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F/AUSA Ot#SOL 1-01 APPLICATIONrOM ILDING PERMIT
COUNTY OF LOS ANGELESB DING /Q���
DEPARTMENT OF COUNTY ENG w Ess f�
ArAt 9A M,
BUILDING AND SAFETY DIVISIONLITY
JOHN A. LAMBIE, COUNTY ENGINEER t
N EST
WILLIAM A.JENSEN SUPT OR BUILDINGorm
S ST.
FOR APPLICANT TO FILL IN DI RICT NO. GROUP TMpE P ESSED BY
CONST,
BIJILDING ISTICAL CLASSIFICATION SLSWER MAP
ADDRESS AHK
SS.NO. DWELL.UNITS
LOT NO. patLoF BL R - NOT REQUIRED RECEIVED
CERTIFICATE:
TRACT
NO.OF BLDGS. NO ({CIRCLE ) STATE MAJOR SECOND, LOCAL
SIZE OF LOT. NOW ON LOT USE ZONE SPECIAL
USE OF CONDITIONS
EXISTING BLDG.
TEL
OWNER / »'I NO. BUILDING YARD HWY STREET NAME EXIST.
SETBACK WIDTH
ADDRESS FRONT
ARCHITECT OR TEL. P. L.
ENGINEER NO. SIDE
G ISs P.L.
ADDRESS TEL INSPECTION RECORD a0
CONTRACTOR ng lqjziNO. U
ADDRESS S' L ag
DESCRIPT[ON40F WOAK
0
NEW ADD ALTER REPAIR DEMOLISH Z
SQ.FT. NO.OF NO.OF
IZE STORIES FAM IES
USE OF
STRUCTURE
SIGNATURE OF
APPLICANT
VALUATION$
APPROVALS DATE INSPECTOR'S SIGNATURE
�f FOUNDATION:LOCATION
F E SoG �� FEE FORMS"
ORMS MATERIALS
FRAME:FIRE STOPS,
I HEREBY 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 WORKMEN'S COMPENSATION INBUR CE.
LATH,EXT.
SIGNATURE OFJf ' - /� HOUSE NUMBER COR-
PERMITTE RECT AND POSTED
ADDRESS FINAL
CLYDE N. DlRLAM, PRINCIPAL STRUCTURAL EN ER
PLAN CHECK VALIDATION cK. M.O. cABH PERM VALIDATION cK. d.0. CABN
...LN;p,0Z6"Z M. 9 2 3. D 2325A
,0 8 8 3; m 3 1 D 4 6.50- W
WORKERS'COMPENSATION DECLARATION
nsure boracertificate of Workers' Compensation consent Insurance, APPLICATION FOR BUILDING PERMIT
or a certified copy thereof (Sec. 3800, Lab. C.), CompanytZL,),S110 COUNTY OF LOS ANGELES BUILDING AND SAFETY
R90licyNo.t
® Certified copy is hereby furnished. FOR APPLICANT TO FILL I ! BUILDING
ADDRESS
Certified copy is filed with the county building inspec- BUILDING Q(/1 � ��s ��
tion department. ADDRESS
Date �n Applicant - 11 uw, CITY ZIP LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. NEAREST
COMPENSATION INSURANCE SIZE OF LOT 151ZNOW ON LOT CROSS
�/ ST.
(This section need not be completed if the permit is for one TRACT 3 BLOCK LOT N%, �3 LESSOR
hundred dollars($100)or less.) /� '',�\ MAP BOOK PAGE PARCEL
r/ E� � C�C>rGN TEL. USEPE
L M
1 certify that in the performance of the work for which this OWNER �/� NOCE NO
permit is Issued, I shall not employ any person in any manner SPECIAL
so as to become subject to the Workers'Compensation Laws. ADDRESS �• � CONDITIONS 8
Date Applicant CITY S �G G� ZIP
NOTICE TO APPLICANT: If, after making'this Certificate of ARCHITECT .r ) DISTRICT GROUP TYPE FIRE PROCESSED BY O
Exemption, you should become subject to the Workers NGINEER i6yn/ CONST. ZONE U
Compensation provisions of the Labor Code, you must forth- ADDRESS a
with comply with such provisions or this permit shall be TEL
deemed revoked. CONTRACTOR NO. STATISTICAL CLASSIFI TION `/ APT. CONDO. Z
LICENSED CONTRACTORS DECLARATION LIC, CLASS NO. DWELL. UNITS!' 1
I hereby affirm that I 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 f CLASS BK E VALIDATION
SQ.1 140.OF NO.OF CHECK
license Number E-1;GT Lic.Class SIZ STORIES FAMILIES ONE
NEW VALUATION Q 7 Jrt
Coniractor�`� I1 eUcrft to f� DESCRIPTION OF WORK NE : 6 I e 72a
1 am exempt under Sec. qZ�'l 4 /tom ALTER Poo.
• e 7 2 a 6 7 5
B.&P.C. for this reason
USE OF 09.U-88'
..
Date: EXISTING BLDG. DE0AOL
Signature APPLICANTL / / TEL. FINAL
OWNER-BUILDER DECLARATION (PRINT)_ 'v DATE CGT
I hereby affirm that 1 am exempt from the Contractor's License ��
Law for the follow ADDRESS following reason (Section 7031.5, Business and FII ALJ P✓�
Professions Code): B
1, as owner of the property, or my employees with ADDRESS 1j
wages as their sole compensation,will do the work and ACT.*
the structure is not intended or offered for sale(Section LOCALITY ,
7044, Business and Professions Code). MOVING TEL. 4
1, as owner of the property,am exclusively contracting CONTRACTOR NO.
7 1 ITEMS
969.Ui
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY SET BACEK° YARD HWY TOT PROP LINE WIDTSETBACK FROM H 1� T'+ � 969.01
I hereby affirm that there is a construction lending agency for FRONT GECK 969■01
the performance of the work for which this permit is issued P.L.
(Sec. 3097, Civ. C.). SIDE CWGE .00
P.L.
Lender's Name LDMA
P.C.Fee S f Permit Feeqc�P.C.
N
Lender's Address 0000-Ml 4/23/90
I certify that I have read this application and state that the Issuance Fee 1 .3100 LDMA P/C M loop 0241 1 AM 9:34
above information is correct. I agree to comply with all County Investigation Fee
ordinances and State laws relating to building construction, Total FeeqW- 01
LDMA Perm. E
R and hereby authorize representatives of this County to enter
upon the above-mentioned property for inspection purposes.
m 4 u•9 D SEE REVERSE FOR EXPLANATORY LANGUAGE
Ignature of Applicant or Agent Date