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8A030A CE#80910.08 APPLICATION FOR BUIL DING' PERMIT
COUNTY OF LOS ANGELES BUILDING
DEPARTMENT OF COUNTY ENGINEER ADDRESS/D Ell 61 • d9A dE
BUILDING AND SAFETY DIVISION LOCALITY Jr'
JOHN A.LAMBIE,COUNTY ENGINEER NEARESTr
CASSATT D.GRIFFIN,SUPT OF BUILDING CROSS ST. ' .p /�'
DIS'TRICTIV GROUP TYPE . P E Y
FOR APPLICANT TO FILL IN )(9 t'I colgsT.
BUILDING SEWER MAP
ADDRESS ����� OL v/s STATISTICAL C SSIFICATION BK PG/
)� s �r� CLASS.NO-2L. -UNITS-
LOT
UNIT /
LOT NOW✓r ic E 4 w� pA MAP STATE YES O
NUMBER HWY..
TRACT-T D USE ZONE SPECIAL
22 NO.OF BLDGS. CONDITIONS
SIZE OF LOT d I NOW ON LOT �l
USE OF AI ' l
EXISTING BLDG.7Z BUILDINGYARD ' HWY STREET NAME EXIST.
SETBACK WIDTH
OWNE UI/JG'd0W ,Oi�� FRONTI
MAIL -7-0O �
ADDRESS149611 � C/t�J (�� SIDE F
EL. P.L.
T
CITY q�(� el .,/` No• INSPECTION RECORD 6
ARCH FC�� �Y�I.6filJ T f f c o
ADDREJJSS �LO 10 ho' s
y {
!FA C-4--c L. /vim C�c•l./b -= `
ADDRESS 2 F,•+a/P'w :, �U�I/
DESCRIPTION OF WORK
EW ADD ALTER REPAIR DEMOLISH
NO.OF NO.OF
SIZE STORIE FAMILIES
USE OF STRUCTURE
!p! 00/ `T r �7
SIGNATURE OFAPPROVALS
APPLICANT bl- .4 s
ADDRESS 7 �7//!�/V7'I� L FOUNDATION: LOCATION I DATE INSOECTOR'S SIGNATURE
FORMS,MATERIALS S Ca--'-e_
$ ` O a P.C. FRAME: FIRE STOPS. V
FEE
BRACING,BOLTS
VALUATION $ _r FURNACE: LOCATION,
M FEE' GAS VENT,DU S.
1 HEREBY ACKNOWLEDGE THAT I HAVE.REAI)THIS AP- LATH,INT.
PLICATION AND ST THAT THE:A14AVE IS CORRECT AND
AGREE TO COMP 1 AL COU OR INANCES AND
STATE LAWS G IN U ING NSTRUCTION. LATH,EXT.
SIGNATURE OFCza HOUSE NUMBER COR-
PERMITTE RECT AND POSTED t
�-I
ADDRES FINAL L
CLYDE N.DIRLAM,PRINCIPAL STqRC
WRAL ENGINEER.
PLAN CHECK VALIDATION f. cx. M.O. cash PAZ=VALIDATION cx. M.O. CASH '
L;03 4 4 8 S-. MAR13 2.'3- A 3.0 0 3
-3 .. t7 ®F
�.�lCo 3 4 4 9�; MAR-13 .. 1. A•.. 12.0-0. • � .
WORKERS'COMPENSATION DECLARATION I
I n hereby affirm fI have certificate of consent to self APPLICATION FOR BUILDING PERMIT
insure, or o certificate of Workers'Compensation Insurance,
or a certified copy thereof (Sec. 3800, Lab. C.) COON;Y OF LOS ANGELES ` BUILDING AND SAFETY
Policy No. Company
BUILDING
❑ ADDRESS
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN
❑ Certified copy is filed with the county building inspec- BUILDING C
tion department. ADDRESS
Date Applicant CITY ZIP LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' V NO.OF BLDGS. NEAREST
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS ST.
(This section need not be completed if the permit is for one AStSESSOR
hundred dollars($100)or•,less.) TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL
r ,
I certify that in the performance of the.work for which this !
OWNER ,�6{ NO.S(�jt�V �* USE ZONE O.
permit is issued, I shall not employ any person in any manner I " e y CONDITIONS
s SPECIAL
/as to become subject to the Workers'Compensation Laws. ADDRESS -e_
fi (ins i
Date Applica t C ' CITY � ZIP
NOT E TO A LIC9 T: If, offer making this Certificate of ARCHITECT R TEL DISTRICT GROUP TYPE FIRE "PROCESSED BY
ENGINEER N r CONSZONE
Exemption, you should become subject to the Workers' \/Compensation provisions of the Labor Code, you must forth- ADDRE with comply with such provisions or this permit shall be T9L. STATISTICAL CLASSIFICATION APT.
deemed revoked. CONTRACTOR
LICENSED CONTRACTORS DECLARATION - I VLIC, CLASS.NO. DWELL. UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 I ADDRESS NO. SEWER MAP
(commencing with Section 7000)of Division 3 of the Business and LIC.
Professions Code, and my license is-in full force and effect. CITY CLASS BK VALIDATION Q
SQ. FT. rNO.OF NO.OF CHECKLicense Number Lic.Class SIZE IES FAMILIES ONE
VALUATION d
Contractor Date DESCRIPTION OF WORK f r NEW $ 2�V 0, O
ADD ❑
❑I am exempt under Sec. ' ALTER' ❑
$ o.
B.BP.C. for this reason I REPAIR It
❑ N'
Date: 4 SE OF• r-- DEMOL ❑ I' y z
I EXISTING BLDG.
Signature APPLICANT TEL j FINAL
OWNER-BUILDER DECLARATION PRINT NO. ,DAT ? ^in, 14,55.50'
" L L•L•1
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and ADDRESS FIN / ; j`I_
LPrroltfessions Code): I PRE E B % ,
BUILDING' �,�;rt_ 1.4-5 - 50
I, as owner of the property, or my employees with I ADDRESS _
wages as their sole compensation,will do the work and• � 1% ,�ij
the structure is not intended or offered for sale(Section LOCALITY 't
7044, Business and Professions Code). MOVING TEL.
v'ifirik7= ,(I[,
❑ I,as owner of the property,am exclusively contracting I CONTRACTOR NO. ;
with licensed contractors to construct the project (Sec- I ADDRESS
tion 7044, Business and Professions Code). I I , i !_s�{'•—l (_f7 / �',:9
CONSTRUCTION LENDING AGENCY REQUIRED TOTAL SETBACK
SET BACK YARD HWY PROP.LINE F;
I hereby affirm that there is a construction lending agency for I FRONT i!:? j i?::v i,i
the performance of the work for which this permit is issued' P.L.
(Sec. 3097, Civ. C.). i SIDE
P.L.
Lender's Name
YlX/J LDMA Ref. 0
o P.C. Fee$ Permit Fee � L
Lender's Address
I certify that I have read this application and state that the, Issuance Fee lD• 150 i CDMA P/C a
above information is correct. I agree to comply with all County. Investigation Fee
ordinances and State laws relating to building construction, TotalFee I CDMA Perm.#! r
and hereby authorize representat'. s of this County to enter• "
span the above- enfioneed'p p �y r inspection purpose4' I'
tion• ,(. SEE REVERSE FOR EXPLANATO LANGUAGE '
Dae
Signature of Applicant or Agent