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7BA638A CE#803 8-83 APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES ABUILDING
DDRESS j Q ,ZST
DEPARTMENT OF COUNTY ENGINEER /
BUILDING AND SAFETY DIVISION LOCALITY 6
JOHN A. LAMBIE, COUNTY ENGINEER NEAREST
WILLIAM A.JENSEN,SUPT OF BUILDING CROSS ST.
DISTRICT NO. I GROUP TYPE PR ESSED BY
FOR APPLICANT TO FILL IN ,��J� CONST- � s
BUILDING $T TISTICAL CLAS IFICATION SEWER MAP
ADDRESS 10631 Lynrose Ste , Temple TV'
BK PG
/ CLASS. NO. DWELL.UNITS
LOT NO. gr �T �p BLOCK WATER
CERTIFICATE: NOT REQUIRED ❑ RECEIVED ❑
TRACT �� MAP NO. 2DD ({CIRCLE)
STATE MAJOR SECOND OCA
/ NO.OF BLDGS.
SIZE OF LOT Q NOW ON LOT USE ZONE bPECIAL
USE OFCONDITIONS
��4 Z
EXISTING BLDG.
a4 /
OWNER Lionel Horse N0L266-391 r BUILDING YARD HWYSTREET NAME EXIST.
_ SETBACK WIDTH
�:,
ADDRESS 9047 E. Olive St. , T. C. FRONT
ARCHITECT OR TEL. P. L.
ENGINEER NO. SIDE
P. L.
ADDRESS
TEL,, lou
CONTRACTOR Vlr 'ln Roof vnodT287-0 I w
ADDRESS 600 So. San Gabriel Blvd. 29
DESCRIPTION OF WORK u
d
NEW ADD ALTER REPAIR DEMOLISH
SQ.FT. NO.OF NO. OF
SIZE STORIES FAMILIES
USE OF Refoor House & att. gar.
STRUCTURE
with , compo. shingles
SIGNATURE OF
APPLICANT
VALUATIONS 260 0 00
APPROVALS DATE INSPECTOR'S SIGNATURE
UNDATION:C. PMT.
FEE S FEE S6.00 FO FORMS, MATER ALSON
FRAME: FIRE STOPS,
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION BRACING. BOLTS
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY FURNACE: LOCATION.
WITHALL COUNT ORDINANCES AND STATE LAWS REGULATING GAS VENT. DUCTS
BUILDING CONSTR CTION. I CERTIFY THAT IN DOING THE WORK
AUTHORIZED HERE I ILL NOT EMPLOY ANY PERSON IN VIOLA- LATH. INT.
TION OF THE LABOR DE OF THE STATE F CALIFORNIA RELAT-
ING TO WORKMEN'S MPENSATION INSURA
LATH.EXT.
SIGNATURE OF HOUSE NUMBER COR-
PERMITTEEp¢ RECT AND POSTED / ^
ADDREss 6Qf1 Cn � �� + g Y FINAL l Fir -��°''�'�
JOHN F. LEWIS. PRINCIPAL ST RAL EN JNEER
PLAN CHECK VALIDATION CK. M.O. CASH PERMIT VALIDATIO CK. M.O. CASH
LAC06 5 6 612 OCT 18 ID 6.0 0 N 17
APPLICATION ULDINC PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS �{ roS ei
I hereby affirm that I have a certificate of consent to self insure, BUI}DIp1G/�D R
or a certificate of Workers'Compensation Insurance,or a certified /Ip/� Pi'
cPoop�t ���C 3�0,Jab.C.)Company -� �I{� C �Y `� � I� Z`y � `J LOCALITY
- SIZE OF LOT NO.OF RLDGS.NOW ON LOT
❑ Certified copy is hereby furnished.
NEAREST CROSS ST
11Certified copy is filed with the county building inspection TRACT BLOCK LOT No.
department.
Applicant
USE ZONE MAP NO.
Date f'1/
ASSESSOR MAP BOOK PAGE PARCEL
SPECIAL CONDITIONS a�� �/
CERTIFICATE OF EXEMPTIO OM WORKERS' NF�R ` TEL NO. YES NO
COMPENSATION IN URANCE , O�yLe/ (9/r L G� 42 WITHIN 1000 FT.OF SCHOOL?
(This section need not be completed if the permit is for one hundred AD SS ^� 1 �� S DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY
dollars($100)or less.) I 1
ZIP/�
I certify that in the performance of the work for which this permit e kL7 1 4, Cf �'Y 7 2 � 5p �.� °
is issued, I shall not employ any person in any manner so as to A CHITECi OR ENGINEER TEL NO.
become subject to the Workers'Compensation Laws. STATISTICAL CLASSIFICATION APT CONDO
Date- Applicant ADDRESS CLASS NO. .5z/ DWELL UNITS
NOTICE TO APPLICANT. If, after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST
Exemption, you should become subject to the Workers' CONTRACTPR� 1 T ) SET BACK YARD HWY PROP UNE WIDTH
Compensation provisions of the Labor Code, you must forthwith !{G�[lt /t// FRONT
comply with such provisions or this permit shall be deemed revoked. AD - /��/► Q--) L r PL
V C SIDE
LICENSED CONTRACTORS DECLARATION CI ) LIC.�aS 35S P L
I hereby affirm that I am licensed underprovisions of Chapter 9 SEWER MAP
(commencing with Section 7000)of Division 3 of the Business and Q.Fr.SIZE N .OF STORIES NO.OF FAMILIES }
Professions Code,a hmy li ensJe iS in full force effect
NEW BK PG 11
License Number / Lic.Class -° L- DES ON OF WORK �j� ADD 11 VALUATION Q
Contractor Date _ ALTER 11 $ U
❑ 1 am exempt under Sec. REPAIR ❑ $ O
i
BAP.C.for this reason DEMOL ❑ LDMA P/C# W
Date: SE OF EXISTING BLDG. URM ❑ i IL
Signature APPLICANT(PRINT) TEL NO. LDMA Perm# a z
s
❑ I, as owner of the property, or my employees with wages as O ACCT a a
their sole compensation, will do the work and the structure is ADDRESS
not intended or offered for sale (Section 7044, Business and FINAL DATE G 33303 107-10
Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL �-Z J ITEMS
❑ 1, as owner of the property, am exclusive) contracting with OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE
Y Y g AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY
licensed contractors to construct the project (Section 7D44, YES 11 NO 11 TOTAL 107 m 10
Business and Professions Code.)
WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDINGCHECK 107.10
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH
CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FOR r,
GUIDELINES �.HANGE .00
I hereby affirm that there is a construction lending agency for YES 11NO❑
W the performance Of the work for which this permit is Issued(Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING
N 3097,CIV.C.) CHECKLIST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE,
TITLE 2.CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING HAZARDOUS 00n0- CIO S 5/24/95
Lender's Name MATERIALS REPORTING AND FOR OBIAINING A PERMIT FROM THE SCAOMD.
0 Lender's Address ���9 1 �� �'Cit
0 OWNER OR AGENT
c I certify that I have read this application and state under penalty
of perjury that the above information is correct.I agree to comply P.C.FEE PERMIT FEE 1
N with all county ordinances and State laws relating to building V °
m construo6n, and hereby a horize rep esentatives of this County ISSUANCE FEE
CO to ent (upon the -me 'oned prop�rty for inspection purpo�@s.`
m �] y/ INVESTIGATION FEE TOTAL FEE
Sgmt=W App!== O—/—��-
7 SEE REVERSE FOR EXPLANATORY LANGUAGE