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HomeMy Public PortalAbout9121 PRIMROSE AVE_Building__ r, F U ' L ® ' N G BUILDING ADORES APPLICATION LOCALITYa.c._ 2 NEAREST DIVISION OF BUILDING AND SAFETY CROSS ST. I/ IDepartmeIIt of County Engineer DISTRICT NO. RECEIPT NO. PERMIT NO. County of Los Angeles S_ J� WM. J. FOX, COUNTY ENGINEER G QUP DATE RECEIVED DATE ISSUED CASSATT D. GRIFFIN, SUPI•r OF BUILDING FOR APPLICANT TO FILL IN TYPE CONST. RECEIVED BY ISSUED BY 66/Y� OWNER MAIL �y/�p / NUMBER b 7 STATE ADDRESS YES NO ` USE ZONE SPECIAL �� / y C:LL[n�(STEL.ffr/ CONDITIONS (� /' CITY YY/ ale �; i NO. ARCHITECT OR ✓ TEL. ENGINEER NO. BUILDING YARD HWY STREET NAME EXIST. ADDRESS SETBACK _ WIDTH / FRONT .0 �I �/ �i �� Mo e) CONTRACTOR NOLO SIDE �x~� ADDRESS BUILDING /n� DATE CORRECTIONS INSPECTOR ADDRESS �d Q/J? O LOT NO. BLOCK A I TRACT APe,.i� C:� Lf'A!)f"_ / NO.OF BLDGS. SIZE OF LOT (J NOW ON LOT USE OF ; EXISTING BLDG. L DESCRIPTION OF WORIC a NEW �jADD© ALTER REPAIR DEMOLISH Z 88'1Z-E' +<J" 3Q aTOR1ES / FAMILIES r USE OF ST UCT NO.OF EMPLOYEES 1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS A16- PLICATION AND STATE THAT THE INFORMATION GIVEN IS APPROVALS INSPECTORS SIGNATURE DATE CORRECT. IAGREE TO COMPLY WITH ALL COUNTY ORDINANCES FOUNDATION: LOCATION f� , ' AND STATE LAWS RE LATINO BUILDING CONST UCTION. FORMS,MATERIAL «S �L Ll ra.c.a,v �Ca � S� FRAME: FIRE STOPSi'_ 'y r -- SIGNATURE OF BRACING,BOLTS _."'4 ^ ✓:� PERMITTE FURNACE: LOOATIJ3W_ GAB VENT,DUCTS - "�!f-<<"� ��/ ADDRESS LATH, INT. / IgoB✓lf AUTHORIZED AOT. /j ' �l , LATH, EXT. �� • / ✓ $ Q Z7 P.C.III HOUSE NUMBER CdR- C FEE RET AND POSTED VALUATION FEE FINAL E' Ib .rt I��Q 7GA63BA 080 3 12-53 -w 013,A I;.aa Asm BATs APPLICATION FOR PERMIT DEPARTMENT OF BUILDING AND SAFETY COUNTY OF LOS ANGELES I WM. J. FOX, CHIEF ENGINEER NO.OF/_ BLDG. ORD.NO. DISTRICT NO. PLAN CK. NO. PERMIT NO. PLANS SETBACK LINE & FIRE APPROVED V `� ZONE �"' BY DATE RECEI � BY DATE OF APPL. 90,119S. USE a APPROVED , �� ��.,,�� ZONE i BY DATE APPLICANT FILL IN HEAVILY OUTLINED PORTION ONLY lK BU p NAME ADDRE88 F W ZW ADDRESS LOCALITY +S • 1- 5 NEAREST UX W CITY CROSS ST. STATE LICENSE NO. .,�i!/ -NOI E NAME z MAIL O NAME �/ ADDRESS ® v p w V O TEL. a ADDRESS CITY NO. d' Z I HEREBY ACKNOWLEDGE THAT 1 -HAVE READ THIS V CITY APPLICATION AND STATE THAT THE ABOVE IS CORRECT STATE TEL. AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES LICENSE NO. NO. AND-STATE LAWS REGULATING BUILDING CONSTRUCTION. ZO LQT NO. SIZE OF LOT,/12 dfp ear SIGNATURE OF OWNER t NO. OF BLDGS. AUTHORIZED AGT ,. x=2e BLOCK NOW ON LOT j U Q TRACT p^ CORRECTIONS USE OF BLDGS. t NOW ON LOT AY►::L44 DESCRIPTION OF WOUB19 USE OF BUILDING n yy J Z a NEW TYPE I GROUP [- ALTERATION ROOMS 3 FAMILIES t ADDITION SIZEi '\.1 REPAIR I STORIES MOVING WALL COVERING DEMOLISH ROOF COVERING ' P.C.�• FINAL APPROVAL F.C ` y FVALUAON goo FEE ��� DA�_/� I INAMECTOR'S��✓ ,1 DIVISION OF BUILDING AND SAFETY ® � NG Department of County Engineer County of Los Angeles WM. J. FOX, COUNTY ENGINEER APPLICATION FOR APPLICANT TO FILL IN FOR OFFICE USE ONLY DISTRICT NO. PLAN CK.DR REC.NO. PEggMIT_NO. ADDRESS 9121 East Rancho Real Road IT off 6a LOCALITY Temple Ci ity 9 California �ECEIYE�D BY Y DATE OF APPL D��UED NfiAREBT CR08HST. LOyIiQ OY' Rosemead BUILDING OWNER Adolph Rich ADDRESSMAIL LOCALITY ADDRESS 9121 East Rancho Real Road'' NEAREST EL CROSS ST. cITY Tem le Cit C al p TEL* E None FIRE No.or I TYPE I GROUP 3 ZONE "' PLANB _' ARCHITECT ORy� TEL ENGINEER None NO. BLDG. �� D ORD. NO. SETBACK LINE ADDREBB USE A APPROVED CONTRACTOR None ZONE BY dDATE� eb- SSTQYIe NO � HOUSE NUMBERING ADDRESS MAP NUMBER NO. ASSIGNED BLEGAL Y DE CRIPTION ,® LOT NO. 14 BLOCK I Be �/��o�f el—'s^,pry— CORRECTIONS r�`r TRACT 1121y 6 SIZE OF LOT62 S 185 i NOW ON LOT B.One USE OFNCL EXISTING BLDG. R ome FAMIL�IEe 1 DESCRIPTION OF WORK M NEW ALTERATION ADDITION "`' "= Z - a REPAIR gC DEMOLITION r SIZE .360 ROOMS One STORIES COVERING Redwood I COVERINS h3na es UedaOFHaTRgo URE r tU INBPECTION FOR ; APPROVALS OCCUPANCY AS INSPECT R'S SIGNATURE DATE FOUNDATION: LOCATION 4 �d.t/L•' 1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS AP- FORMS, MATERIALS !O PLICATION AND STATE THAT THE INFORMATION GIVEN IS' FRAME: FIRE BTOPS, CORRECT. BRACING,BOLTS N I AGREE TO COMPLY WITH ALL COUNTY ORDINANCES FURNACE: LOCATION, AND SLTATE LAWS REO TTNB BUILDING CON&TRUCTI N. GAN VENT,DUCTS SIGNATURE OF LATH, INT. � PERMITTER / �! (/ LO a LATH, EXT. ADORES PLASTERr INT. AUTHORIZED AST. PLASTER, EXT. HOUSE NUMBER COR- / / FEE / O RECT AND POSTED VALUATION l/ FEE f� p� FINAL 76AS313A DBS 3 1-58 - VZPARTMENT OF BUILDING AND SAFETY AYl'L1Li811V1v rUXL YZ.l ML A COUNTY OF LOS ANGELES � ' WM. J. FOX. CHIEF ENGINEER Imm FOR APPLICANT TO FILL IN FOR OFFICE USE ONLY BUILDINGs p DISTRICT NO. PLAN CK.NO. PERMIT NO. ADDRESS JY ,y , Q� 19 Q r� f� LOCALITY ./fit / ..� 1( RECEIVED BY DATE OF APPL. DATE ISSUED _c A Es,'T. Z tJ.P. 17 n�i_ ` //5.4 .� - o---a ADDREISS OWNER (: , MAIL ADDRESSTEL�r•� , r , �p LOCALITY i C� NEAREST -0—Ty .,l NO. PTT ` CROSS ST. �B / FIRE NO.OF TYPE- / GROUP ARCHITECT OR Q TELZON^ PLANSa� �! ENGINEER NO. BLDG. < ORD.NO. , ADDRESS SETBACK LINE �_i� / �J.e/L /. APPROVED CONTRACTOR CONTRACTOR & () NOL. BY DATE USE APPROVED ADDRESS ZONE J BY DATE DE CRIIPPTION LOT NO. BLOCK P f 7 CORRECTIONS TRACT —/— / SIZE OF LOT G ,Y/S-7 NOW I NO.OF BLDGS. / — ON LOT USE OF y> I NO.OF I I NO.OF �� , Z NG BLDG. EXISTI ®��� 1FAMiuee ROOMS DESCRIPTION-OF WORK V NEW ALTERATION ADDITION D A REPAIR e� MDVING DEMOLISH p Bq.FT. j r�77 NO.OF Z SIZE ,• -F ROOMS STORIES r WALL COVERING !//"/,9 I COVERING ,7 j,= USE OF NEW / BUILDING / �Cr XQ e;11-2 -' rY c l 1 H a r r I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPROVALS APPLICATION AND STATE THAT THE ABOVE IS CORRECT FOUNDATION: LOCATION NSPECTOR DATE ; AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES FORMS,MATERIALS AND STATE LAWS REGULATING BUILDING CONSTRUCTION. FRAME: FIRE STOPS, SIGNATURE OF j\ / BRACING.BOLTS PERMITTE s 1 r LATH, INT. AUTHORIZED AST LATH, EXT. 76A638A-3 7-49 $ P.C.s PLASTER,INT. P. FEE PLASTER,EXT. f i VALUATION FEE G FINAL 0. /��4i I ., WORKERS'COMPENSATION DECLARATION hereby affirm that I have certificate of consent to self insure, I CC I I4 FOR BUILDING 1 Y V I L®I N G P E RM I T insure, 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 Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING ` ADDRESS Certified copy is filed with the county building inspec- BUILDING tion department. ADDRESS L IL Date Applicant CITY �� CFAN GN ZIP LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. NEAREST COMPENSATION INSURANCE SIZE OF LOT 0 OI,O 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 TEL. USE ZONE MAP I certify that in the performance of the work for which this OWNER �. NO. — NO. y_ permit is issued,I shall note ploy any person in any manner �^l SPECIAL so as to become subject to t e W"ject ' ensation L s ADDRESS d AD � � A Q CONDITIONS 0 Ap 2 CIT m i G ZIP @; Date —3� Applicant NOTICE TO APPLICANT: If, afteCertificate of ARCHITECT OR T (1r)� DISTRICT OUP TYPE FIRE PROC ED BY Exemption, you should becomthe Workers' ENGINEER O. ``v CONST. ZONE U Compensation provisions of the Labor Cade, you must forth- _ I0 with comply with such provisions or this permit shall be ADDRESS TEL. STATISTICAL CLASSIFICATION APT. C NDO. deemed revoked. CONTRACTOR NO. LICENSED CONTRACTORS DECLARATION LIC, CLASS NO. DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. (commencing with Section 7000)of Division 3 of the Business andLIC SEWER MAP Professions Code, and my license is in full force and effect. CITY CLASS BK PG VALIDATION SQ. FT. NO.OF NO.OF CHECK License Number Lic.Class SIZE �Jp STORIES FAMILIES ONE VALUATION Contractor Date DESCRIPTION OF WORK NEW D ❑ $ 2� / iA�� 1 am exempt under Sec. r/` (� 10. ALTER B.BP.C. for this reasonREPAIR ❑ $ Date: USE OF DEMOL ❑ ;2 5 2 11 A EXISTING BLDG. Signature 1� APPLICANTTEL.�(( ( / FINAL # 0 0 0 0 0 1 OWNER-BUILDER DECLARATION PRINT NOdplp'1pIaZt7 DATEO03 o I hereby affirm that I am exempt from the Contractor's License � �i}� ? P��G`? ( - 27375 Law for the following reason (Section 7031.5, Business and ADDRESS 4 f FIN Professions Code): PRESENT B o 0 2 77 S x 13 1, v I, a •owner of the property, or my employees with ADDRESS Zes as their sole compensation,will do the work and 8 1 2—86 tructure is not intended or offered for sale(Section LOCALITY , Business and Professions Code). MOVING TEL.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 REQUIRED SET BACK YARD HWY TOTAL SETBACK FRO I hereby affirm that there is a construction lending agency for FRONT PROP.LINE WIDTH the performance of the work for which this permit is issued P.L. (Sec. 3097, Civ. C.). SIDE a P.L. i Lender's Name / a LDMA'Ref. # 3 P.C. Fee$ Permit Fee 6 3 Lender's Address J6,50 � �+y I certify that I have read this application and state that the Issuance Fee V V V O-LDIA P/C# r above information is correct. I agree to comply with all County Investigation Fee ordinances and State laws relating to building construction, Total Fee 2 13 67" LDMA Perm. # and hereby authorize representatives of this County to enter ( �ea en ne rop ty for inspection purppooses_� SEE REVERSE FOR EXPLANATORY LANGUAGE Applicant or Agent Date ©� i s WORKERS'COMPENSATION DECLARATION insure bor afcertif catte of Worke s'tCompensation ent to self Insurance, APPLICATION F®R S U 1 L D I N C PERMIT � or a certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES I BUILDING AND SAFETY Policy No. Company ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ';.AopD SS 12% Certified copy is filed with the county building inspec- BUILDING �L�O ZEAL p„p^ I tion department. ADDRESS..r,M Z V4��// �D Date Applicant CITY G t 9 G Fry ZIP 11O d 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 (� ASSESSOR hundred dollars($100)or less.) TRACT /JcQ (S BLOCK LOT NO. MAP BOOK PAGE PARCEL d'MP 6 z� x,T TEL �y'iq a USE ZONE MAP OWNER MpR I certify that in the performance of the work for which this >_(� n NO. A. permit is issued, I shall not employ any person in.any manner ADDRESS �1 4Z-PNG 0 RG 14 L A f) I ��' SPECIAL so as to become subject to th Workers',Co do La s. /- CONDITIONS //� CITY' LG C-FY ZIP 9 1� O Date �4pplicant NOTICE TO APPLICANT: If, after ma 'ng this Certificate of ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PROCE ED BY Exemption, you should become subject to the Workers' ENGINEER NO 1 - s `' CONST. ZONE 6 O Compensation provisions of the Labor Code, you must forth- ADDRESS 7th UX �%SJ with comply with such provisions or this permit shall be g deemed revoked. TEL. ::STATISTICAL CLASSIFICATION APT. C DO. CONTRACTOR KV/ NO. LICENSED CONTRACTORS DECLARATION /V LIC. CLASS NO. 23 DWELL. UNITSs I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS ! NO. (commencing with Section 7000)of Division 3 of the Business and LIC SEWER MAP Professions Code, and my license is in full force and effect. CITY CLASSBK VALIDATION SQ. FT. NO.OF NO.OF CHECK i License Number Lic.Class SIZE ISTORIES FAMILIES ONE //��//�� ^ VALUATION DESCRIPTION OF WORK &OR_ Dow" NEW ❑�, Contractor Date nn� r ADD o $ I am exempt under Sec. ® � b S qZ " d' LT ❑ ALTER ❑ 01111 B.&P.C. for this reason 11f+) W •Y REPAIR ❑ $ USE OF r Date: EXISTING BLDG. J 1 O M�Y16_k DEMOL Signature APPLICANT �p7 TEL. ( 1�! FIN &/ DECLARATION (PRINT) V_-t �ULVS NO.n T6 tDloc.0 DA A I hereby affirm that I am exempt from the Contractor's License ADDRESS-1 �lL�b �� IJ 1 rte- Law for the following reason (Section 7031.5, Business and 4 7 2 A Professions Code): BUILDING / # 0 0 0 0 0 1 1, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and I o o 6 Q 5 0 the structure is not intended or offered for sale(Section LOCALITY 7044, Business and Professions Code). MOVING TEL. ® o 0 0 6 Q 5 0 50 I,as owner of the property,am exclusively contracting CONTRACTOR NO. with licensed contractors to construct the project (Sec- ADDRESS 0 606-86 tion 7044, Business and Professions Code). ; REQUIRED TOTAL SETBACK FRO CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH i 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 a P.L. Q Lender's Name �' WMA Ref. # P.C.Fee$ Permit Fee ' - Lender's Address I certify that I have read this application and state that the Issuance Fee O LDMA P/C# above information is correct. I agree to comply with all County Investigation Fee ordinances and State laws relating to building construction, Total Fee V V LDMA Perm. # J and hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. a = SEE REVERSE FOR EXPLANATORY LANGUAGE 0 Date O Signature of Applicant or Agent I ' ° P APPLICA`I N - BUILDING PERMIT COUNTY OF.L05 q�G`ELF� G BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN 4 BUIL57.kkADDRESS I hereby affirm that I have a certificate of consent to self insure, BUILD GIAQDRES h � ..� or a certificate of Workers'Compensation Insurance,or a certified CM) G I'Vg o copy thereof(Sec.3800,Lab.C.) CIT �LL ZIP h T V V LOCALITY Policy No. Company SIZ QALJDTOF BLDG9.NOW ON LOT ❑ Certified copy is hereby furnished. NEAREST CROSS ST ❑ Certified copy is filed with the county building inspection TRA J ('J BLOCKY LOT NMOL I department. a � 1`� USE ZONE MAP NO. Date Applicant ASSESSOR�Q0 n PAGE n� PARCEL. 30 d SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' r COMPENSATION INSURANCE OWNER .�V� }{ C O' O/ 1 -WITHIN 1000 FT.OF SCHOOL? YES NO (This section need not be completed if the permit is for one hundred AD Es Q `� 0 6b Alv dollars($100)or less.) {� NL O DISTRICT GROUP 7 C sr. FIRE ZONE PROCESSED BY I certify that in the performance of the work for which this permit CIT M�4� G'1 ZIP 1 n is issued, I Shall not employ any person in any manner so as t0 ARCHITECT OR ENGINEER Gig TEL NO. `J. L �• become subject to the Workers'Compensation Laws. STATISTICAL CLASSIFICATION APT CONDO Date Applicant ADDRESS CLASS NO. 1=52 DWELL UNITS NOTICE TO APPLICANT If, after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST Exemption, you should become subject to the Workers CONTRACTORTEL NO. SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith 0 FRONT comply with such provisions or this permit shall be deemed revoked. ADDRESS UC.NO. PL LICENSED CONTRACTORS DECLARATION SIDE CITY LIC.CLASS PL I hereby affirm that I am licensed underprovisions of Chapter 9 SEWER MAP (commencing with Section 7000)of Division 3 of the Business and SQ.FT SIZE NO.OF STORIES NO.OF FAMILIES Professions Code,and my license is in full force and effect. NEW BK PG Q License Number Lic.Class CRI ION OF WORK ADD ❑ VALUATION Contractor Date G ALTER 1:1P QL11 O S bN ❑ I am exempt under Sec. �+ REPAIR El H B.BP.C.for this reason fj`{ . DEMOL ❑ LDMA P/C# V, Date: U E OF EXISTING BLDG. URM ❑ U, \ Signature APPLICANT(PRINT) TEL NO. LDMA Perm# �I 1, as owner of the property, or my employees with wages as z ;?,,- t •a their sole compensation, will do the work and the structure is ADDRESS 0 not intended or offered for sale (Section 7044, Business and FINAL DATE Professions Code.) i +— WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL rl OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE r J L a i e'1 i= ❑ 1, as owner of the property, am exclusively contracting With AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY 0 licensed contractors to construct the project (Section 7044, i TAIL 121 m 35 VES❑ NO❑ Business and Professions Code.) WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING (- t��'�'•EJ 'r:� '�= OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH = �4 E --—°1•• CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FOR } GUIDELINES ;'H 7Pit3� •__ I hereby affirm that there is a construction lending agency for VES❑ NO❑ cli the performance Of the work for which this permit IS Issued(SBC. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING 3097,CIV.C.) CHECKLIST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, r { a TITLE 2.CHAPTER 2.20 SECTIONS 220.100 THROUGH 220.140 CONCERNING HAZARDOUS Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD. 0 Lender's Address — c';' # '")� i"X OWNER OR AGENT O c I certify that I have read this application and state under penalty 6 of perjury that the above information is correct.I agree to comply P.C.FEE PERMIT FEE N with all county ordinances and St laws relating to building 9 construction, d h rahm ri sentatives of this County ISSUANCE FEE ✓� at e to upon a ti e o y for insp�c+ipL1 p es, O(���� ` '�" ' •` ' m 3 INVESTIGATION FEE TOTAL FEE ue0 SEE REVERSE FOR EXPLANATORY LANGUAGE APPLICATION FOR BUILDING PERMIT COUNTY OF`LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN. LDING ADD SS I hereby affirm that I have a certificate of consent to self insure, ' BUIL G ADDRESS G L or a certificate of Workers'Compensation Insurance,or a certified �,0 ` em l,t L copy thereof(Sec.3800,Lab.C.) CITY ZIP ^� � � � �� LOCALITY No. Company SIZ OF}OT ) NO.OF BLDGS.NOW ON LOT '❑ Certified copy'LS hereby furnished.' NEAREST CROSS S[_,1'L 11 Certified copy is filed with the county building inspection TRACT BLOC ) LOT NO. I department. 1fL USE ZONE MAP NO. Date Applicant ASSESSOR MAP BQOK PAGE PARCEL IAL CONDITI 7 SPECIAL CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER nJ� ?. T L O. YES NQ _ COMPENSATION INSURANCE u( V V I WITHIN 1000 Fr OF SCHOOL? y (This section need not be completed if the permit is for one hundred ADPKESS dollars($100)or less.) NL� p� DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY I certify that in the performance of the work for which this permit CITY_VA Z G 1 ^ z 1 b D O 019 _ is issued, I Shall not employ any person in any manner so as to ARCHITECT OR ENGINEER V TEL NO. , become subject to the Workers'Compensation Laws. STATISTICAL CLASSIFICATION APT CONDO Date ApplicantADDRESS CLASS NO.� DWELL UNITS NOTICE 70 APPLICANT. If, after making this Certificate Of REQUIRED TOTAL SETBACK FROM EXIST Exemption, you should become' subject to the Workers' CONTRACTOR TEL NO. SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor.Code, you must forthwith' FRONT comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC.NO. PL LICENSED CONTRACTORS DECLARATION SIDE CRY LIC.CLASS PL - I hereby.affirm that I am licensed underprovisions of Chapter 9 SEWER MAP } (commencing with Section 7000)Of Division 3 of the Business and SQIZE NO.OfSTORIES NO.O FAMILIES NEW 11BK PG CL Professions Code,and my license is in full force and effect. 1 ' CC License Number Lic.Class DESCRIPTION OF WORK ADD VALUATION Contractor Date N 6 L\v 1 N 9.0 b n CPO _ TT ALTER ❑ $ V 0 6 r Ix II am exempt under Sec. .VREPAIR ❑ $ I-- BAP.C.for this reason \�j'(j1�� , W DEMOL ❑ LDMA P/C# LL Date: OF EXIWUG BLDG. IA�O .,��i URM ❑ i3 Signature APPLICA (MNT) C+ TEL NO. LDMA Perm# ` ' '. Av"I e-L Z I, as owner'of•the property, or my employees with wages as 1 Z t_ ADDRESS �•I O f3 c-O.J. U. their sole compensation, will do the work and the structure is ':j,j{.,�J not intended or offered for sale (Section 7044, Business and' FINAL DATE a ` n Professions Code.) J _ ' { ' WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL Sy! C 4 ✓ OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE J - S ❑ I, as OWTIer Of the property, am exclusively contracting with AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? licensed BY i1�•;••�-Ir contractors to construct the project (Section 7044, Business and Professions Code.) ves 11 NO❑ J WILL THE INTENDED USE OF THE BUIDUNG BY THE APPLICANT OR FUTURE BUILDING ►►��++ ' OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTHFF a' CONSTRUCTION LENDING AGENCY COAST AIR DUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKUST FOR •+ t I `- GUIDELINES. ' I hereby affirm that there.is a construction'lending agency for YES 13NO❑ t rF I RL 1963.34 a 'the performance of the work for which this permit is issued(Sec. rF�I:�. i;-,t; —y O) I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING ! � gy O L'{ •'; a 3097,CIV.C.) CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, r' TITLE 2,CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING HAZARDOUS 3 ,., �Ir1 Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD. CHANGE o l o Lender's Address � OWNER OR MEN? ' c I certify that I have read this application and state under penalty O 01 of perjury that the above information is correct.I agree to comply, P.C.FEE 7a PERMIT FEE GG a with all count ordinances and State laws relatingto building d 'r� construction, and hereby authorize p ntativeIS his County ISSUANCE FEE 2:23 1 Ai 11.142' e ter upon t e ab d 'pe t for insn purp ses. , (p•�Q as lTC a�i3 INVESTIGATION FEE TOTAL FEE SEE REVERSE FOR EXPLANATORY LANGUAGE