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APPLICATION FOR BUILDING PERMIT •y
1
FCRAPF'"�C ANT TO 5ILL IN (Print or type only)
COUNTY OF LOS ANGELES
BUILDING
ADDRESS d - DEPARTMENT OF COUNTY ENGINEER
CITY � � ZIP BUILDING AND SAFETY DMS ON
NO.OF . BUILDING
SIZE OF LOT NOW ONN LOT LOT ADDRESS
TRACT BLOCK T Y LOCALITY Z
TEL. NEAREST
OWNER / NO. CROSS ST.
ASSESSOR
ADDRESS MAP BOOK GE PARCEL
DISTRICT G,ROIJFTY FIRE PROC SE�Y
.CITY �� ZIP '�' �1 NST 'ZO
ARCHITECT O . ' TEL. �. (J
ENGINEER STATISTICALCLASSISEWE P
ADDRESS CLASS NO. DWELL.UNITS BK PG
CONT ZONE MAP �~
LIC. NO. O -
ADDR O D SPECIAL
LIC. CONDITIONS
CITY r CLASS ROAD DEPARTMENT APPROVAL REQUIRED YES ❑ NO ❑
CONSTRUCTION LENDER
NAME AND BRANCH BLDG.SETBACK FROM
FRONT PROP.LINE OF (STREET)
ADDRESS CITY TOTAL SETBACK FROM TYPE OF EXISTING
SQ.FT .OF NO.OF CHECK HIGHWAY F YARD = FRONT PROP.LINE HIGHWAY WIDTH
SIZE ORIES LIES ONE }
DESCRIPTION OF ORIA NEW + O
ADD ❑ B G.SETBACK FROM oc
SIDE PROP.LINE OF (STREET) O
ALTER ❑ TOTAL SETBACK FROM TYPE OF EXISTING G
_ HIGHWAY + YARD = SIDE PROP.LINE HIGHWAY WIDTH N
USE OF REPAIR ❑ Z
EXISTING BLDG. DEMOL ❑ +
APPLICANT TEL CORNER CUTOFF YS ❑ NO ❑
(PRINT) NO.
IN OPEN SPACE YS ❑ NO ❑
BY(SIGNATURE(
to,
IN COASTAL PERMIT ZONE YES ❑ NO ❑
VALUATION$ // 23LI HEREBY ACKNOWLEDGE THAT READ THI PPLICATION AND STATE /
THAT THE ABOVE IS CORRECT AGREE O CO Y WITH ALL ORDINANCES _
AND LAWS REGULATING BUI G CONSTR TION. C IFY THAT IN DOING THE yC C
WORK AUTHORIZED HERE I WILL NOT PLOY RSON IN VIOLATION OF
THE LABOR CODE OF TH ATE OF CA RNIA IN T G TO WORKMEN'S COM-
PENSATION INSURAN
01
SIGNATURE
IGN T URETEP C �3I�Ci/h / !'621PERf"rl
ADDRESS /
TEL. FINAL
DATE
CITY NO. !�
MAKE CHECKS PAYABLE TO: FEE F ET 'Z
LHARVEYT.BRANDT•COUNTY ENGINEER 5L44, 32 _.. _
c+
PLAN CHECK VALIDATION -cam M.O. CASH _ PERMIT VALIDATION CK__ M.O. CASH
4 9 B tit'>AY- 8 —D`� T Q
` t S T� 4 9 9
1� ?�iHY 18 1 7 9.0 0 �>s
H0LDE R:O�L
as 76A638A CE#803 3.75' (J
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1
BABSBA CE*B03-10-98 APPLICATION FOR BUILDING PERMIT _ �•
BUILDING AND SAFETY DIVISIONBUILDINGCA
ADDRESS
Department of County Engineer, _
County of Los Angeles LOCALITY r
JOHN A.LAMBIE. COUNTY ENGINEER NEAREST - I
CASSATT D.GRIFFIN, SUPT OF BUILDING CROSS ST.
DISTRICT NO. AGAOUP TffPE SEWER .MAP
FOR APPLICANT TO FILL IN t—, BK PG
CONST. ,
BUILDING , r
ADDRESS) STATISTICAL CLASSIFICATION
LOT NO. BLOCK CLASS. NO.—L—DWELL. UNITS—/_I
MAP (f STATE YES NO
NUMBER HWY
TRACT USE Z NE SPECIAL
NO.OF BLDGS. -CONDITIONS
SIZE OF LOT&<A,�'d 7? ,� I NOW ON LOT
USE OF Q�V
EXISTING BLDG. r BUILDING YARD HWY STREET NAME EXIST,
_ �•-- .r) j i SETBACK WIDTH
OWNER' e, r /n J�I A I C Y`1"P_;/%0�L FII/'. FRONT
MAIL �/�ya" —1 P-
ADDRESS � � SIDE �a/ t3`j r
T . -
CITY 4&b-a-& �/ � INSPECTION RECORD - '•
ARCHITECT�DR E a
ENGINEER.; /
ADDRESS
AlTEL.�/�
CONTRACTOFA&5 �t At /3: dV adW. %.. '�
ADDRESS deQ1
DESCidTION OF WORK -
NEW TTrr��A ADD ALTER REPAIR DEMOLISH -
S ZETf'S .7Z&7 ftSTOR1ES FAMILIES
�g
USffPS�Q C �h C - � �
APPROVALS
SIGNATURE O
APPLICANT d /, 7/ DATE INSPECTORS SIGNATURE
ADDRESS/-,1:3L /11,,05/ G.t7Lri�/I//1 FOUNDATION: G r�
.G
P,C, $ fj(� FRAME: FIRE STOPS.
/Q7®e 0 . FEE JBRACING / 7/ !"'!`/6"LLs°•.y ,r
.BOLTS
VALUATION $ FURNACE: LOCATION.
FEE -� GAS VENT. DUCTS
1 HEREBY ACKNOWLEDGTHAT 1 HAVE READ THIS AP- LATH. INT.
E
PLICATION AND STATE THAT THE ABOVE IS CORRECT AND _
AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND
LATH, EXT.
STATE LAWS REGULATING BUILDING CONSTRUCTION. -
OFA HOUSE NUMBER COR-
SIGNATURE ,,
, f
PERMITTEE 'A RECT AND POSTED �/
ADDRES FINAL �%' /orti
OHN A.LAMBIE. CVUNTY ENGINEER, 0 CLYDE N. DIRLAM. PRINCIPAL STRU��CT.URAL.ENGINEER
PLAN CHECK VALIDATION c M.O. CASH PBEMIT VALIDATION /CK J M.O: CASH
AUG 6 1 6 1 8.0 0 D
:_.'! o
0 .9 3 2M AUG 8 i 3 6.0 0
APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
;41F d WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS /-,7
r
BUILDIN AD SS " /{�� d / V V
,I hereby affirm that I have a certificate of consent to self insure, �� � � � � � J Y .� `
or a certificate of Workers'Compensation Insurance,or a certified /P C c. '�D
copy thereof(Sec.3800,Lab.C.) CIT 4 /^ ZIP / QD LOCALITY L
Policy No. Company SIZE OF L-0-T-70'— [C NO.OF BLLDDGGS..NOW QON LOT
❑ Certified copy is hereby furnished. / NEAREST CR ST.- I
❑ Certified copy is filed with the county building inspection T BLOCK LOT NO. Q. L�!/�
department. ASS6S USE ZONE MAP NO.
Date Applicant qG P Milo
PO
SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' °W T L NCOMPENSATION INSURANCElfq�ke4l ¢ 90WITHIN 1000 FT.OF SCHOOL? ves No
ADDRESSS '•
(This section need not be completed if the permit is for one hundred I �� & O /L v DISTRICT GROUP TYP ONST. FIRE ZONE PROCESSED BY
dollars($100) or less.) ! C
I certify that in the performance of the work for which this permit '�/' 1-7
is issued, I shall not employ any on in any manner sous to CI el 1-74k" ZIP
become subject to the Workers' om en t n La S. ARCHITECT R ENGINEER TEL NO.
STATISTICAL CLASSIFICATION APT CONDO
Date �� Applicant N!r ADDRESS CLASS NO. DWELL UNITS
NOTICE TO APPLICANT.• If, after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST
Exemption, you should become subject to the Workers' TR TOR TEL NSET BACK YARD HWY PROP LINE WIDTH
Compensation provisions of the Labor Code, you must forthwith N FRONT
comply with such provisions or this permit shall be deemed revoked. A DRESS rf // NO. PL
LICENSED CONTRACTORS DECLARATION Q o K l d - SIDE
CI Y t. � Lj LASS PL
I hereby affirm that I am licensed underprovisions of Chapter 9 L SEWER MAP
(commencing with Section 7000)of Division 3 of the Business andQ.FT.S ZE NO.OF STORIES NO.OF FAMILI
Professions Code an lice s in full force an Ct. NEW BK PG ® n
License Nu r LIC.Class DESCRIPT=N OF K cc rADD ❑ VALUATION ✓`. C
Contractor d-b w !27 ate —27 ALTER ❑ $ tS 092
/4 1 w . e�a (,� ►a✓ REPAIR 11C
❑ 1 am exempt under Sec. _� $ C
BAP.C.for this reason Q Z QI DEMOL ❑ LDMA P/C# CL
Date- USeEXIST�N G. URM ❑ �,-- { (f.Signature AP i^f TEL NO. ` �� LDMA Perm#❑ I, as owner of the property, or my employees with wages as 4 / Ztheir sole compensation, will do the work and the structure is ` C 11- O
AD �/ / 1I._ • U G FINAL DATE
not intended or offered for sale (Section 7044, Business and d �jL TTL%-C. Q
Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL i +'-:°��•'
OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE
El 1, as owner of the property, am exclusively contracting with AMOUNTS SPECIRE9 ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY / 0 -1 1 T C TI,
El contractors to construct the project (Section 7044, YES NO may'/ y
Business and Professions Code.) -
WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING •�•:I i i-!L 29 e ,
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH _
CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FOR !EK 2 ,T 2,T-°
GUIDELINES =•t Il+ti•Fti
I hereby affirm that there is a construction lending agency for VES❑ No _
iA the performance of the work for which this permit is issued(Sec. s IRAN 3E °'"("
I HAVE READ T A DOLS MATERIALS INFORMATIO IDE AND THE SCAQMD PERMITTING
N 3097,CIV.C.) _` CHECKU UNDER AND Y REQUIREMENTS U HE LOS AS COUNTY CODE,
lVl/ TITLE 2, PIER 0 IONS 2 H 'H 2 20 1 klltl8 HAZARDOUS
Lender's Name MATERI S REPO IN D FOR O ING A WT
R AQMD.
in Lender's Address
OWNER M3ENT
oI certify that I have read this application and state under penalty =�t Nll
of perjur that the above information is correct.I agree to comply P.C.FEE / PERMIT FEE �� r
N with c unty ordinances and ate laws relating to building g
con ructi , a hereby authWrepre atives of this County ISSUANCE F to me pon abo ir inspection) purposes.
INVESTIGATION FEE TOTAL FEEQ r
ro /U a�
Sptiluro°I AaR'cnl a Aa:1
W.
SEE REVERSE FOR EXPLANATORY LANGUAGE