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/6A688A CE0803 B-63 APPLICATION FOR BUILDING PEWIT
COUNTY OF LOS ANGELES BUILDING
DEPARTMENT OF COUNTY ENGINEER ADDRESS
BUILDING AND SAFETY DIVISION LOCALITY
JOHN A. LAMBIE. COUNTY ENGINEER NEAREST
WILLIAM A.JENSEN,SUPT OF BUILDING CROSS ST.
m II
DISTRICT NO. GaaUP TYPE P OCE p Y
FOR APPLICANT TO FILL IN _� CONST.
BUILDING STATISTICAL CLASSIFICATION SEWER MAP
ADDRESS BK PG
CLASS. NO. ® DWELL.UNITS
LOT NO. . BLOCK WATER
CERTIFICATE: NOT REQUIRED ❑ RECEIVED ❑
TRACT / No "CIRCLE) STATE MAJOR SECOND. OCAL
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT USE ZONE SPECIAL
USE OF CONDITIONS
EXISTING BLDG. L. R_
OWNER �QTJ G7',%05% NO. Z� BUILDING EXIST.
SETBACK YARD HWY STREET NAME WIDTH
ADDRESS J f f`y Yr Se-AAD. L FRONT
ARCHITECT OR TEL P. L.
ENGINEER (%}` NO� /Sy SIDE
Qp P. L.
ADDRESS / e W.&
TEL. O
CONTRACTOR NO. 'V V
ADDRESS Q'
O
DESCRIPTION OF WORK 13
1 % rd
ADD ALTER REPAIR DEMOLISH &A
NO.OF NO. OF
SIZE ��G/a STORIES FAMILIES
USE OF
STRUCTURE
SIGNATU E OF _J
APPLICA rN
VALUATION $ S�
ao APPROVALS DATE INSP CTOR•S SIGNATU E
FEE $✓� FOUNDATION: LOCATION /
P C ¢'-� FEE $ - FORMS, MATERIALS lev i
FRAME: FIRE STOPS,
44
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION BRACING. BOLTS L) j•: !' �r ,Y.:/.�.1'�/�r+�•�-'a��
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY FURNACE: LOCATION. },I
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING GAS VENT. DUCTS
BU.ILDI NG CONSTRUCTION. I CERTIFY THAT IN DOING THE WORK
AUTHORIZED HEREBY 1 WILL NOT EMPLOY ANY PERSON IN VIOLA- LATH, INT. ,I•'�I
TION OF THE LABOR CODE OF THE STATE OF CALIFORNIA RELAT-
ING TO WORKMEN'S PENSATION INSURANCE.4 . LATH.EXT.W44 VINC
`
SIGNATURE OF HOUSE NUMBER CORC
PERMITTEE RECT AND POSTEDADDRES FINALJOHN F. LEWST C RAL ENGINEER
PLAN CHECK VALIDATION CK. M.O. CASH PERMIT VALIDATION CK. M.O. CASH
`U'jo 1 1.5-2 ZS JUL 10 2,3 A 32.00A v
__ 0160°2 5 7 4 AUG 13 i A 64,00-
WORKERS'COMPENSATION DECLARATION
hereby affirm that I have certificate of consent to self APPLICATION * FOR BUILDING PERMIT
insure, or a certificate of Workers'Compensation Insurance, I
or a certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
1:1 FOR APPLICANT TO FILL IN ADDRESS
Certified copy is hereby furnished. BUILDING
❑ Certified copy is filed with the county building inspec- BUILDING /
tion department. ADDRESS I�dS LOCALITY
NEAREST
Date Applicant CITY ZIP CROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. -ASSESSOR
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAPBOOK PAGE PARCEL
(This section need not be completed if the permit is for one USE ZONE MAP
hundred dollars($100)or less.) TRACT BLOCK LOT NO. , r NO.
TEL. SPECIAL
I certify that in the performance of the work for which this OWNER C1/� "(l NO. � CONDITIONS rL
permit is issued,I shall not employ any'person in any manner / DISTRICT .GROUP TYPE FIRE P CESSED BY
so as to become subject to the Workers'Comp n�sation L s. ADDRESSRocco �`%.k� / CONST* ZO
Date _ Applican � ` ad
CITY ZIP STAT✓IISSTICAL CLASSIFICATION APT. CONDO. I-
NOTICE TO APPLICANT: If, after ing t Certificate of ARCHITECT OR TEL.
`Exemption, you should become subject to the Workers' ENGINEER NO. CLASS NO. DWELL.UNITS 9L
Compensation provisions of the Labor Code, you must forth- ADDRESSW
with comply with such provisions or this permit shall be `'A`' SEWER MAP Z
deemed revoked. CONTRACTOR dqi$ NO. BK. PG, VALIDATION
LICENSED CONTRACTORS DECLARATION LIC.
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. VALUATION
(commencing with Section 7000)of Divisioh 3 of the Business and LIC. (
Professions Code,and my license is in full force and effect. CITY CLASS $
SQ.FT. NO.OF NO.OF CHECK
License Number Lic.Class SIZE ISTORIES FAMILIES ONE
$
Contractor Date DESCRIPTION OF WORK NEW C]
❑
.r �� ❑I am exempt under Sec. ~ �'1/ ADD ALTER ❑ FINAL d �i
B.BP.C. for this reason REPAIR ❑ DATE
USE OF r
Date: EXISTING BLDG. DEMOL ❑ FINAL S`C J pt."
Signature APPLICANT
g OWNER-BUILDER DECLARATION PRINT 1'A n ��
I hereby affirm that I am exempt from the Contractor's License ADDRESS QCit: dCCG) �N� ,
Law for the following reason (Section 7031.5, Business and _
Pr fessions Code): PRESENT C�l1Q
BUILDING
I, as owner of the property,'or my employees with ADDRESS
wages as their sole compensation,will do the work and LOCALITY
the structure is not intended or offered for sale(Section
7044, Business and Professions Code). MOVING TEL. ;F1 29,0A'
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).
REQUIRED TOTAL SETBACK FROM EXIST. 2 - - 59.25
'CONSTRUCTION LENDING AGENCY SET BACK YARD 'HWY PROP. LINE WIDTH
I hereby affirm that there is a construction lending agency for FRONT ® 0'0 0 5 9 2 ti'C
the performance of the work for which this permit is issued P.L.
iSec. 3097, Civ. C.). SIDE
04, 1 9-83
i P.L.
i Lender's Name
' Lender's Address
P.C.Fee$ Permit Fee ( .
I certify that I have read this application and state that the Issuance Fee 0
above information is correct. I agree to comply with all County Investigation Fee
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter Total Fee
upon the above-mentioned rty for inspection purposes.
9 SEE REVERSE FOR EXPLANATORY LANGUAGE
nature f Applicant or Agent Date; i ®s
,0000�