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638A CEweG35.6, APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILD
(ESNs � � 2_
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION LOCALITY
JOHN A. LAMBIE, COUNTY ENGINEER NEAREST
WILLIAM A. JENSEN SUPT OF BUILDING CROSS ST.. .G.
DISTRICT NO. G TYPE
P BY
FOR APPLICANT TO FILL IN �� �� TYPE 2
BUILDING _ STATISTICAL CLASSIFICATION SEWER MAP
ADDRESS-'(Jc�(G',�G��/ til/iK�l✓O / / CLASS. NO. DWELL. UNITS l
LOT NO. /�
_`> % BLOCK WATERNOT REQUIRED RECEIVED
CERTIFICATE:
TRACT e, MAP /� HIGHWAY STATE MAJOR SECON LOCA
L- r�
NO.OF BLDGS. NO. ` (CIRCLE)
SIZEOFUSE OF LOTS C5Y �-" NOW ON LOT US-- ZONE OND TI ONS
EXISTING BLDG.
TEL. - >t` 4-o l
OWNER L�/c�/1�2�.5-G.�/ NO. B l EXIST.
SETBACK Y RD HWY STREET NAME WIDTH
ADDRESS FRONT J
ARCHITECT OR TEL. P. L. O}.
ENGINEER NO. SIDE T� O
P. L. U
ADDRESS TEL. INSPECTION RECORD w
CONTRACTOR �5'p�/ilr.+r� !Y NO. 3Jj+�Zi O
1-
ADDRESS i N ! W
DESCRIPTION OF WORK ` L
((
NEW ADD ALTER REPAIR DEMOLISH C
SCJ. FT. NO. OF NO.OF _ - 41
IZE — STORIES FAMILIES
STRUUSE
OCTURE / AOL
SIGNATUR OF
APPLICANT I -
VALUATION �
APPROVALS DATE INSPECTOR'S SIGNATURE
FEE �ff,, q�� �1 FOUNDATION: LOCATION
L'r �' ` FEE (. C�� FORMS, MATERIALS
FRAME: FIRE STOPS, )
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION _B_RACING, BOLTS
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. I CERTIFY THAT IN DOING THE WORK
AUTHORIJLAC'ODE
ILL NOT EMPLOY ANY PERSON IN VIOLA- LATH, INT.
TION TOF THE STATE O CALIFORNIA RELAT-
ING WOPENSATICELATH, EXT.SIGN U *%� HOUSE NUMBER COR- \
PERMIT RECT AND POSTED
ADDRESS --- FINAL _
CLYDE N. DIRLAM, PRINCIPAL STRU2TURAL ENGINEER
P CHECK VALIDATIONcK M.O. CASH PERVALIDATION cK.; M.O. CASH
9 O � 3U c
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DD LACO 2 9 3 O:6 riJG1 j 1 D 71.00— -1cv
�.�12?AWG�%rrtyC/ '
WORKERS'COMPENSATION DECLARATIONI hereaffirm tha
insurebor a certif carte of Workers'Compen at on insurance, APPLICATION FOR BUILDING PERMIT
or a certified copy thereof (Sec: 3800, Lab, C.) a
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. 5302068Company Homeland Ins BUILDING .
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS ()J�6
n Certified copy is filed with the cou uil ing inspec- BUILDING
1� tion department. ADDRESS
r ,
Date 6-5-85 Applicant G cITYTemple Cit zip Ca LOCALITY
CERTIFICATE OF EXEMPTION'FROM'WORKE ' I NO.OF BLDGS. NEAREST
COMPENSATION INSURANCE ' A SIZE OF LOT NOW ON LOT CROSS ST. YV
(This section need not be completed if the permit is for ones TRACTBLOCK LOT NO. ASSESSOR MAP BOOK PAGE PARCEL
hundred dollars($100,)or less.)
OWNER Kladifko TEL' -5123 USE ONE MAP n
I certify that in the performance of the work for which this' No. pC }
permit.is issued, I shall not employ any person in any manner' 348 W. Las Flores Ave �� SPECIAL 4.
so as to become subject to the Workers'Compensation Laws. ADDRESS CONDITIONS V
CITY Arcadia zip 91006 IN
U
Date Applicant ARCHITECT OR TEL. O
NOTICE TO APPLICANT: If, after making this Certificate of . CONST. Z NE y
ENGINEER NODISTRICT GROUP TYPE FIRE PRO SED BY
Exemption, you should become subject to the Workers' `,� 0, 2 Im
Compensation provisions of the Labor Code, you must forth- ADDRESS r n J V/ y
with comply with.such provisions or this permit shall be L. STATISTICAL CLASSIFICATION APT.
deemed revoked. CONTRACTOR J'.L.Shipley Rfc.90 792-243 CO
LICENSED CONTRACTORS DECLARATION LIC. ; CLASS NO. Z.r DWELL UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS 265 N. V inedo No. 309178
(commencing with Sectiori 7000)of Division 3 of the Business and LIC. SEWER MAP
Professions Code, and my license is in full force and effect. CITY Pasadena 91107 CLASS C39 BK PG VALIDATION
SQ.FT. NO:OF NO.OF CHECK
License Number 3 0 8178 Lic.Class C 3 9 SIZE STORIES FAMILIES ONE .
VALUATION.
Contractor J.L•Shipley Date 6-5-85 DESCRIPTION OF WORK Shingle n/side NEW ❑ $ 1,427. 00 2 2 4.2 A
w/220# shingle Class 'A' ADD ❑
I am exempt under Sec. PoolALTER ❑ # o 0 0 0.0 1
B.BP.C. for this reason REPAIR ® $ 1 - - 49.88
USE OF
Date: EXISTING BLDG. HOUse DEMOL ❑ 0 0 0 (j Q$8 U
Signature APPLICANT TEL. FINAL
OWNER-BUILDER DECLARATION PRINT NO.7 DATE 1 —,85
I hereby affirm that I am exempt from the Contractor's License 2 6 5 N N. Vinedo Ave Pasaden 0
Law for the following reason (Section 7031.5, Business and ADDRESS FINA
'Professions Code): PRESENT BY
❑ BUILDING
I, as owner of the property, or my employees with ADDRESS 00
wages as their sole compensation,will do the work and ,
the structure is not intended or offered for sale(Section LOCALITY
7044, Business and Professions Code). MOVING TEL.
I,as owner of the property,am exclusively contracting CONTRACTOR NO.
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY SETT REQBACK YARD HWY TOTAL SETBACK FROM WIDTH
I hereby affirm that there is a construction lending agency for FRONT
the performance of the work for which this permit is issued P.L.
(Sec. 3097, Civ. C.). SIDE
a P.L.
Q Lender's Name
LDMA Ref. #
Lender's Address
P.C.Fee$ Permit Fee 39 . 38
- 'I certify that I have read this application and state that the Issuance Fee 10.5 0 LDMA P/C#
above information is correct. I agree to comply with all County i Investigation Fee
ordinances and State laws relating to building construction, Total Fee 49 .88 LDMA Perm.#
and hereb aut TorIntion
representatives of this County to enter
upon the ov ed perty for inspection purposes._ r
o ? SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Ap scant or ent Date t