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.•.•••=•u•a= I APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES eUILDINc
DEPARTMENT OF COUNTY ENGINEER ADDRESS �{ .S
BUILDING AND SAFETY DMSION LOCAITY L
JOHN A. LAMBIE. COUNTY ENGINEER NEAREST
WILLIAM A. JENBEN SUPT FBUILDIND CROSSST.
DlljilGOT �.RQIIP TYPE P S B
FOR APPLICANT TO FLU IN CONST.
BUILDING iC' STATISTICAL CL7SSIFICATION SEWER MAP
ADDRESS Ol / PG
CE
Iy CLAS—DWELL.UNITS
LOT NO. ! �^♦♦ / / LOCK WATER NOT REQUIRED RECEIVED Ll
TRACT 6 J
CERTIFICATE, HIGHWAY
NO.OF BLDGS. _ _NO �('Q q (CIRCLE) STATE MAJOR SECOND. CAL
SIZE OF LOT O 2•O NOW ON LOT USE ZONE' SPECIAL [—�
USE OF CONDITIONS J
EXISTING BLDG. TEL. / .p
OWNER -.V r—' 9ev .NO. 'b�01 �O
)
SETBACK YARD HWY STREET NAME WIDTH
ADDRESS) 7� QM'J C Q/� /� FRONT A
ARCHITECT OR TEL. P.L. G.
ENGINEER NO. SIDE
P.L. >
ADDRESS INSPECTION RECORD O
CONTRACTOR ff, e_drY NreL.O.
r � � K
ADDRESS ZL- C C 6�aj R ' O
DESCREPTICTN OF WORK v
NEW I ADD ALTER REPAIR DEMOLISH Z
SO FT_ NoOF ZE I Z 7 STORIES I FAMINO. LIES
USE OF
STRUCTURE Ian^
jr
SIGNATURE OF
APPLICANT '
VALUATION S
APPROVALS #DATE INSPECT 'S UAE
P.C. '7 Q PMT. Q FOUNDATION:LOCATION / as
FEE G D FE! FORMS. MATERIALS
FRAME: FIRE STOPS.
I HERESY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION BRA ING BOLTS 1214,63
AND STATE THAT THE ABOVE IS coRR[ci AND AOnc[To COMPLY FURNACE: LOCATION.
WITH ALL COUNTY ORDINANCES ANO STATE LAWS REGULATING GAS VENT DUCTS
BUILDINo CONSTRUCTION. I CERTIFY THAT IN ODING THE WORK
AUTHORIZED HEREBY I WILL NOT EMPLOY ANY PERSON IN VIOLA- LATH. INT. Ile
TION OF THE LABOR CODE OF THE STATE OF C IFORNIA RELAT.
ING TO WORKMEN'S COMPENSATION INS AN LATH.EXT.
SIGNATURE OF HOUSE NUMBER COR-
PERMITTE RECT AND POSTED
ADDREss 6 — t e/ FINAL CLYDE N. DIRLAM. PRINCIPAL ST RAL ENGINEER
PLAN CHECK VALIDATION M.O. wN PERMIT VALIDATION CK M.O. CASH
23�' OOT 9 23 D 28.50A v
,� uk;D1 5 0 ?" GGT16 1D 57.00 ;
WORKERS COMPENSATION-DECLARATION II
hereby affirm that I have a certificate of consent to self APPLICATION FO BUI DIN PERMIT LLLLLL
insure or a cenifico,e of Worker Compenstion Insurance or
a certified copy thereof (Sec 3800, Lab C )
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No Company
BUILDNG
Certified copy is hereby furnished PDD
OR APPLICANT TO FILL IN ADDRESS r
Certified copy is filed with the county building mspec G tion department SS LOCALITY i'Y1
NEAREST
Dote Applicant ZIP CROSS ST Ae
CERTIFICATE OF EXEMPTION FROM WORKERS / / NO OF BLAS ASSESSOR
COMPENSATION INSURANCE LOT X NOW ON LOT MAP BOOK PAGE PARCEL
(This section need not be completed if the permit is for one USE ZONE •1�'
hundred dollars ($100)or less ) BLOCK LOT tJ0 /J NO cal IL
TEL F / SPECIAL 6
I certify that in the performance of the work for which ,his NO CONDITIONS O
permit is issued I shall not employ any person in any manner DISTRICT GROUP PE FIRE SSED BY V
so as,o ome subleq to the Workers Compeltsation Laws S 5�8 CONST ZONE a
��/J/,�T / � /' CJ rO
Date C'ti� Sficont �`_�� '� "✓� (.� ZIP STATISTICAL CLASSIFICATION APT CONDO V
NOTICE TO APPLICANT If after making this Certificate of ARCHITECT EER O!,0i1roAi ILA3Soe, IEjLL 7 y-(�y- 6Exemption you should become subject to the Workers CLASS NODWELL UNITS_Compensation provisions of the Labor Code you must forth SS C SEWER MAP
with comply with such provisions or this permit shall be TELdeemed revoked ACTOR NO BK d PG Z VALIDATION
LICENSED CONTRACTORS DECLARATION UC
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO VALUATION
(commencing with Section 7000)of Division 3 of the Business and LIC �s
Professions Code and my license is in full force and effect CITY CLASS $ �� DE/• d
50 FT / tJ0 OF NO OF CHECK
License Number Lic Class SIZE OF
FAMILIES ONE -
/ v S
Contractor Date DESCRIPTION OF WORK 8 NEW
1 am exempt from the licensing requirements as I am a ADD ❑
licensed architect or a registered professional engineer ALTER ❑❑ DATE L 24.3 a
acting in my professional capacity (Section 7051 REPAIR
Business and Professions Code) USE OF
EXISTING BLDG DEMOL FINAL
LIC_or Reg No Dote APPLICANTTEL e1 # is - 2 3
OWNER BUILDER DECLARATION PRINT NO 2 • - 2R80
I hereby affirm that I am exempt from the Contractor s License
Law for the following reason (Section 7031 5 Business and ADDRESS . . . 2 8 8 0
professions Code) PRESENT
1, as owner of the property or my employees with BUILDING
�,� 07-8
wages as their sole compensation will do the work and ADDRESS
the structure is not intended or offered for sale(Section LOCALITY
7044 Business and Professions Code) MOVING TEL
1 as owner of the property am exclusively contracting CONTRACTOR NO A 0 2 4,4 A
with licensed contractors to construct the project (Sec ADDRESS
tion 7044 Business and Professions Code) fJ
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP LINE WIDTH
REQUIRED TOTAL SETBACK FROM EXIST
hereby affirm that there is a construction lending agency for FROM 2 • • 4 3 0 0
the performance of the work for which this permit is issued PL
(Sec 3097 civ C ) SIDE • • • 4 3 0 0 r'
PL
Lender s Name 0 7 0.7—8 1
_$ Lender's Address • PC Fee S- oL^^ ffo Permit Fee
1 certify that I have read this application and state that the Isuuonce Fee
above information is correct I agree to comply with all County Investigation Fee
ordmances and Slate jaws relating to budding construction Toiol Fee -11Air a
and hereby au,hor¢e representatives of this County to enter
up the above mentioned PrqV1srtx for inspection purposes
�OGlCa, ui�,L SEE REVERSE FOR EXPLANATORY LANGUAGE
Signowre of Appl,coni or Agent Date ms