' Certified copy is hereby furnished FOR APPLICANT TO FILL IN 'BUILDING. §^
❑ 1 ADDRESS �� v
Certrfied copy is filed with the county_building mspeo-i� BUILDING' �
/tion department,; D ADDRESS ,, /�
Da �: 0te b APPl.cant �� CITY' C� ZIP / LOCALITY 7
CE TIFCA
ITE OF•EXEMPTION FROM; ORKERS' 4 NO OF-BLDGS, "%'' NEAREST
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT'. "x CROSS ST / e
^;(This+'section need not be,completed if & permit is'for one. ; ASSESSOR ;
hundred dollars(5100) or less ) TRACT BLOCK LOTY,NO MAP BOOK',. : 1• ` PAGE
OWNER t.R 14�P NO r ter_-� USE ZONE. . MAP,,_ rV r �
I certify that in the performance of the work for which,this, NO J R r
permit is issued, I'shall not employ ony-person in any manner " SPECIAL^„3
aADDRESSt nJ a' CONDITIONS
so s to,become subject to the,Wor rs'Compensatio aws r _
CITY, - ZIPS.
Date Applicant ARCHITECT OR.' a r K TEL,-,''
NOTI T APPLICANT If,,,after-make g-this Certificate,ofRD STRICT GROUP, TYPE FIRE PROCESSED BY.1"
Exemption, you, should'become subject to the Workers" ENGINEER NO CONST: r ZONE,
Compensation-provisions of the Labor Code-,'you forth- D�
ADDRESS
wi'A,comply',with-such provisions or 'this permit shall be ' TEC' - STATISTICAL CLA55 CAT N -'APT CONDO `
deemed revoked CONTRACTOR NO
LICENSED CONTRACTORS DECLARATION' CL4SS No DWELL UNITS
LIC
I.hereby affirm that I am lice'n'sed,under,pro'visions of Chapter 9 ADDRESS Q 'NO �°
(commencing with'Section 7000).of Division 3 of the Business and LIC SEWER P
x ' Profession_s'Code, and my+license rs,in full force,and effect CITY . CLASS C PGL O VALIDATION r
�t` -•�r qY y f SQ FT NO OF NO OF
License Number AM3'7L Lic Class**e.* SIZE'. STORIES FAMILIES ONE
r C VALUATION
ContrdctOf'�Ic-Ar C�1�,Cr Ddte 7/"
DESCRIPTION OF WORK Qv NEW ❑ ®• _
r 'ADD ❑ $ 0
❑ lam exempt under`'Sec r �'
ALTER: y'"_
B_&P C for this reason, } REPAIR, O = �'
D Te i' USE OF:' ^` DEMOL Z
EXISTING'BLDG
Signature Q_ ..p.@• APPLICANT' - . TEL FINAL - f
OWNER' ILDER DECLARATION_ PRINT) NO DATE "•
" - I,hereby affirm'thot I'dm•ezempt from the Contractor's License " . r '
'law'for the`followmg reason_(Section 7031 5, Business an'd ADDRESS
Y FINAL
�Prafessions Code) r - PRE w �' _Y
.❑ , ," - - ` •- _ BUILDING;, t - '� ;4 s : i, _: ,. ��� r -�• ,
I„as'owner;`of Fthe,property; or my employees with ADDRESS �r e , f r
swages as tVieir,sole compensatiori, will do'the work and �• % � � 'ACCL4
the strui:M'e'is not intended or offered for Yale(Section LOCALITY lY y �F - �' �, � __ - :Iva,.[ I"
,• '7,044, Business and Professions Code) MOVING TEL �.
❑ I, as`owner of•ihe properiy;am exclusively,controcting CONTRACTOR NO
` lfGlh7 1
with licensed coritFactors to construct,f 6 project (Sec-. ��.� 1
-fior 7044, Business and-'Profe`s`sions Code)'^ °ADDRESSa• _, ;a^ Y• s"
T...
T' CONSTRUGTION-LENDING AGENCY REQUIRED' r •YARD �HWY TOTAL SETBACK - a r
i, SETBACK PROP LINE, WIDTH " di �
hereby affirm that there is a construction'lendmg agency fors', FRONTs.:
i' the performance of the work'for which'this permit is issued PL ,`Y,- y: 00'
,(Sec 3097, Civ C )` :} . ;, _ :'SIDE �.. Rtr i n rq
nr P L
Lenders'Name'
"
LDMA-Ref
q �; VI�VV-,11U111i ., �lw�"
m Lender's Address' z kr2 -a P C Fee$ _ Permit Fee' _ _ Q •r^ 84'_
I certify,that,I have read�,this application and state tHot the _ ��
------------
o •• ssuance Fee -•� �• LDMA P/C# •"
oab64e information is,correct 1'6gree to-comply with all County Investigation Fees
9 ordinances and State laws relatin' to buildin construction,
o g g Total Fee. _�.l LDMA Perm
-.and hereby auth&riie'representatives of this County-to enter _
upo )the above-men iiored roperty`foi inspection purposes
- g SEE REVERSE FOR EXPLANATORY'LANGUAGE f
$ig Wre of Applicant or Agent Date '� - ' • ^ ,� - ,
{r i .. . 1 r a r • 4 1 q•' 7 Y