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HomeMy Public PortalAbout9216 OLIVE ST_Building__ ;':mi---' -T 'OF .BUIL:} _. APPLICATION FOR PERMIT. ' :;WNTY. OF LO'' . . WM. J. FOX `' FOR APPLICANT T TO FILL• IN FOR OFFIC£ USE .ONLY.. DISTRICT NO. PLAN CK. NO. PERMIT NO. P ODRES304- �! Jf l�4 LOCALIRECEIVED BY DATE OF APPL.. DATE ISSUED NCEARE R08 SS 2-- INS ADDREBBOWNER ? • MAIL LOCALITY t-1-'!•+�'•-a�•'s• •a - ADDREBB + •6 •' �, 1. . . ! NEAREST �'`• �:" < j ,.. TEL. .I - // �.., t. 3�•. �+ e CITY �. C; 1 .+.J.Jrs? ! NO. f:.'. 1'i3 4�1 n CROSS ST. p -t �G9r t•c. a e�vf' ti t FIRE I NO.OF. TYPE .� GROUP" T'` ARCHITECT flR TEL. ZONE . PLANS .;ENGINEER' I/ .NO. + t1�•--_' BLDG.. ORD. NO... ' ADDRESS SETBACK LINE TEL. APPROVED CONTRACTOR '`"'�-� NO. BY DATE ^\. 'USE '/+ /' APPROVED ADDRESS BY (.. DATE ` LEGALCORRECTIONS ' DESCRIPTION I LOT NO . I 'BLOCK f� " TRACT ,r NO OF SLDG9. 6 SIZE OF:LOT a X. / O I NOW ON LOT USE OF cel EXISTING BLDG.t+�^r';rJ.:.�.' FAMILIES.!!! ROOMS../ 4 DESCRIPTION-OF WORK NEW ti ALTERATION ADDITION. J � REPAIR. MOVING DEMOLISH ® ' 8W. FT.' +, ��+o� NO.OF r;• } 51ZE i+•t +7) ROOMS STORIES / • WALL ��( -�- •� ROOF ^ + :COVERING �d �� CJ I COVERING UBE OF'NEW t �' • BUILDING l�.lr��. •.. n. .Ji'.s.•- �` - APPROVALS I HEREBY ACKNOWLEDGE THAT I HAVE READ' THIS INSPECTOR DATE APPLICATION AND;STATE THAT THE ABOVE 15 CORRECT FOUNDATION: LOCAT..IONr ' AND AGREE TO COMPLY WITH-ALL COUNTY ORDINANCES FORMS. MATERIALS '`'fylpF�, AND STATE LAW9.REGULATING.9UILDINB CONSTRUCTION. FRAME: 'FIRE STOPS, SIGNATURE OF ! BRACING. BOLTS OWNER '�,'. � , � ,. ;J.. t "LATH INT.: Vf�;. r r •' j i ✓ AUTHORIZED AGT'. LATH, EXT.: ' j I S P. O: PLASTER, INT. ' FEE PLASTER, EXT., VALUATION. a:.P rC>"Gl FINAL •'" '2 7 FEE '" WORKERS'COMPENSATION DECLARATION I hereb affirm tAot I have a certificate of consent to self APPLICATION" � insure, or a certificate of Workers'Compensation Insurance, ■iO R BUILDING PEIT or a certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN " BUILDING '`ADDRESS ❑ Certified copy is filed with the county building inspec- BUILDING �/ 9�� tion department. ADDRESS ,y 6- n a .4 ' Date Applicant CITY ZIP �! C/ LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' 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 TRACT BLOCK LOT NO. ASSESSOR hundred dollars($100)or less.) j MAP BOOK PAGE PARCEL TEL. USE ZONE MAP I certify that in the performance of the work for which this OWNS /✓ N1417 O. 3 NO. permit is issued, I shall not employ any person in any manner ADDRESS SPECIAL so as to become subject to the Worker'Compenso i Laws. �t CONDITIONS Date !_ Applica CITY ZIP �7ry V NOTICE TO APPLICANT: If, aft making this Certificate of ' ARCHITECT TEL. �, DISTRICT G UP TYPE FIRE PROCESSED BY O Exemption, you should become subject to the Workers' ENGINEER NO. : CpNST, ZOgIE / U Compensation provisions of the Labor Code, you must forth- ADDRESS r . /� V W with comply with such provisions or this permit shall be ) t / STATISTICAL CLASSIFICATION APT. CONDO. N deemed revoked. CONTRACTOR A/ NO. Z LICENSED CONTRACTORS DECLARATION V 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 LIC. Professions Code, and my license is in full force and effect. CITY CLASS BK P VALIDATION SQ.FT. NO.,OF NO.OF CHECK License Number Lic.Class SIZE STORIES FAMILIES ONE VALL IAWIO Contractor Date DESCRIPTION OF WORK NEW ❑ $ -76 `,� I am exempt under Sec. fti1g, ADD ❑ ALTER `. B.BP.C. for this reason ✓ REPAIR ❑ $ Date: USE OF DEMOL ❑ 9 3 b 9 A EXISTING BLDG. Signature APPLICANT TEL. FINAL # 0 0 0 0-0,1 OWNER-BUILDER DECLARATION PRINT NO. DATE I hereby affirm that I am exempt from the Contractor's License ,1 o o 2 a 5 O Law for the following reason (Section 7031.5, Business andADDRESS FINAL Professions Code): R o 00 j By 2 a 5 Q I, as owner of the property, or my employees with ADDRESS 0 4, 12-88 f; wages as their sole compensation,will do the work and Vv- the structure is not intended or offered for sale(Section LOCALITY 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 F tion 7044, Business and Professions Code). REQUIRED TOTAL SETBACKOft M15 CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE 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. MRS=E12 Lender's Name LDMA Ref. # m P.C.Fee$ Permit Fee Lender's Address I certify that I have read this application and state that the Issuance Fee (J LDMA P/C# 9 above information is correct. I agree to comply with all County Investigation Fee aordinances and State laws relating to building construction, Total Fee LDMA perm.'# $ and hereby authorize representatives of this County to enter :.,.... . :%•.. m upon)he above-menti ed property for inspection purposes. n -p 12 67 SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date WORKERS'COMPENSATION DECLARATIONel �� I re affirm that I have certificate of consent to self ® P 1%N F BUILDING P E RM I T insure, or a certificate of Workers'Compensation Insurance, Lf� or a certified copy thereof (Sec. 3800, Lab. C.) COUN'% OF 10S ANGWS BUILDING AND SAFETY Policy No. Company ❑ Certified co is hereb furnished. FOR APPLICANT TO FILL IN BUILDING n / PY Y ADDRESS �A�(� ❑ Certified copy is filed with the county building inspec- BUILDIN tion department. ADDRESS 1f! l/ - t Date Applicant CITY ZIP LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. '.NEAREST COMPENSATION INSURANCE \ SIZE OF LOT NOW ON LOT CROSS ST. ASSESSOR , (This section need not be completed if the permit is for one TRACT BOCK LOT NO. '"MAP BOOK ���Q PAGE A991 PARCEL 040L hundred dollars ($100)or less.) 0. TEL. OWNER i NO,-2&/,2,yUSE ZONE IMAP I certify that in the performance of the work for which this NO. permit is issued, I shall not employ any person in any manner ADDRESS s ��/ SPECIALCL CONDITIONS so as to become subject to the Workers'Compensation Laws. r O U CITY /C. C 1 zIP Date Applicant ARCHITECT OR y TEL. W /+� DISTRICT GROUP TYPE FIRE PROCESSED BY O NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER / �7�NO� CONST. ZONE l- Exemption, you should become subject to the Workers' B tJ Compensation provisions of the Labor Code, you must forth- ADDR a v `3 j� ' W with comply with such provisions or this permit shall be. p� TEL ;STATISTICALCLASSIFIC8TION PT. CONDO. Z deemed revoked. CONTRACTOR �V 3 _ LIC. CLASS NO. DWE li::2ITS LICENSED CONTRACTORS DECLARATION 'ADDRESS NO. 'd I hereby affirm that I am licensed under provisions of Chapter 9 SEWER MAP (commencing with Section 7000)of Division 3 of the Business LIC. „� and Professions Code,and my license is in full force and effect. CITY NO.OF CLASS BK PG VALIDATION SQ. License Number Lic. Class SIZE STORIES NO.OF CHECK FAMILIES ONE VALUATION Contractor Date DESCRIPTION OF WORK NEW ❑ EJ1 am exempt under Sec. C�.� g �f ADD/ El AL1;ER ❑ ., B.BP.C. for this reason $ USE OF REPAIR ❑ '• Date: EXISTING BLDG. DEMOL Signature APPLICANT TEL. FINAL OWNER-BUILDER DECLARATION (PRINT) NO, ,. DATE -31` I hereby affirm that I am exempt from the Contractor's License f. Law for the following reason (Section 7031.5, Business and ADDRESS FINAL Professions Code): y .PRESENT By a BUILDING ACCT.Or ❑ I, as owner of the property, or my employees with tir ADDRESS -, wages as their sole compensation,will do the work and ,511►.7 170.45 the structure is not intended or offered for sale Section LOCALITY _ c 7044, Business and Professions Code.) ( MOVING TEL. 1 1�E S I,as owner of the property,am exclusively contracting .. CONTRACTOR NO. TOTAL 170 �.�cF with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code.) CHECK 170.25 REQUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH CHANGE .01, 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. 0000-0001 11/1,5/9'2 Lender's Name. �-�O LDMA Ref.# r4�Q AM 8:51 P.C. Fee$ Permit Fee Lender's Address F-1-1 1 certify that I have read this application and state that the Issuance Fee 7� LDMA P/C# above information is correct. I agree to comply with all County Investigation Fee / O f I ordinances n tate laws lating to building construction, Total Fee •7 LDMA Perm. # i an hereb a orize repr ntatives of this Coun y to enter MEL I uft the m do proplerA for inspectio p vSEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent JF Date APPLICATION FOR BUILDING PERMIT *° COUNTY CO LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDDI ADDRESS Gy�J I hereby affirm that I have a certificate of consent to self insure, BUIL q�gt�RESDVE T . �� or a certificate of Workers'Compensation Insurance,or a certified O(��p [ . copy thereof(Sec.3800,Lab.C.) ZIP EM �' LOCALITY Policy NO. Company SIZE OF LOT '17jNO OF BLDGS.NOW ON LOT ❑ Certified copy is hereby furnished. NEAREST CROSS ST. ❑ Certified copy is filed with the county building inspection TRA TBLOCK LOT NO. department. USE ZONE MAP NO. Date Applicant ASS F7�6A B OK PAG Ply EL S ` SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' WY NER COMPENSATION INSURANCE ', T �No WITHIN 1000 FT.OF SCHOOL? YES NO (This section need not be completed if the permit is for one hundred R S DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED Y dollars($100)or less.) V ,� ZI [r I certify that in the performance of the work for which this permit �] CrIV TLM is issued, I shall not employ any person in any manner so as to ��0 —� become subject to the Workers'Compensation Laws. A E OR NEER TEL NO. STATISTICAL CL SIFICATION APT CONDO Date Applicant 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' JF�CpTQ�/f? TEL NO. SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith (/�f����/.��ff/ 1 FRONT comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC.NO. PL } LICENSED CONTRACTORS DECLARATION SIDE C CITY LIC.CLASS 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 80.FT SIZE NO.OF STORIES NO.OF FAMILIES Professions Code,and my license is in full force and effect. n NEW BK PG FC- License Number Lic.Class D TKN OF WOR r- ADD [3VALUATION ® U Contractor Date IM ALTER ❑ $ �®O tl I CA ❑ I am exempt under Sec. REPAIR ❑ $ z B.BP.C.for this reason DEMOL ❑ LDMA P/C# Date: USE OF EXISTING BLDG. URM ❑ Signature LI NT / LDMA Perm# ,V I, as owner of the property, or my employees with wages as G �J their sole compensation, will do the work and the structure is AD S >` 0ACCT.it not intended or offered for sale (Section 7044, Business and S� ` FINAL DATE Q -+� Professions Code.) �'�03 1 WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL ❑ I, as owner of the OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE property, am exclusively contracting With AMOUNTS SPED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY �j 1 ITEMS licensed contractors to construct the project (Section 7044, .-- Business and Professions Code.) 'Es❑ N T0TAL i•s-o �!� HALL THE INTENDED USE OF THE BUIDUNG BY THE APPLICANT OR FUTURE BUILDING CHECK OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH H .•((+•5C C CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FOR [ �i a-J•.1 GUIDELINES. CHANGE C I hereby affirm that there is a construction lending agency for VES 11 NO the performance of the work for which this permit is issued(Sec. IHAVE READ THE ZARDOUSMATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING 3097,CIV.C.) ECK I U RSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE. ����`� � TLE P 2.20 SE ONS 220 100 THROUGH 220 140 CONCERNING HAZARDOUS 4l;.+� aaaQ333� Lender's Name R RTING AN FOR OBTAINING A PERMIT FROM THE SCAOMD 4 Lender's Address /3♦ I r�jI 2 OWNER OR AGENT �`I'V •I. (�'f' 5:22 3 1 certify that I have read this application and state under penalty p of perjury that the above information is Correct.I agree to comply P.C.FEE PERMIT FEE W with all co ty alginances And State laws relating to building W c ructio , reby rize representatives 0 this ounty ISSUANCE FEE ge t r t o o - ned property for ins Wp ,"es, ff�d INVESTIGATION FEE TOTAL FEE4 Iwe al l w Apmo SEE REVERSE FOR EXPLANATORY LANGUAGE WORKERS' COMPENSATION DECLARATION hereby affirm'that I have a certificate of consent to self APPLICATION FOR U I L®I-IV PERMIT insylre, or a certificate of Workers' Compensation Insurance, or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company 1:1 Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS ❑ Certified copy is filed with the county building inspec- BUILDING ,Z F/� tion department. ADDRESS i(f� �- (� CITY 1PL-b+ OA ZIP r LOCALITY / Date ApplicantNO. F BLDGS. NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT ��d NOW ON LOT CROSS ST. COMPENSATION INSURANCE ASSESSOR 11-4-C12— (This section need not be completed if the permit is for one TRACT BLOCK LOT NO. MAP BOOK PAGE VO / PARCEL40O hundred dollars ($100)or less.) Li` ,� �q� TEL. _ g�� eget d NO. USE ZONE MAP y 7 I certify that in the performance of the work for which this �y //++ a�nne i' ^ SPE permit is issued, I shall not employ an person in an manner ADDRESSq 14p v�+d�/ ��t� r SPECIAL p P Y Y P Y CONDITIONS so as to become subject to the Workers'Compensation Laws. OV CITY —�� 0_ ZIP Date Applicant ARCHITECT TEL. ��{{d DISTRICT GROUP TYPE FIRE PROCESSED BY 0 NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER ``� � NO.� —4 CONST. Z NE Exemption, you should become subject to the Workers' ADDRE 0 ^. �� " Od -9 17) Compensation provisions of the Labor Code, you must forth- v7 with comply with such provisions or this permit shall be CONTRALTO p��`� TEL STATISTICAL CLASSIFICATION APT. CONDO. deemed revoked. P P rc`W e^ �f Z LIC. CLASS NO. / DWELL. UNITS LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 NO..,ADDRESS SEWER MAP (commencing with Section 7000)of Division 3 of the Business LIC. and Professions Code,and my license is in full force and effect. CITY CLASS BK. <PG. rA VALIDATION SQ. NO.OF �f NO. OF CHECK License Number Lic. Class SIZE r�(!f� STORIES FAMILIES' ONE VA ATION Contractor Date DESCRIPTION OF WORK r0%A I NEW I am exempt under Sec. ❑ 6 �� /f 6`� r J s✓ON^� n Q� S 4 0"` ADD ❑ _ I �' ALTER ` O DO B.BP.C, for this reason RID EPAIR ❑ $ Date: U O ^ -- EXISTING BLDG.PQ I V DEMOL ❑ Signature APP(PRINT) o �NANT �. I" FINAL OWNER-BUILDER DECLARATION DATE - i - • _,�a, _ I hereby affirm that I am exempt from the Contractor's License ADDRESS' FINAL Law for the following reason (Section 7031.5, Business and Professions Code): PRESENT BY ❑ d9 OU I, as owner of the property, or my employees with BUILDING ADDRESS _ wages as their sole compensation,will do the work and a__ the structure is not intended or offered for sale(Section LOCALITY r -. --'•r - - 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 TOTAPROPALINE FROM 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 O• _ e. zl rye P.L. f". Cr1 Lender's Name 9 "-I I !t80— Ref° ° P.C. Fee$ �✓` "/0 Permit Fee Lender's Address I certify that I have read this application and state that the / Issuance Ff 7.� MA P/C# Poo above information is correct. I agree to comply with all County Investigation Fee ord' antes and State laws relating to building construction, Total Fee '© t*"9 LD MA Perm. # hereby uth r' a repre ntatives of this Count to nter n th o v ntione roperty for inspectionr s. h-+ rra ,�t r +r9 SEE REVERSE FOR EXPLANATORY UNOUAGE e ;.A _0 ignatu of Applicant or Agent Dofe 11 C=, h•+' T'+ iJT {JY APPLICATION R BUILDING PERMIT � 1 � COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATIOIN FOR APPLICANT TO FILL IN BUILDING ADDRESS I hereby affirm that I have a certificate of consent to self Insure, BUILDING ADDRESS" C_ or a certificate of Workers'Compensation Insurance,or a certified �, G _f LIVE J copy thereof(Sec.31100,Lab.C.) CI ZIP Policy No. Company 'l7 � LOCALITY SIZE OF LO NO.OF BL GS.NOW ON LOT !lam ❑ NEAREST CROSS ST Certified copy is hereby furnished. p sa ❑ Certified copy is filed with the county building Inspection TRACT BLOCK LOT No. department. / `2 USE ZONE MAP NO. ASSESS R AP BOOK PAGE PARCEL Date Applicant 00/ O� SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER t TEL NO. YES NO COMPENSATION INSURANCE ! n ''�� WITHIN 1000 FT.OF SCHOOL? DDRESS (This section need not be completed if the permit Is for one hundred sv DISTRICT GROUP TYPE CONST' FIRE ZONE CESSED dollars($hat or less.) ZIP / �� 516�1 RJ y 3 )� I certify that in the performance of the work for which this permit / G� I/ Is issued, I shall not employ any person in any manner so as to ARCHITE ORE GINEER TEL NO. become subject to the Workers'Compensation Laws. STATISTICAL CLASSIFICATION APT CONDO Date Applicant 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' CONTRACTOR TEL NO. SETBACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code,you must forthwith Ft8 —Z�S .S� FRONT comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC.No. PL LICENSED CONTRACTORS DECLARATION CITY LIC.CLASS SIDE r PL O I hereby affirm that I am licensed under provisions of Chapter 9 '� �� SEWER MAP v v .Fr..SIZE NO.OF STORES NO.OF FAMILIES I= (commencing with Section 7000)of Division 3 of the Business and Professions Code,and m is in an / NEW ❑ BK PG DESCRIPTION OF WORK ❑ License Number Lic.Class ADD VALUATION rW Contractor Date , ALTER ❑ REPAIR ❑ ❑ I am exempt under Sec. BARC.for this reason DEMOL ❑ LDMA P/C# Date: USE OF EXISTING BLDG. URM IJS' Signature APPLICANT(PFIWD TEL NO. LOMA Perm# 1 ❑ I, as owner of the property, or my employees with wages as &A p their sole compensation,will do the work and the structure Is ADDRESS F ACCT.s not intended or offered for sale (Section 7044, Business and V/ CSL s 8 FINAL DATE a Professions Code. p p ,`LI r' 14113.2'!1 WILLTHEAPPLICANT OR FUTURE BUILDING OCCUPANT HANDLEA HAZARDOUS MATERIAL ❑ OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN I, as owner of the property, am exclusively contracting withJ)d C� THE AMOUNTS•S•�PEQ.�IFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY 1 ITEMS E S licensed contractors to construct the project (Section 7044, YES 11NO Lam, Business and Professions Code.) DVE TOT-AL 14.0 a 2� WILL THE INTEN D USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING OCCUPANT REQUIREA PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTHj �/ 140.4d.�y n"CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST CHECK 140 o ii FOR GUIDELINES. I hereby affirm that there is a construction lending agency for YES❑ NQ �yh�fE ,;fit! the performance Of the work for which this permit is issued(Sec. I HAVE READ HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD 3097,CIV.C.). PERMITTING C KLISL I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE,TITLEZ CHAPTER 2.20 SECTIONS 2.20.100THROUGH 2.20.140 CONCERNING Lender's Name HAZARDOUS MATERIALS REPORTING AND FOR OBTAINING APERMIT FROM THE SCAQMD. CIOOO-000 1 5/10/911 Lender's Address f' CL o 059 1 Aft 11'1 r 0 1 certify that I have read this application and state that the above P.C.FEE PERMIT FEE '2 information is correct. I agree to comply with all county 7 ordinances and State laws relating to building construction,and hereby authorize representatives of this County to enter upon ISSUANCE FEE t the above-mentioned property for inspection purposes. f + O E INVESTIGATION FEE TOTAL FEE I fignseooMMP2WM1aAYad Dem SEE REVERSE FOR EXPLANATORY LANGUAGE WORiCERSa COMPENSATION DECLARATION U5 4z� TSL /��•' /- /--v /--/ ` ' insure, or a certificate of Workers'tCompensat on ifico?e of eInsurance, APPLICATImim FOR 'BU'L O N PERMIT 'or a certifie copy thereof(Sec. 3800, Lab. C.) & / Al �o .e -yam,/^ COUNTY OF LOS ANGELES BUILDING AND SAFETY PolicyNo.3V'4 Company_ Cfi�u/t«i �.EtEvV `� / Certified copy is hereby furnished. LAMFOR APPLICANT TO FILL IN BUDDING Certified copy is filed with the county building inspec- BUILDING J tion department. ADDRESS /p Date ti L C P�7Applicant CITY %e w /e 0,Ae ZIP LOCALITY CERTIFICATE OF EXEMPTION Fk6m WOR(C RS' NO.OF BLDGS. NEAREST COMPENSATION INSURANCE SIZE OF LOT 049 Jy I f2el NOW ON LOT / CROSS ST. J-, �.. (This section need not be completed if the permit is for one TRACT// 2- BLOCK LOT NO. "ASSESSOR hundred dollars($100)or less.) MAP BOOK PAGE PARCEL ?SperTEL. d(l3/ USE ZONE I certify that in the performance of the work for which this OWNER • O. . NOP C - Z 6-6- permit mit is issued, I shall not employ any person in any manner / r SPECIAL so as to become subject to the Workers'Compensation Laws. ADDRESS 19.2 e, eP -Aone �1_�� CONDITIONS U Date Applicant CIN %L� h/ ZIP NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR T L• + DISTRICT GROUP TYPE FIRE R ESSED BY O ENGINEER NO• CONST. ZONE 17- Exemption, you should become subject to the Workers' "? () Compensation provisions of the Labor Code, you must forth- ADDRESS I J'- 2 1 with comply with such provisions or this permit shall be TEL. �f�� STATISTICAL CLA551FI ATION APT. CONDO. fA deemed revoked. ; CONTRACTOR O„ , 7 Z Z LICENSED CONTRACTORS DECLARATION �llc, CLA55 NO. l DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS , X- /lr. sQNO..2 G 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 Sc;n I 'de, C CLASS AV-/ s. B VP PG ,Z rVALIDATION " 42 SIZE 4Jr STORIOES / 'FAMILLIIES CHECK ONE License Number•• �-�•��7tre Lic.Class VALUATION NEW Contractor=.,&. 7/aCxl Date /} �% DESCRIPTION OF WORK A D ❑ $ /> Lgv I am exempt under Sec. O` ALTER , B.BP.C. for this reason REPAIR $ f. ❑ USE OF Date: EXISTING BLDG. W ��c' DEMOL ❑ . (- ?Signature oe�-✓ ,9!c d5621f APPLICANT TEL.,0Sr".8 Y%/_/ FINAL2 OWNER-BUILDER DECLARATION PRINT) r��G; aufir- NO. 3' 3 Yi DATA I herebyaffirm that I am exempt from the Contractor's License Law fothe following reason (Section 7031.5, Business and .ADDRESS-1.^' Al S'o/i ✓%s iY� /�d� S4r�L:6/7�/ FI9Y Professions Code): PRE ENT El BUILDING I, as owner of the property, or my employees with . ADDRESS wages as their sole compensation,will do the work and t the structure is not intended or offered for sale(Section y--.LOCALITY 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 )` 8 6 7 G A tion 7044, Business and Professions Cade). CONSTRUCTION LENDING AGENCY SETT BACK YARD HWY TOTALSETBACKWIDTH #f 0 0 0 0 0.1 I hereby affirm that there is a construction lending agency for FRONT o 0 59.25 the performance of the work for which this permit is issued P.L. (Sec. 3097, Civ. C.). SIDE o 0 0 (�r.5 v P.L. Lender's Name 12 2-9 8 7 LDMA Ref. q c P.C.Fee$ Permit Fee 7-5 Lender's Address / r I certify that I have read this application and state that the Issuance Fee / G' -� LDMA P/C# above information is correct. I agree to comply with all County Investigation Fee q ordinances and State laws relating to building construction, / y_J F N and hereby authorize representatives of this County to enter Total Fee LDMA Perm.q upon the above-mentioned property for Inspection purposes. Sr SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date