HomeMy Public PortalAbout9076 RANCHO REAL RD_Building_1963-07-01 TEMPLE ZITY
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aeneae/Iee�aoe•I—eI APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING Cj '7
DEPARTMENT OF COUNTY ENGINEER ADDRESS
BUILDING AND SAFETY DMSION LOCALITY t PL E C[7-r,
JOHN A. LAMBIE, COUNTY ENGINEER NEAREST �
WILLIAM A.JENSEN SUPT OF BUILDING CROSS ST. g V x-7-6 7-6 ,A/
APPLICANT TO FILL.IN DISTRIElm
GEMUP TYPE'c' - PROCESSED BY
CONST.—(j 6 o e-o VrcY
BUILDING f�j STATISTICAL CLASSIFICATION SEWER MAP
ADDREss(7o7e, h�iitN Gh�r� �"P F,�a /11� CLASS.NO. DWELL.UNITS K s{�
LOT NO. BLOCK WATER NOT REQUIRED RECEIVED
TRACTCERTIFICATE:
� .. . )fir,) HWA
NO.OF BLDGS. NO. Z 0 17. HCG CLE STATE MAJOR SECOND, OCAL
SIZE OF LOT�C.,4 i`//l Y I NOW ON LOT USE ZONE SPECIAL
USE OFEXISTING BLDG.14f�)S� //��,//J� ,y ,1 R—` CONDITIONS
OWNER C.,4 OLIN G �J(K �I NO.AT-695 ` BUILDING YARD HWY STREET NAME EXIST.
A D D R E S D71, OJIml,v I �S EAL 0e SETBACK _T WIDTH'
ARCHIT CT,OR TEL. FP.L.T ZO N-h t j4C. �0 2ERF 6'0
ENGINEER NO. SIDE
CL
>_ADDRESS TELp f INSPECTION/RECORD „ p
CONTRACTOF6 Z E NO . .$ I
ADDRESS ,V6 t2 . I( G 411
0
DESCRIPTION OF ORK e
ILIW
NEW ADD ALTER REPAIR DEMOLISH N
SQ.FT. NO.OF {N O.OF ?
IZE STORIES /FAMILIES I
USE OF //��
STRUCTURE A
SIGNATURE APPLICANT
VALUATION S 78 a. D I r
APPROVALS ATE A/-INSP_ECTOII'S SLGHATURE
F E S FEE*C. PMT 5:.—//�� FOFORMS!MATER ALSLOCATION
FRAME:FIRESTOPS
f} e_A,1111 (Xr,,f/�-/
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION BRACING BOLTS pp `� /' = L�C•4/�
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY FURNACE:LOCATION, !
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING GAS VENT DUCTS
BUILDING CONSTRUCTION. 1 CERTIFY THAT IN DOING THE WORK
"AUTHORIZED HEREBY I WILL NOT EMPLOY ANY PERSON IN VIOLA- LATH,INT. n
TION OF THE LABOR CODE SF-THE STATE OF CALIFORNIA RELAT- • /�
ING TO WORKMEN'S COMPENSATION INSURANCE. LATH,EXT.).
SIGNATURE ) ( HOUSE NUMBER COR=
PERMITTEE" ! -- RECT AND POSTED /)4/7
ADDRESS FINAL 191 vl l/f f%" �v
CLYDE N. DIRLAM, P INCIPAL STRUCTURAL ENPN"R
PLAN CHECK VALIDATION CK. M.O. CASH PERM V ATION CK. M.O. tsRf"
LI i D
6 9 ii 8 w JUL 1 A 1 1 .5 0— C.
WORKERS'COMPENSATION DECLARATION
>` L herr y affirm I have certificate of consent to self APPLICATION FOR BUILDING PERMIT
m ure, der q certificate of Workers'Compensation Insurance,
or a certified copy thereof(Sec. 3800, Lab. C.)
COUNTY OF LOS ANGELES BUILDING ANDS FETY
Policy No. Company
r"iCertified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING
ADDRESS
❑ Certified copy is filed with the county building inspec- BUILDING
tion department. ADDRESS Q
Date Applicant CITY I L ZIP 130LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' +� NO.OF BLDGS. NEAREST `
COMPENSATION INSURANCE SIZE OF LOT / 19 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 NgO�r MAP BOOK PAGE PARCEL
NOo\b7+3 I USE ZONE MAP
I certify that in the performance of the work for which this OWNER (t- NO.
permit is issued, I shall not employ y person in any manner ADDRESS I/EO CON SPECDTIONS IL
so as to become subject to the W ers' an n Laws. /� 0
Datel'�� g? Applicant CITY{ � t 4l- ZIP 1 g0 tm
NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR NOTEL. TRICT GROUP TYPE FIDE PR CESSED BY'
ENGINEER NO. /t, CONST. r 1'
Exemption, you should become subject to the Workers' � �
Compensation provisions of the Labor Code, you must forth- ADDRESS ��
with comply with such provisions or this permit shall be IL
IL
deemed revoked. TEL. STATISTICAL CLASSIFICATION APT. C DO.
CONTRACTOR U✓ NO.
LICENSED CONTRACTORS DECLARATION LIC, CLASS NO. DWELL. UNITS
—
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRE 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 PG VALIDATION
SQ. _ NO.OF NO.OF CHECK
License Number Lic.Class SIZE STORIES FAMILIES ONE
VALVA O
Contractor Date DESCRIPTION OF WORK NEW ❑
❑ _I y�t I ADD ® ,
I am exempt under Sec. �(, C/VV` ❑
ALTER
B.&P.C. for this reason REPAIR ❑ $
USE OF
Date: EXISTING BLDG. DEMOL ❑
APPLICANT 1 TEL.
Signature PRINT 1 aW NO.ASS 34 FINAL
OWNER-BUILDER DECLARATION DATE
I hereby affirm that I am exempt from the Contractor's License `b 9 9 A
Law for the following reason (Section 7031.5, Business and ADDRESS r FI
Professions Code): BUILDING # 0 0 0 0 0 1
I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and LOCALITY , ° 1 7.1,7 5
the structure is not intended or offered for sale(Section
7044, Business and Professions Code). MOVING TEL.
❑ I, as owner of the property,am exclusively contracting CONTRACTOR NO. o o.1 7 1,750 i
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY TOTA SETBPROP. CK FROM WIDTH
O504-87
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.
Q Lender's Name , c LDMA Ref. #
P.C.Fee$ permit Fee Jbzz
- Lender's Address '
rI ce tify that I have read this application and state that the Issuance Fee .J LDMA P/C#
aft v information is correct. I agree to comply with all County Investigation Fee
or in nces and State laws relating to building construction, Total Fee / LDMA Perm.#
i a ereby a thor'ze represe tativas of this County to enter
3 u the abo - It'on d party for inspection purposes. '
t SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature o Applicant or Agent Date
1