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75A686A CE}1608.7-61 APPLICATION FORBUILDING PER IT
�1 COUNTY OF,LOS ANGELES
BUILDING / t
' 1
DEPARTMENT OF COUNTY ENGINEER ADDRESS
f BUILDING AND SAFETY DMSION LOCALITY
JOHN A. LAMBIE, COUNTY ENGINEER NEAREST - ?• -
' WILLIAM A. JENSEN SUP'T•OF Bu1LDING CROSS ST. ('
DISTRICT NO. G OUP TYPE. P SSED BY
j` FOR APPLICANT TO FILL IN j��. CONST.
/n Y? ,y � � STATISTICAL CLASSIFICATION / SE ER MAP
BUILDING Ly /`L'• BK PG
ADDRESS I 1
CLASS. NO.—/—,WELL.DWELL. UNITS
LOT NO. - BLOCK WATER NOT REQUIRED . RECEIVED 77
�1 / CERTIFICATE:
TRACT q[ (p ,�/J MAP' J / A: HccR WAY STATE MAJOR SECOND, OCAL
NO.OF BLDGSIZEOF LOT. ® I��D� i NOW ON LOTS USZONE L C! SPECIAL
USE OF CONDITIONS
EXISTING BLDG. '
�/ -TEL./ Jy/� C�
' OWNER A(,&Jf, KAfDIr NOI7%7./®�J BUILDING � - - EXIST.
;YARD HWY REET NAME
SETBACK WIDTH'
ADDRESS- ®�.�'�g�-` N�OSC� FRONT _ _
ARCHITECT OR .}�Q ay TEL. i``i Pk.L. - rJ""C� - •`-" �- '
ENGINEER PL�./�+IS �I"F��J[a NO. w340- •SIDE
ADDRESS/T/JP ,41/f"IO�1WLg /�i6o,Ct Ul r-TEL. r' '�. INSPECTIONI RECORD ,
CONTRACTOR a A//JI/''Q.R NO. iw _
ADDRESS - - R/14/1L 1. ', I�'•T'%".( �f�.6F/t/r�.0 .`v".I 'YUr O`
DESCRIPTION OF WORKc
�/ a
EI ADD ALTER REPAIR DEMOLISH '=�
YSQ.FT. �+ NO.OF NO..OF..
IZE �J STORIES 'F MIti S /
USE OF
STRUCTURE.
SIGNATURE F - Y - '
.APPL"ICANT
VALUATION
APPROVALS . -1 D?A�JTE INSPECTOR'S SIGNUR
ATE
PMT. FOUNDATION:
FON /
MS,MATERIALS
O ' /�/.i/v+lam-• ~.a r� 4
FEE $
FRAME: FIRE STOPS, ••AA
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
GAS VENT DUCT$
BUILDING.CONSTRUCTION. I CERTIFY THATAN DOING TH E.WORK,
AUTHORIZED HEREBY I WILL NOT EMPLOY ANY PERSON IN'VIOLA•' LATH, INT.
TION OF THE LABOR CODEOFTHE STATE OF CALIFORNIA RELAT
ING TO WORKMEN'S COMPENSATION INSURANCE. LATH,EXT.
SIGNATURE OF - ' - HOUSENUMBERCORd
PERMITTEE ? �`' RECT AND POSTED
ADDRESS-/& ��. ���'�Y/✓i?�S S '.- •.� FINAL -
CLYDE N. DIRLAM, PRINCIPAL STC--ilpRAL ENGINEER
PLAN CHECK VALIDATION 16�) M.O. cnsH PERMIT VALIDATION, I CK.I M.O. :CASH
3 5.50
`� a Q 9` X29 . 1 .'u 7 'CO
�- ``WORKERS' COMPENSATION DECLARATION \
to s
insure, or afirm certif certificate of Workers' Compensation that I have a certificate ofconsent Insuran e, A P P L I CAT I O N"F O R BU I L'D I N G PERMIT 11
or a certified copy thereof (Sec. 3800, Lab. C.)
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy,No.. Company
El Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING
ADDRESS
❑ Certified copy is filed with the county building inspec- BUILDING {_
Tion department. `' ADDRESS /OZ. t- -0&i
Date
Applicant CITY �1 p L.� C�/ �L�, ZIP / �1 6 LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' > a ( NO. OF BLDGS. •�� NEAREST
COMPENSATION INSURANCE SIZE OF LOT 50 X 1x10 NOW ON LOT /L CROSS SL
(This section need not be completed if the permit is for one - ASSESSOR
hundred dollars ($100)or less.) TRACT BLOCK LOT NO.rEL. �j �* MAP BOOK PAGE• PARCEL
OWNER 1TT>� �. �•, /�C',Nrl,I NO.
f®�J- USE PNE MAP
(certify that in the performance of the work for which,this, NO.
permit is,issued, I shall not employ any person in any manner LJ SPECIAL 7 CL
so as To become'subject to the Workers'Co pensation Laws. ADDRESS 5 �� CONDITIONS V
7 CITY ZIP
Dare Applicant ARCHITECT OR P� TEL. _ V
NOTICE TO APPLICANT: If, after making A is Certificate ENGINEER ��U��� NO. DISTRICT GROUP TYPE FIRE PR E ED BY
Exemption, you should become subject to the Worke s' _1 CONST.j -Z�OINE W
Compensation.provisions of^the Labor Code, you must forth- ADDRESSAS } Boo-E,
with comply-with such provisions or this permit shall. be TEL. STATISTICAL CLASSIFICATION APT. C DO. Z
deemed revoked: CONTRACTOR NO. ''
LICENSED CONTRACTORS DECLARATION- _ LIC. - CLASS NO. DWELL. UNITS
I hereby affirm that.l am licensed under provisions of Chapter 9 ADDRESS NO.
(commencing with Section 7000)of Division 3 of the Business and LIC.- SEWER MAP
Professions Code, and my license is in full force and effect. CITY CLASS BK PG VALIDATION
SQ. FTS�.)1![ NO. OF NO. OF CHECK
License Number Lic.Class SIZE%S-0 STORIES FAMILIES ONE
VALUATION
Contractor Date DESCRIPTION OF WORK NEW-
12
Ll r ADD ❑ s 75 ,
❑ I am exempt'under Sec. ,.�{e S- )6? ! El
B.BP.C. for this reason REPAIR ❑ $
Date: USE OF
EXISTING BLDG. DEMOL ❑
Signature
- APPLICANT TEL.
FINAL PRINT) NO.
OWNER-BUILDER DECLARATION DATE �� Q.•
I hereby.affirm that I am exempt from the Contractor's License
Law for the following feason (Section 7031.5, Business and ADDRESS FINAL
Professions Code): PRESENT BY. J
'
I, as owner of the property, or my employees with BUILDINGADDR_ESS
wages as their sole compensation,will do the work and - ?�
The structure is not intended or offered for sale(Section LOCALITY ' i ;2 3 36 8 A-
7044, Business and Professions Code). MOVING TEL. _
❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO. # e o 0 0 0 1
with licensed contractors to construct the project (Sec-
_ '1' 0 040,50^
DRESS
tion 7044, Business and Professions Code). AD :\ ,• +. ;
REQUIREDTOTAL SETBACK FROM I T. ti
'CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH 20:I hereby affirm that there is a construction lending agency for FRONT 0 0 0 4 0 5 0 2 '.
-the performance of the work for which this permit is issued P.I. - -
(Sec. 3097, Civ. C.). SIDE I 1. 01 =85 '
o
P.L. e
Lender's Name
P.C. Fee$ Permit Fee ..
- Lender's Address
it _,I-certify that I have read this.application and state that the Issuance Fee - LDMA P/C#
above information is correct. I agree to comply with all County Investigation Fee , ;
o ordinances and State laws relating to building construction,
E and hereby authorize representatives of this County to enter Total Fee LDMA Perm'
upon the'above-m fitioned property for inspection purposes.
)�? �^A SEE REVERSE FOR EXPLANATORY LANGUAGE
Signa re of App scant or Age D e — -