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DEPARTMENT OF BUILDING AND SAFETY APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES BUILDING
WM. J. FOX, CHIEF ENGINEER
FOR APPLICANT TO FILL IN FOR OFFICE USE ONLY
BUILDING DISTRICT XIO. PLAN CK. NO. PERMIT NO.
ADDRESS t /
LOCALITY ��, / J� R IVE�BY DATE OF APPL. DATE ISSUED
CROSS ST. BPf�jv �J (� ®. tjT
BUILDING /
w f��)//.. ADDRESS cMAILj (3 �jyG,(10j,,�rr._�/ li�rlA
OWNiR /f9 _ `G-�P� Ad'p�R.E�„�,1i,'j,';'� .•y�' /f LOCALITY, ?� /'�� � I �
ADDRESS /�SP �1 / l� rj�i'';' PE C1n � �L� NEAREST �f FJAA./ f'/ -. 1 r
L. CROSS ST. P n' 1y A o
TEN33 3
CITY Pr!�J� a O.® f FIRE IPLANS I TYPE _V�' I GROUP
ARCHITECT OR TEL. ZONE YY r
ENGINEER NO. BLDG. / b� //��� ORD. NO.
SETBACK LINE -O
ADDRESS j APPROVED
BY DATE
CONTRACTOR (O' iZ A fl. ll NO. ZONE ��. APPROVED BY DATE
ADDRESS HOUSE NUMBERING
LEGAL
DESCRIPTION I LOT NO. I BLOCK MAP NUMBER �S' FIELD CHECK BY
TRACT NO. ASSIGNED BY I3AT
NO. OF BLDGS. CORRECTIONS
SIZE OF LOT NOW ON LOT �"
USE OF I NO. OF
EXISTING BLDG, FAMILIES
DESCRIPTION OF WORK �15 ezo d Am e o s. Q'AiLe.•
NEW I I ALTERATION I I ADDITION
Bur•A .Sl.,Is�1.vcll'✓1.-� S�r��n�' O
REPAIR I I DEMOLITION 'G
SQ. FT. NO. OF ' r-j 4
SIZE ROOMS STORIES 2
EXT. WALL ROOF r
COVERING I COVERING,-
USE
OVERING,-
USE OF STRUCTURE e i
C/ +
APPROVALS
INSPECTOR'S SIGNATURE DATE
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS AP- FOUNDATION: LOCATION f
PLICATION AND STATE THAT THE INFORMATION GIVEN IS FORMS, MATERIALS /
CORRECT.
1 AGRER TO COMPLY WITH THE CORRECTIONS LISTED FRAME: FIRE STOPS, �y
HEREON AND WITH ALL COUNTY ORDINANCES AND STATE BRACING, BOLTS
LAWS REGULATIN BUILDING CONSTRUCTION.
FURNACE: LOCATION,
SIGNATURE OF �, P/ GAS VENT, DUCTS
PERMITTZ e z �`��✓✓ !sIP'>`
LATH, INT.
ADDRESS 4/1 1
v , LATH, EXT.
AUTHORIZED AGT.
/� vp PLASTER, INT.
70Ae78A•D893 10-50 .$ `ji (//✓ P. C. S
® FEE PLASTER, EXT. 1/
VALUATION
+� . ' WORKERS' COMPENSATION DECLARATION
insure herebor%affcertif cairm tte of Workers' Compensation I have a certificate of eInsurancef A P P L I C/�T I O N FOR BUILDING PERMIT
or a certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company t1J�v(/1 - 2J)
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING Z ADDRESS -
:MVd!W 0-4777-f
❑ Certified copy is filed with the county building inspec- BUILDING j5K J/Z A2v� JZJ)
tion department. ADDRES
S
"9A F `
CITY r v 1 W ZIP a 7� LOCALITY t/l7 0
Date Applicant NO. OF BLDGS. NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT ,NOW ON LOT CROSS ST.
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if the permit is for one TRACT �. BLOCK LOT NO. "i <�%' (� . `� C'�% `�
hundred dollars ($100)or less.) 9 t(�� TE MAP BOOK ," PAGE PARCEL "
OWNER �C�` r P�a{t6VG� N ,��� USE ZONE MAP
I certify that in the performance of the work for which this �p NO.
-iZIP �o�� ,�j �'^ SPECIAL
�'
permit is issued, I shall not employ any person in any manner ADDRESS ` ,� /a/� S� G CONDITIONS n
so as to become subject to the Workers'Compensation Laws. CITY ��' Vp uO
Dafe Applicant ARCHITECT OR 7 DISTRICT GROUP TYPE FIRE PROCESSED BY 0
NOTICE TO APPLICANT: If, after making this Certificate of `� CONST ZONE (—
Exemption, you should become subject to the Workers' /+ p� ^ q�y o 8 U
Compensation provisions of the Labor Code, you must forth- ADDRESS ' 5 ��A�-��c W /st1C . ` a
with comply with such provisions or this STATISTICAL CLASSIFICATION APT. CO O, N
p y p permit shall be TEL. 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. SEWER MAP
(commencing with Section 7000)of Division 3 of the Business LIC.
and Professions Code,and my license is in full force and effect. CITY CLASS BK PG VALIDATION
' SQ. FT. NO. OF NO. OF CHECK
License Number Lic. Class SIZE STORIES FAMILIES f ONE
VALUATION
Contractor Date DESCRIPTION OF WORK NEW ❑ $
ElI am exempt under Sec. A-001-16ADDJ V poll.❑
B,BP.C. for this reason /' �/ REPAIR E] $
Date: USE STOING BLDG.71 L I r DEMOL ❑
Signature APPLICANT TE•g� FINAL
OWNER-BUILDER DECLARATION (PRINT) �e H�. N )3Saj v
F
I hereby affirm that I am exempt from the Contractor's License �Q'12 �, � /1 /�-�
DATE
Law for the following reason (Section 7031.5, Business and ADDRESS FINAL
Pf o}essions Code): PRESENT B -
/JT4p`ryJ I, as owner of the property, or m employees with BUILDING �& D y
P P Y� YADDRESS
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section LOCALITY0r4eW -
7044, Business and Professions Code.) MOVING TEL.
❑ I, as owner of the property,am exclusively contracting CONTRACTOR NO.
with licensed contractors to construct the project (Sec-
ADDRESS �-�"='- + �v
tion 7044, Business and Professions Code.)
CONSTRUCTION LENDING AGENCY SETT BACK YARD HWY TOTAPROPLINE FROM WIDTFI _:•_r °"T'
I hereby affirm that there is a construction lending agency for FRONT y
the performance of the work for which this permit is issued P.L.
(Sec. 3097, Civ. C.). SIDE "�� ,r
P.L.
3.
Lender's Name
$ 77 LDMA Ref. 9 y
P.C. Fee$ Permit Fee ���
Lender's Address �+ -
I certify that I have read this application and state that the Issuance Fee LDMA P/C N
3 above information is correct.I agree to comply with all County Investigation Fee �3 _
$ ordinances and State laws relatingto building construction, �_)-I:t- I'I
9 Total Fee . LDMA Perm. N - -
and hereby authorize representatives of this County to enter
upo the above-mentioned prolerty for inspection purposes.
oC> A I'�e SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent