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70A080A O6#8032/60 APPLICATION FOR. BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING' -/•� G+ b
DEPARTMENT OF COUNTY ENGINEER ADDRESS
BUILDING AND SAFETY DIVISION LOCALITY >'
JOHN A. LAMBIE. COUNTY ENGINEER NEAREST
P•
WILLIAM A.JENSEN.SUT of BUILDING CROSS ST.
DISTR�T NO. GROUPgypE P SED-BY '
FOR APPLICANT TO FILL IN colvsr. I
BUILDING r soe3 STATISTICAL CLASSIFICATION SEW R MAP
ADDRESS+f' .� ,v`C `� �K CLASS.NO. DWELL.UNIT �K PG
LOT NO.. O Oe .S° , vo oCdr LOCK MAP ,/ STATENUMBER YES O
TRACT k/d tL6 US ZONE SPECIAL
HWY.
NO.OF BLDGS. I CONDITIONS
SIZE OF LOT 3CIC I NOW ON LOT J /
USE OF
EXISTING BLDG. �, �.Z 9UILDI IG YARD HWY STREET NAME EXIST.
TEL SETBACK i WIDTH
OWNER �L°J NO. !Z FRONT s�
NP.L.
ADDRESMCA4 _ SIDE
ARCHITECT OR TEL. P.L.
ENGINEER NO. INSPECTION RECORD
ADDRESS
EOL � �Go O L
CONTRACTOR.�' P� NC
yiV+ vO
. � �
ADDRESS A� SP`1
DESCRIPTION OF WORK
X s7-try r'vx r a c k ,,T r. tr H
NEW X ADD ALTER REPAIR DEMOLISH J
SQ.•FT. NO.OF i NO.OF "'L.�.v-I�er1
SIZE �`3 STORIES FAMILIES 1
USE OF ``�_.YJ.�'f' q�' {_�'.L�r•_. FFFIII
STRUCTURE /
SIGNATURE OF
APPLICANT
VALUATION
APPROVALS DATE. INSPECTOR'S SIGNATURE
P.C. . PMT: 6a FO FORMS,MATERIALS
LOCATION Grp C• - !�-t,'l�Se. -3:
FEE!$ FEE $� -
1 HEREBY AC NOWLEDGE THAT 1 HAVE READ THIS AP- F BRACING,BOLTSS� 7,ao,�,lf _4�
PLICATION AND STATE THAT THE ABOVE IS CORRECT AND FURNACE:LOCATION. `-•l
AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND GAS VENT,DUCTS A
STATE LAWS REGULATING BUILDING`CONSTRUCTION.
I CERTIFY THAT IN DOING THE WORK AUTHORIZED I LATH,INT. , /O�/F �7��1J, Ise .>
WILL NOT EMPLOY A Y PERSON IN VIOLATION OF THE
WORKMEN'S COMPS Tl0 LA OF LIFORNIA. LATH,EXT.
SIGNATURE OF HOUSE NUMBER COR-
PERMITTE RECT AND POSTED
ADDRESS FINAL �+
CLYDE N. DIRLAM, PRINCIPAL STR RAL ENGINEER
PLAN CHECK VALIDATION omM.o. CASH PERMIT VALIDATION cK. M.C. CASH
L' oa521 -0-4 FcB1523D 13.50 OF
L�':�.�...l..Li..�.;�...FSB ?G p -27..0.0 ".
V,V RKSRS�rCOMFENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance, A P P L I CiT I O N FOR BUILDING PERMIT
u
or a certified copy thereof (Sec. 3800, Lab. C.)
Policy No. Company COUNTY OF LOS ANGELES BUILDING AND SAFETYBUILDING
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS/—
❑ Certified copy is filed with the county building inspec- BUILDINGr
6 111S A
tion department. ADDRESS -
F 7y
Date Applicant CITY ZIP ;y /v LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' .o OF BLDG& NEAREST
COMPENSATION INSURANCE SIZE OF I.OtelrV G7 IsP NOW ON LOT CROSS ST. '
(This section need not be completed if the permit is for one ASSESSOR
hundred dollars($100)or less.) TRACT BLOCK LOT NO. MAP BOOK [PAGE PARCEL
OWNER LCs �5 1 jE �iS �c� USE NE MAP SD 27
I certify that'in the performance of the work for which this NO };
permit is issued, I shall not employ'an erson in any manner C�y cG� I SPECIAL Qi
sot eco a sub'ect to the Wo ers=�o pe ration Laws. ADDRESS 7S [ - _ '11�1i CONDITIONS U:
5 1
Applicant CITY it ZIP
0.'
N TILE O APPLI NT: If, offer makin thi ertificate of ARCHITECT OR AA TEL. DISTRICT GROUP TYPE FI PR ESSED BY O
g ENGINEER II NO• -� CONST. 'Z EJ F-
empt' n, you should become subject to the Workers' ,J' ,// V(�) ()
Compensation provisions of the Labor Code, you must forth- ADDRESS I d
with comply with such provisions or this permit shall be +' TEL, STATISTICAL CLASSIF CATION APT. rNDO. N
deemed revoked. CONTRACTOR 1 NO. Z
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 and i LIC. /(
Professions Code, and'my license is in full force and effect. CITY i - CLA55 BK ,FPG 16 Y VALIDATION
SQ.FT. NO.OF NQ.OF CHECK
License Number Lic.Class SIZE STORIES
FAMILIES f ONE VALU TION a Q
DESCRIPTION OF WORK D
Contractor Date a $ (�VV�✓� /
. , 27834A
A
❑ I am exempt under Sec. ❑
ALTER '#;o,0 0 0 0
B.$P.C. for this reason REPAIR ❑ $ fl •
Date: USE OF J ❑ 'l a a 9(j,7 5
1-DEMOLEXISTING BLDG. /� �( 9 6
Signature APPLICANTEOL..Z_ ' FINAL o o o
PRINT 7 y�G NO. . ,i�7=fir 0 9,,�3`8?
OWNER-BUILDER DECLARATION DATE
1 hereby affirm that I am exempt from the Contractor's License S� �v }�
Law for the following reason (Section 7031.5, Business and gDDRESFI Al,
9 <'
'Professions Code): PRE
BUILDING
I, as owner of the property, or my employees with ADDRESS
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.
❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO.
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY. SETT BACK YARD HWY TOTAPROP. LISETBACNE WIDTH
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.
(Sec. 3097, Civ. C.). SIDE
P.L.
Lender's Name LDMA.�
P.C.Fee$ Permit Fee Ref. N
Lender's Address
I certify that I have read this application and state that the Issuance Fee L/t �v LDMA P/C q
above information is correct. I agree to comply with all County Investigation Fee
oordinances and State laws relating to building construction, I Total Fee LDMA Perm. 4
o and hereby authorize representatives of this County to enter
upon the above- ntioned property for In pect' urpo s.
/ SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent