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Home My Public Portal About9574-9592 LOWER AZUSA RD_Building__ DEPARTMENT OF BUILDING AND SAFETY APPLICATION FOR PERMIT COUNTY OF LOS ANGELES ' WM J FOX, OH1lF ENGINEER LD ING FOR APPLICANT TO FILL IlL ri J FOR OFFICE USE ONLY BUILDING DISTRICT NO PLAN CK.NO PERMITo ADDRESS arll'� - t LOCALITY Q it REO[IV' Y DATE OF APPL DATE ISSUED t NEAREST �CROMOT BUILAIN OWNER Q ADDRESS MAIL i- t S LOCALITY ADDRESS -f v __ 1TYA1641 00 to v G TEL O Z CROBB BT L t AB1S1�'OR TSL. ZONE PLANE � TYPE GROUP ENGINEER day BLDG t 5� ORD I#A A DREBB d BE LIN r L 11 1 APPROVED CONTRACTOR`yy��/4' N 47 �k BY DAT[ USE APPROVED ADDRESS ZONE BY DATE DESCRIPTION a Q•� �� CORRECTIONS TRACT Ax 9`7 Jl Q / ore SIZE OF LOT .e ZOO I NOW ON LOT® USEOF OF ND Or EXISTING I FAMI ROO SCRIPTION OF W NEW :J-.ALTERATION fj ADDITION O S REPAIR MOVING DEMOLISH p SO FT �I NO OF Z SIZE ROOMS STORIES r WALL I ROOF COVERT COVERING USE OF EW A i BUILDING �L 1 HEREBY ACKNOWLICOBC THAT 1 HAVE READ THIS APPROVALS APPLICATION AND STATE THAT THE ABOVE 18 CORRECT FOUNDATIONi LOCATION IN [CTOR DAT! AND AGREE TO PLY WIT ALL COUNTY ORDINANCES FORMS,MATERIALS AND STATE LJ► U �BUILDING CONSTRUCTION FRAM[ FIRE8TOPB, !c SIGNATURE ORACIN BOLTS PERMITT LATH.INT i AUTHORIZED AOT LATH.EXT i DBS 3 SOM SETS 1 48 P D O PLASTER.INT FEE PLAST[R,EXT 000 (/ s VALUATION FINAL S FE! COUNTlyd-,':-- GELES `1 { f La I _ WM. J. FOX. CHIEQ ENGINEER, ��b y i 1 FOR APPLICANT TO FILL IN FOR OFFICE USE ONLY BUILDING�- DISTRICT NOr(I CK. NO PERMIT NO. ADDRESS 21 S Z 2 S 1 / 4 / LoW@tL ZuSA 10 sco �/ v LOCALITY Q y h 1 /� .p � L I - RECEIVED BY DATE OF ADPL. [DATE ISSUED NEAREST , CROSS ST. <uyc r - lz t-yn. -7, 41 � �4 % �� l BUILDING PW6 OWNER Q ADDRESS 2/5�-�i Sb - 2-/rA 4 ius.gee,9 _ 1 ADDRESS 1� I 111,4 LOCALITY �EIypLE C i T Y ' pp� NEAREST 0 CITY /!'4�� NO r oil CROSS ST _S U IVSf-T tBLu_Q -ENGINEER , R • �S TEL', w Y FIRE I NO OF I TYPE i GROUP O. 1 ZONE PLANE �il� BLDG �� ORD. NC. ADDRESS Z F AIT SETBACK LINE 4M AlL"" APPROVED CONTRACTOR "' NOL BY +DATE � APPROVED �.S : ADDRESS t Unlit Unlit SY DATE ' 4 C LEGAL DESCRIPTION - LOT 49L 20- I BLOCK '� r CORRECTIONS -- TRACT I Z IS ?oil6—. ND or BLOGS O { 1 SIZE OF LOT /�� .. . NOW ON LOT USE OR NO orI NO OF EXISTING BLDG FwMlup ROOMS DESCRIPTION OF WORK NEW Ki ALTERATION I ADDITION O R REPAIR MOVING DEMOLISH �No.ori p 8 ZE�� R OMB BTORIEB t2tj WALL car COVERING %AS T& ICOVERIN ` a - i USE OF NEW BUILDING sro 5Q ET Cy S-7ageo d 'ol 1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPROVALS APPLICATION AND STATE THAT THE ABOVE 18 CORRECT FOUNDATIONS LOCATION, INSPECTOR DATE AND AGREE TO COMPLY WITWALL COUNTY ORDINANCES FORMS, MATERIALS AND STATE LAWS REGULATING BUILDING CONSTRUCTION FRAME. F112E STOPS, SIGNATURE OF ^� BRACING, BOLTS OWNER TH. INT I AUTHORIZED A A&" LATH, EXT I a PLASTER,-INT. F66 • �� PLASTER, EXT. />✓�q VALUATION s PSE FINAL � �� APPLICATION FOR COU TY OF LOS ANGELES t . I DEPARTME T OF COUNTY ENGINEER BUILDING PERMIT ! BUILDIN AND SAFETY DIVISION-17 FOR APPLICANT TO FILL IN ADDRIESS Z . BUILDING //JJ /��. ' ADDRESS ` - ��4 LOCALITY i CITY L. + C NEST ZIP EAR CROSS ST NO OF BLDGS ASSESSOR 1 SIZE OF LOT X NOW ON LOT V4.J4r MAP BOOK PAGE PARCEL /9.047A DISTRICT GROUP TYPE FIRE P ED Y TRACT BLOCK LOT NO Z SO CONS Z TEL OWNER NO r� STATISTICALCLASSIFI SEWER MIQ ADDRESS /,vQ Ave CLASS NO DWELL UNITS BK PG CITYSAW ZIP I Q USE ZONE NOP / ARCHITECT TEL SPECIAL ENGINEER N '� 'Z CONDITIONS + ADDRESS W M 1 TT ISV . ROAD DEPARTMENT APPROVALR UIRED YES❑ NO❑ TEL ' BLDG SETBACK FRO CONTRACTOR NO FRONT PROP LINE OF (STREEiI 445kLIC ADDRESS NO HIGHWAY + YARD = TOTAL SETBA M TYPE OF EXISTING FRONT PROP LINE HIGHWAY WIDTH CITY seV� . CLASS If CONSTRUCTION LENDER L NAME AND BRANCH BLDG SETBACK FROM ADDRESS CITY SIDE PROP LINE OF (STREET) me SOF NO OF NO OF CHECK HIGHWAY + YARD __ TOTAL SETBACK FROM TYPE OF EXISTING SIZE STORIESDV� FAMILIES'' ONE SIDE PROP LINE HI AY WIDTH w Z DESCRIPTION OF WORK NEW ADD ❑ CORNER CUTOFF YES ❑ NO ❑ ALTER IN OPEN SPACE YES ❑ NO ❑ USE OF REPAIR IN COASTAL PERMIT ZONE YES ❑ NO ❑ EXISTING BLDG DEMOL APPLICAN TE (PRINT) CZ TN 3- r, BY ISIGNATURE) I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL ORDINANCES AND LAWS REGULATING BUILDING CONSTRUCTION 1 CERTIFY THAT IN DOING THE WORK AUTHORIZED HEREBY I WILL NOT EMPLOY ANY PERSON IN VIOLATION OF THE LABOR CODE OF THE STATE OF CALIFORNIA IN RELATING TO WORKMEN S COM PENSATION INSURANCE SIGNATURE OF FINAL BY PERMITTEE DATE , ADDRESS AVEf `TEL P C'Fee$ Permit Fee CITY 12OA0 NO VALUATION$� Issuance Fee Total Fee PLAN CHECK VALIDATION C ,�I�di CASH ., PERMIT VALIDATION CK M o CASH 757XJUL ld23 0 877.20 ® OS 76AS38A CE/003A 8/77 DEPARTMENT OF SUII16ING AND SAFETY APPLICATION FOR PERMIT t •'L9---COUNTY OF LOS'ANGELES ® � SWM. J.-FOX, CHIEF ENGINEER FOR APPLICANT TO FILL IN FOR OFFICE USE ONLY ! DISTRICT NO PLANCK NO PERMIT NO BUILDING ADDRESS LOCALITY /�/Z/pE/� �i ( � RFBEWIED BY DATE OFAPPL DATE ISSUED NEAREST Q 9 �s�, SOS► raI CR089 BT . B7Pam 7 BUILDING OWNER ADDRESS MAIL LOCALITY ADDRESS )Ala& vans NEARE8T TEL CROSS ST Sdo CITY NO FIRE NO OF TYP^ r GROUP ARCHITECT OR TEL ZONE PLANS i�dr ENGINEER NO BLDG ORD NO ADDRESS "ag– SETBACK LINE APPROVED TEL CONTRACTOR NO BY DATE USEAPPROVED ADDRESS - ZON - BY DATE LEGAL �yCORRECTIONS DESCRIPTION LOT NO20wa 12.BLOCK!p TRACT /dr Map OE9 7 11 a iyNO OF SIZE OF LOT I NOW ON LOTS 1 USE OF NO OF NO OF EXISTING BLDG �— FAMILIES ROOMS DESCRIPTION OF WORK NEW ALTERATION ADDITION O S REPAIR MOVING DEMOLISH p 8q FT • NO OF Y SIZE ROOMS STORIES WALL ROOF r COVERING I COVERING a -IR USE OF NEW B BUILDING d oar w � D I Ll 1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPROVALS APPLICATION AND STATE THAT THE ABOVE 18 CORRECT FOUNDATION LOCATION INSPECTOR DATE AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES FORMS,MATERIALS AND STATE LAWS REGULATING BUILDING CONSTRUCTION ' FRAME FIRE STOPS, SIGNATURE OF BRACING,BOLTS OWHER < LATH.INT. AUTHORIZED AST h"F9 LATH,EXT. DBS-3 2SM BETS 4-47 $ C b P C # PLASTER,INT FEE I PLASTER,EXT VALUATIONFEE Ad �� FINAL j y 40 76AGS8A CE#8035... APPLICATION FOR BUILDING RMIT COUNTY OF LOS ANGELES BUILDING DEPARTMENT OF COUNTY MGM= ADDRESS Q v- BUILDING AND SAFETY DIVISION LOCALITY JOHN A. LAMBIE, COUNTY ENGINEER NEAREST ^ WI LIAM A. JENSEN Ur r of BUILO.No CROSS ST. � h FOR APPLICANT TO FILL IN DIJRICT N ROU CON D B e;r A4 1 CONST. f .BUILDING � STATISTICAL C SI (CATION SEWER MAP ADDRESS WI�T C3 ( SK PO CLASS.NO DWELL.UNITS �— LOT NO. BLOCK WATER NOT REQUIRED RECEIVED CERTIFICATE: Er TRACT MAP HIGHWAY NO.OF BLDGS. NO. (CIRCLE) STATE MAJO SECOND LOCAL SIZE OF LOT I NOW ON LOT USE ZONE SPECIAL USE OF - ^ CONDITIONS � EXISTING BLDG. C//J' TEL. OWNER k NO. UILDING EXIST. `_ SETBACK YARD HWY STREET NAME WIDTH ADDRESS t! FRONT ARCHITECT OR TEL. P. L. t ENGINEER NO. SIDE O P.L. U ADDRESS _ INSPECTION ,RECORD CONTRACTOR - L OL. no ADDRESS V W DESCRIPTION OF WORK v NEW ADD ALTER REPAIR DEMOLISH NO.OF NO.OF G Z 1 IZE STORIES FAMILI S USE Off' STRUCTURE y SIGNATURE OF y APPLICANT VALUATION$ h APPROVALS DATE INSPECT 'S SI ATU FOUNDATION,: LOCATION P.C. PMT. FEE FEE FORMS.MATERIALS (7 � $ $ l FRAME: FIRE STOPS, '1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS ICATION BRACING BOLTS � AND STATE THAT THE,ABOVE IS RRECT AND AOR TO COMPLY FURNACE:LOCATION, WITH ALL COUNTY ORDINANCE NO STATE LAW RE ULATING G VENT DUCTS BUILDING CONSTRUCTION. 1 TIFY THAT IN D ING W K AUTHORIZED.HEREBY I WIL T E OY ANY RS VIAS - LATH,INT. TION OF THE LABOR COD O HE ATE OF C IA T- ING TO WORKMEN'S CO ATI IN N LATH,EXT. ' SIGNATURE OF r HOUSE NUMBER COR- PERMITTEE RECT AND POSTED ADDRES FINAL 'r CLYDE N. DIRLAM, PRINCIPAL STRUCTURAL EN �1 � PLAN CHECK VALIDATION CK. N.O. CASH PERMIT VALIDATION cK. Wo. ,C�; 8C954 'I'D FEB 7g 1 D 2.00 r ` I ra' 76A638A�11803REV 11/78) APPIL.ICAT1 U ILDIN E MIT COUNTY OF LOS A69; N LES BUILDING AND SAFETY C{�/ / FOR APQPLI 4NT TO FILL IN ADIDRIESS NG BU ADIDRESS-17 % ,2ZVR�>�if� LOCALITY / NEAREST CITY CMV E C'I L 1( ZIP CROSS ST 9 NO OF BLDGS ASSESSOR SIZE OF LOT 113 S X 3 Z NOW ON LOT 4W MAP BOOK PAGE PARCEL 7p�q DISTRICT GROUP TYPE E P ESSED BY TRACT 4 /7G9 BLOCK LOT NO ZI�ZTEL �o✓ ONS OWNER S A)4F-r> NOS' - '7 (l/' �jSTATISTICAL CLA IF TION /?EWER ADDRESS J Z �CL-SNA Al_vS CLASS NO DWELL UNITS---] f��--lam BK CITYeA%*44j7 CRR es ZIP Qz7 ENGINEERARCHITECTT r?L TEL SO J NO c07 QZ e��p VALUATION $;4995: � ADDRESS t'G5 A0>4 L S+'! Q 7 IIO C� BLDG SETBACKS FROM EL FRONT PROP LINE OF ET) CONTRACTOR NOZS�D TOTAL SETBACK FRO TYPE OF EXISTING LIC, HIGHWAY + YARD = FRONT PROP LIN HIGHWAY WIDTH ADDRESS NO •� 1 R UC + CITY O CLASS "` CONSTRUCTION LENDER_ - BLDG SETBACK FROM NAME AND BRANCH V- SQL i -4^-TeQ SIDE PROP LINE OF (STREET( HIGHWAY + YARD _ TOTAL SETBACK FROM TYPE OF EXISTING ADDRESS CITY SIDE PROP LINE HIGHWAY WIDTH Q SQ FT ,! NO OF rr NO OF CHECK + = V SIZE 10477 STORIES�/VC FAMILIES� ONE � USE ZONE OP y� 0 DESCRIPTION O//F++_WORK NEW �A SPECIAL !/ �6� (�O /Ie� L S vPS ADD CO/N/DITIOQN'S 0. L ALTER FINA DATEL r/ (rj GJ t/ BY `J REPAIR ❑ ^r USE OF EXISTING BLDG '-� DEMOL y� C APPLICANT TEL / IPRINTI Ctz J N0293-2-40 Q� O BY(SIGNATURE) IHEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE Yu THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL ORDINANCES Id ' AND LAWS REGULATING BUILDING CONSTRUCTION I CERTIFY THAT IN DOING THE _ WORK AUTHORIZED HEREBY I WILL NOT EMPLOY ANY PERSON IN VIOLATION OF THE LABOR CODE OF THE STATE OF CALIFORNIA IN RELATING TO WORKMEN S COM PENSATION INSURANCE 90 r} 0 0 0 0 0 1 i SIGNATURE OF f 1 1 0 S 0 PERMITTEE ADDRESS I Z 0 1 1 0 3 O _ CITY G r !/ NO t! t 01 ;;, 2-tq PC Fee$ Permit Fee Al Issuance Fee / 7i Total Fee // 109.ffo '�L� �/ 1 WORKERS COMPENSATION DECLARATION ' - 9S7 y Insurance Z hereby ahrtconsent certificate of Workers Compensation APPLICATION FOR., BUILDING PERMIT � or a certifi co y t erre� 00Company N5 W it 71of(Sec 38Lab C ) 0 v �— COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No 13 Certified copy is hereby furnished FOR APPLICANT TO FILL IN BAwms O'lslf/1J Certified copy is filed with the county building mspec BUILDINGe� tion department ADDRESS s� LOCALITY NEAREST Date Applicant CITYJ3J!L,-tkfLl9 Csn4ZIP CROSS ST CERTIFICATE OF EXEMPTION FROM WORKERS NJ SIZE OF LOT NOW F B LO MAP BOOK PAGE PARCEL ASSESSOR COMPENSATION INSURANCE (This section need not be completed if the permit is for one SE ZONE I MAPfit? hundred dollars($100)or less ) TRACT BLOCK LOT NOINC, ld— I, SPECIAL I certify that in the performance of the work for which this OWNER WN 1 1,S' T NO / CONDITIONS d permit Is issued I shall not employ any person in any manner DISTRICT GROUP CO W ZONE BY V so as to become subject to the Workers Compensation Laws ADDRESS 5(�1/�� • OL 3 CITY Date Applicant ARCHITECT OR ZIP TEL STATISTICAL FICAT— ONDO V NOTICE TO APPLICANT If after making this Certificate of ENGINEER NO CLASS NO DWELL UNITS W Exemption you should become subject to the Workers H Compensation provisions of the Labor Code you must forth ADDRESS SEWER MAP Z with comply with such provisions or this permit shall be TEL deemed revoked CONTRACTOR '5((, No Cj (p BK &-PG 3 " VALIDATION LICENSED CONTRACTORS DECLARATION L . 71 I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS VALUATION (commencing with Section 7000)of Division 3 of the Business and UC Professions Code and my license is in full force and effect CITY l«MC CLASS 1000 ► SQ FT NO OF NO OF CHECK License Number 3S� d lic ClassSIZE STORIES .rC FAMILIES ONE a oo Contracto Or�8s1dU IrSPIALA,Date -1-a 6 ` DESCRIPTION OF WORK NEW ADD am exempt under Sec 1 ALTER Q FINAL r • • e • 2 3 B 8P C for this reason REPAIR ❑ DATE 2 • • �'] �0 USE OF FINAL Date EXISTING BLDG DEMOL 0 Signature APP •- LICANT TEL BY PRINT NOo o e 3 7 5 0 5 OWNER BUILDER DECLARATION , SSS' O? _$3 I hereby affirm that 1 am exempt from the Contractor s License , Law for the following reason (Section 7031 5 Business and Professions Code) QBUILDING 1 as owner of the property or my employees with ADDRESS °4 0 7 8 A 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 TEL ° ° ° - 23 I as owner of the property am exclusively contracting CONTRACTOR NO with licensed contractors to construct the project (Sec ADDRESS 2 • • 43,79 tion 7044 Business and Professions Code) CONSTRUCTION LENDING AGENCY %BACIK YARD HWY TOTAL FROM IDSTH e o o ((3�7 9 cxi 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 07 29-830 9—$3 (Sec 3D97 Civ C ) SIDE o PL Lender s Name $ PC Fee S 13 7 50 Permit Fee /G 3 1 3fH • ka Lender s Address ' 1 � I certify that I have read this application and state that the / 3, Issuance Fee / S� N • O above information is correct I agree to comply with all County Investigation Fee ,� • --4ordinances and State laws relating to building construction Total Fee d� 3 ,J • •0 and hereby authorize representatives of this County to enter '`f � u n he above mentioned property for inspection purposes �� SEE REVERSE FOR EXPLANATORY LANGUAaR �s Re Signature of Applicant or Agent Dote 4 WORKERS COMPENSATION DECLARATION hereby affirm That I have a certificate of consent to self APPLICATION FOR BUILDING PERMIT insure or a certificate of Workers Compenstion Insurance or a certified copy thereof(Sec 3800 Lob C ) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No Company BUILDING Certified copy is hereby furnished FOR APPLICANT TO FILL IN ADDRESS _ y' Z gx Certified copy is filed with the county building inspec BUILDING tion department ADDRESS !A LOCALITY NEAREST Date Applicant CITY G ZIP CROSS S CERTIFICATE OF EXEMPTION FROM WORKERS NO OF BLDGS ASSESSOR COMPENSATION INSURANCE SIZE OF LOT A3..S U NOW ON LOT MAP BOOK PAGE PARCEL (This section need not be completed if the permit is for one w USE ZONE MAP hundred dollars ($100)or less ) TRACT BLOCK LOT NO l SPECIAL I certify that in the performance of the work for which this OWNER T Ke �)p y CONDITIONS 0 permit is issued I shall not employ any person in any mannerDISTRICT GROUPTYPE FIRE SSED BY V so as to become subject to the Workers Compensation Laws ADDRESS �nR SZ 'O B-2— CONS ZONE 0 Date Applicant CITY ZIP STATISTICAL CLASSIFICATION APT CONDO C NOTICE TO APPLICANT If after making this Certificate of ARCHITECT OR L TEL NO Exemption you should become subject to the Workers ENGINEER 6?7- CLASS NO DWELL UNITS N Compensation provisions of the Labor Code you must forth ADDRESS 1 ( SEWER MAP ? with comply with such provisions or this permit shall be d� deemed revoked CONTRACTOR L NO �� `� VALIDATION LICENSED CONTRACTORS DECLARATIONLIC I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS C R-Y NO VALUATION (commencing with Section 7000)of Division 3 of the Business andLICProfessions Code and my license is in full force and effect CITY^ CA CLASS r,2R $ ._4 0 O C SQ FT NO OF 1 NO OF CHECK License Number Lic Class SIZE STORIES 1 FAMILIES ONE NEW $ Contractor Date DESCRIPTION OF WORK /►n ❑ D D ❑ licensed exempt from the licensing requirements as I am a f}/I'1 1 � r i licensed architect or a registered professional engineer --MP LTER FINAL acting in my professional capacity (Section 7051 µ-1 P. Ileg-3hik EPAIR DATE❑ Business and Professions Code) USE OF EXISTING BLDG r,�' FINAL Lic or Reg No Date APPLICANT TEL c� By OWNER BUILDER DECLARATION PRINT t N-O7�(J 3� �,/o♦ ,y 5� I hereby affirm that I am exempt from the Contractor s License ADDRESS J I S fl 1 / Law for the following reason (Section 7031 5 Business and �J- Professions Code) P ❑ BUILDING I as owner of the property or my employees with ADDRESS C wages as their sole compensation will do the work and the structure is not intended or offered for sale(Section [AD LITY 7044 Business and Professions Code) NG TEL a 3 1 as owner of the property am exclusively contracting RACTOR NO with licensed contractors to construct the project (Sec ESS tion 7044 Business and Professions Code) �-7 �7O UIRED TOTAL SETBACK FROM EXIST / �,O� ✓^� CONSTRUCTION LENDING AGENCY BACK YARD HWY PROP LINE WIDTH I hereby affirm that there is a construction lending agency for ONT the performance of the work for which this permit is issued (Sec 3097 Civ C ) E Lender s Name A/ Lender s Address ee E mit Fee1 certify that I have read this application and state that the Iss cFe above information is correct I agree to comply with all County igation Fee ordinances and State jaws relating to building construction and hereby authorize representatives of this County to enter Wtj4e pup fhe above mentions property for inspection urpo s /D'2 V SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Dot r WORKERS COMPENSATION DECLARATION hereby affirm that I have a certificate of consent toself APPLICATION F O BUILDING PERMIT insure or a certificate of Workers Compenstion Insurance or a certified copy thereof(Sec 3800 Lab C ) COUNTY OF LOS ANGELS @ BUILDING AND SAFETY Policy No Company BUILDING Certified copy is hereby furnished FOR APPLICANT TO FILL IN ADDRESS —� Certified copy is filed with the county building inspec BUILDING //_ �p tion department ADDRESS 7 JO � Ul Z[fS LOCALITY NEAREST Dote Applicant CITY ZIP CROSS S7 f CERTIFICATE OF EXEMPTION FROM WORKERS NO OF BLDGS ASSESSOR COMPENSATION INSURANCE SIZE OF LO Q NOW ON LOT MAP BOOK PAGE PARCEL (This section need not be completed if the permit is for one o USE ZONE MA TRACT BLOCK LOT NO NO hundred dollars ($100)or less ) TEL �a SPECIAL � OWNER e O CONDITIONS IL I certify that in the performance of the work for which this u permit is issued I shall not employ any person in any manner `U� DISTRICT GROUP TYPE FIRE CESSED BY ADDRESS 6> so as to become subject to the Workers Compensation Laws CONST NE 0L O/� 6 O Date Applicant CITY ZIP It✓Q � STATISTICALCLACATION APT JCON NOTICE TO APPLICANT If after making this Certificate of ARCHITECT OR L NO Exemption you should become subject to the Workers ENGINEER CLASS NO DWELL UNITS N Compensation provisions of fhe Labor Code you must forth ADDRESS ( SEWER P Z with comply with such provisions or this permit shall be j-�TEL �Q VALIDATION B deemed revoked CONTRACTOR NO LICENSED CONTRACTORS DECLARATION LIC I hereby affirm that I am licensed under provisions of Chapter 9 ADDR _ N VAL ATJON (commencing with Section 7000)of Division 3 of the Business and LIC Q Professions Code and my license is in full force and effect CITY CIAS$' E wo a SQ FT NO OF NO OF CHECK License Number Lic Class SIZE STORIES FAMILIES ONE Contractor Date DESCRIPTION OF WORK NEW ❑ $ ` i I am exempt from the licensing requirements as I am a ` ' 7 / ADD ❑ t ALTER FINAL licensed architect or a registered professional engineer teU� ❑ acting in my professional capacity (Section 7051 � 'REPAIR ❑ DATE Business and Professions Code) USE OF i EXISTING BLDG �j ❑ FINAL By Lic or Reg No Date APPLICANT L TEL OWNER BUILDER DECLARATION S NO I hereby affirm that I am exempt from the Contractor s License Law for the following reason (Section 7031 5 Business andADDRESS S , LA Professions Code) n i BUIL ,I/ I as owner of the property or my employees with ADDRE wages as their sole compensation will do the work and the structure is not intended or offered for sale(Section LOCALITY 7044 Business and Professions Code) MOVING 1 as owner of the property am exclusively contracting CONTRACTOR O with licensed contractors to construct the project (Sec2 2 8 b 3 A tion 7044 Business and Professions Code) ADDRESS REQUIRED TOTAL SETBA EXIST g # • • • * 23 CONSTRUCTION LENDING AGENCY SET BACK YARg,, PROP LINE WIDTH �j I hereby affirm that there is a construction lending agency for FRONT 2 - 304 r 0 the performance of the work for which this permit is issued P L (Sec 3097 Civ C ) S L � • • 304,20 Lender s Name �J $ Fee oG O Perm' I a 3 0"8 0 ^ Lender s Address P C lop I certify that I have read this application and state that the Issuance Fee ID ' above information is correct I agree to comply with all County Investigation Fee ordinances and State laws relating to building construction law and hereby authorize representatives of this County to enter ee d Zz� ovZ�� inspection purposes ^ Q U SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Ageol D6te ®s