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HomeMy Public PortalAbout5545-5545 1/2 SANTA ANITA AVE_Building__ Y APPLICATION FOR BUILDING PERMIT �1 COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADD I hereby affirm that I have a certificate of consent to self Insure, - B�yl�gl G AD or I3 certificate of Workers'Compensation Insurance,or a CertifiedC 7AA17A MAI Dopy thereof(Sec.3800,Lab.C.) �G LOCALITY POIICy NO. Company . SI.;E OF LOTNO.O BLDGs.NOW ON LOT ❑ Certified copy Is hereby furnished. 4 � QJ NEAREST CROSS ❑ SK 100— Certified copy is filed with the county building Inspection TRACrA4,31 C1 I BLOCKS LOT NO� �- USE ZONE MAP NO. department. Date Applicant ASS S-73�BOOK PAGE j� PARCEL SPECIAL CONDITIONS V i CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER I TEL NO. YES NO COMPENSATION INSURANCE 'Z WITHIN 7000 FT OF SCHOOL? ADDRESSc (This section need not be completed if the permit is for one hundred S =.7 DISTRICT 'GROUP TYPE CONST.' FIRE ZONE PROCESSED BY dollars($100)or less.) CI z I certify that in the performance of the work for which this permit ` 1 Is Issued, I shall not employ any person In any manner so as to ARCHITECT OR ENGINEER TEL NO. J become subject to the Workers'Compensation Laws. STATISTICAL CLASSIFICATION APT CONDO Data Applicant ADDRESS CLASS NO. DWELLUNITS NOTICE TO APPLICANT. If, after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST Exemption, you should become subject to the Workers' CONTRACTOR TEL-NO. SETBACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code,you must forthwith FRONT comply with such provisions or this permit shall be deemdTevokd. ADDRESS LIC.NO. PL SIDE C LICENSED CONTRACTORS DECLARATION CITY LIC,CLASS PL � I hereby affirm that I am licensed under provisions of Chapter 9 ' glzE NO.OF STORES NO.OF FAMILIES SEWER MAP C (commencing with Section 7000)of Division 3.of the Business and Professions Code,and my license is In full force and effect. NEW ❑ BK PG , N WOR DES RIPTION OF K V ON License Number Lic.Class _ � O ADD �, Contractor Date �j�T REPAIR 11ALTER 1:11 "`� ❑ I am exempt under Sec. $' B.BP.C.for this reason DEMOL ❑ LDMA PIC# Date: USE OF EXISTING BLDG. •URM. ❑ ignature� APPLICANT(PRINT) TEL NO. t LDMA Perm# Z z as owner of the p perty,or my employees th wages es So� S/ �� O their sole compensation,will do the work and the structure is ADDRESSF . t+.I-T not Intended or offered for sale (Section 7044, Business and 5S FlNALttATE .7_I- Professions Code.) p G irk=s• WILLTHEAPPLICANT OR FUTURE BUILDING OCCUPANT HANDLEA HAZARDOUS MATERIAL tl� ❑ I, es owner of theproperty; TH A MDUNTS CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN am exclusively contracting with THE AMOUNTSSPECIF ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL /` tali•= licensed contractors to construct the project.(Section 7044, YES 11 NO I"I gI "-_ Business and Professions Code.) , WILL THE INTENDED USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING CONSTRUCTION LENDING AGENCY PERMIT FOR CONSTRUCTION OR MODIFICATION PROMTHESOUTH AiOCCUPAn QUALITYIAMANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST CHECK FOR 6UIDEUNEB� I hereby affirm that there is a construction lending agency for "❑ NO �,, �.. AINE the performance of the work for Which this permit Is issued(SBC. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD V 3097,CIV.C.). PERMITTING CHECKLIST.IFTAND MY REQUIREMENTS UNDER THE LOS ANGELES • COUNTYCOOF TRLE2,C 22MlWTHR000H 2ffi740 CONCERNING '+• - r Ef.r? Lenders Name HAZARDOUS MATER D NINOAPERMIT FTiOMTHE BCAOM0. Lenders Address ,- OVRM OR AGOIr '� 4 o° I certify that I have read this application and state that the above RC.FEE PERMIT FEE information is correct. I agree to comply with all county ordinances and State laws relating to building construction,and ' hereby authorize representatives of this County to enter upon ISSUANCE FEE the ab entiG d property for inspection purposes ;-;I74_ 72 T2, INVESTIGATION FEE TOTAL FEE m=1Ayplk rApmt •J SEE REVERSE FOR EXPLANATORY LANGUAGE. WORKERS'COMPENSATION DECLARATION l n hereby affirm that I have certificate of consent to self A P P L I CATION FOR BUILDING PERMIT c insure, or a•certificate of Worr kers'Compensation Insurance, or a certified'cdpy'thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY PolNo.icy %g 1 Company ` 1j JJ CBUILDING ertified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS ,�•J! , J! Jy� *� ��/r �Uff Certified copy is filed with the county building inspec- BUILDING !J/,( Alp tion epaartmenf. ADDRESS ✓77..// ///•1/ /y�/� Date e1"5' Applicant fYiS�u/y of CITY r & Lam/ GO& ZIP 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 TRACT BLOCK LOT NO. ASSESSOR hundred dollars ($100)or less.) ) MAP BOOK PAGE PARCEL /DuAJT• TEL. // �+ USE ZONE MAP OWNER 4 ' NO. J-74 -d 2J I certify that in the performance of the work for which this �D _ NO. pefmit'is issued, I shall not employ any person in any manner ADDRESS �� . �iT' �[�ii� J�S �' I[ SPECIAL so as to become subject to the Workers'Compensation Laws. n ,p ) p 999��� CONDITIONS V CITY J,.4#V 4144 ZIP /l7 7 e OL Date Applicant ARCHITECT OR TEL. O NOTICE TO APPLICANT: If, after making this Certificate of DISTRICT GROUP TYPE FIRE PRO SSD BY ENGINEER NO. CONST. ZONE Exemption, you should become subject to the Workers' 1/ � Compensation provisions of the Lalior Code, you must forth- ADDRESS St JK � V � H with comply with such-provisions or this permit shall be TEL. /G STATISTICAL CLASSIFI TION APT. CON . Z deemed revoked. CONTRACTOR 6kZ& ) 4405 • NO.691— LICENSED CONTRACTORS DECLARATION- LC • ,r— CLA55 NO. DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS ,r XJh11NO, 3 . (commencing with Section 7000)of Division 3 of the Business and �J/ (� / /� LIC ,r SEWER MAP ' Professions Code, and my license is in full force and'effect. CITY �!`T/'y 4CA0 � CLASS l BK PG 'VALIDATION ,),r SQ. FT. NO.OF j NO.OF CHECK License Number M LPc.Class SIZE STORIES ! FAMILIES ONE /'p • !nS r••' ` VALUATION Contractor(7I�Gt`/++ Y�J Dafe DESCRIPTION OF WORK "(r�5 NEW&ddE]I am exempt under Sec. s� — Lff sk w ele — ADD ❑ $ , �� Zo-/ ALTER ❑ $B.&P.C. for this reason - REPAIR Jw ' Date: USE OF EXISTING BLDG. — (//T�I�� DEMOL Si nature APPLICANT /� TEL. FINA g OWNER-BUILDER DECLARATION PRINT L7ICE/Er IJ S. NO. ��� DA EL I hereby affirm that I.am exempt from the Contractor's License ADDRESS .� Wf FINAL' . Law for the following reason (Section 7031.5, Business and Professions Code): "' PRESET 'By ' _. I, as owner of the property, or my employees with BUILDINGADDRESS wages as their sole compensation,will do the work and the structure is not intended or offered for sale(Section LOCALITY ' 7044, Business and Professions Code). MOVING' TEL. @35t 8 A I, as owner of the property,am exclusively contracting CONTRACTOR NO. with licensed contractors to construct the project (Sec- # 0 0 0 0.0 .1 tion 7044, Business and Professions Code). ADDRESS REQUIRED . YARD HWY TOTAL SETBACK FROM T. CONSTRUCTION LENDING AGENCY SETBACK PROP. LINE WIDTH - - 6(150 I hereby affirm that there is a construction lending agency for FRONT the performance of the work for which this permit is issued P.L. 0 0 0 6 Q 5 0 (Sec. 3097, Civ. C.). SIDE P.L. 1203-85 Q Lender's Name LDMA Ref. # - Lender's Address P.C. Fee$ Permit Fee / v ✓/� - rI certify that I have read this application and state that the Issuance Fee ! S� LDMA P/C# above information is correct. I agree to comply with all County Investigation Fee 8 ordinances and State laws relating to building construction, Total Fee 19 Ors LDMA Perm. # and hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. a SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date WORKERS"COMPENSATION DECLARATION I hereby•affirm that I have r certificate of consent to pelf APPLICATION FOR- BUILDING PERMIT � insure, or a certificate of Workers'Compensation Insurance', or•a'certified copy thereof(Sec. 3800, Lab. Cyt�) ! COUNTY OF LOS ANGELES BUILDING•AND SAFETY Policy No.J Company ��+'��'� BUILDING a Certified copy is hereby furnished. . I FOR APPLICANT TO FILL IN ADDRESS S+-Sf,f oZ i9stf7 /A 0406 Certified copy is filed with the county building inspec- BUILDING �✓� a VE ttiioon.depalrrtcment'. ADDRESS .1 Date /o�_21Q�r Applicant ���� �o-s CITY ^ tiiG C/ ZIP LOCALITY CERTIFICATE OF EXEMPTION'FROM WORKERS' l NO:OF BLDGS. NEAREST 01 _ 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 BLOCK LOT NO. MAP BOOK PAGE PARCEL J1 //+�'� TEL. �+ USE ZONE MAP OWNER �c .4/ 'L L(J• NO. S�� rpJf I certify that in the performance of the work for which this: NO. - permit is issued, I shall not employ any person i�t any a , ��� T� �� - �/� SPECIAL so as'to become subject to the'Workers'Compensation Laws. ADDRESS • u 1` CONDITIONS V Date Applicant CITY �& ZIP ®C NOTICE TO APPLICANT: 'If, after makingthis Certificate of ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PROCE ED BY ENGINEER NO. CONST. ZONE ij Exemption; you 'should become subject to the Workers' ,Q W Compensation-provisions of the Labor:Cade, you must-forth- ADDRESS S-A �• - '✓ 64 - - with -with comply with such- provisions or. this permit shall be' TEL. ••ff STATISTICAL CLASSIFICATION APT. Z deemed,revoked. CONTRACTOR 3 NO, 4 ?s LICENSED CONTRACTORS DECLARATIONS - `-'__ _/` LIC, 1 CLASS NO. �' bWELL. 11NITS= I hereby affirm that I am licensed- under provisions of Chapter 9 ADDRESS (,(/�OIClIJ NO. .�� (commencing with Section 7000)of Division 3 of the Business and 1 /1 LIC SEWER MAP Professions Code, and my license is in full force and effect. CITY/� CLASS Com- j i BK ' :, VALIDATION 1 aa Lic.Class ` �; SIZE S ORIIES I FAMIOLIES CONE • HECK License,Number �=©7�L'� - / DESCRIPTION OF.WORK �' � NEW � VALUATION Contractor 64 1161895 1 1895 Date /02/. ❑ ; i ADD I am exempt under Sec. , ALTER B.BP.C. for this reason �/C L-C7 REPAIR Q ; ' Date:- USE OF DEMOL EXISTING BLDG. A-C 9 'Signature' APPLICANT TEL.. FINAL OWNER-BUILDER DECLARATION PRINT ffRDJ S •. IVO. » DATE 1-hereby affirm that I am exempt from the Contractor's License ADDRESS l!J• OdQ �� Law for the following-reason (Section 7031.5, Business anFIN d' "Professions Code): PRE ENT BY BUILDING ; 'I, as owner of the property, or my employees with ADDRESS 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 5 A tion 7044, Business and Professions Code). i REQUIRED TOTAL SETBACK FROM' .. '' # 0 0 0.0 o CONSTRUCTION LENDING'AGENCY SET BACK YARD • HWY PROP.LINE WIDTH I hereby off irm that there is a construction lending agency for FRONT' '•-the.performance of the work for which this permit is issued P.L. - I o.o 6 Q-5 0 (Sec. 3097, Civ. C.). SIDE P.L. a a a 6Q5A� - o Lender's Name $ P.C. Fee$ Permit Fee Q•� LDMA Ref. # ',I 2 0 5._8 5 Lender's Address V I certify that I..have read this application and state.that the Issuance Fee /v sS. 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 as u -and hereby authorize representatives of this County to enter LDMA Perm.# up o the above-mentioned property for inspection pur oses. od -� f• ��5� SEE REVERSE FOR EXPLANATORY LANGUAGE 40 Signature of Applicant or Agent Date t WORKERS'COMPENSATION DECLARATION 1 hereby affirm that I have certificate of consent to self APPLICATION F OR BUILDING PERMIT 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. CompanyS '5;1- f Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING SS �'!j/ 4NJT US ADDRESS ✓ 77 Certified copy is filed with the county building inspec- BUILDING ttion Pepyrtment..i p�.�,�� ADDRESS �� � Date M �C Applicant 6,ce s&Us• CITY je- Cf� ,7LG ZIP LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' O.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 TRACT BLOCK LOT NOASSESSOR hundred dollars($100)or less.) . MAP BOOK PAGE PARCEL �J �L' USE ONE MAP OWNER / NO. - 3 I certify that in the performance of the work for which this NO. IL permit is issued, I shall not employ any person in any manner ADDRESS �'/ -7o). .s j S �� J SPECIAL so as td become subject to the Workers'Compensation Laws. /� CONDITIONS V CITY S(7/^� 1- ZIP 9177� OC Date Applicant ARCHITECT OR TEL. NOTICE TO APPLICANT: If, after making this Certificate of DISTRICT GROUP CONST. ZONE PROCE D BY V ENGINEER NO. Exemption, you' should become subject to -the;Workers' i �� ��( ��� �/ 3 � Compensation provisions of the Labor Code, you must forth- ADDRESS 0 (, with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION APT. NDO. Z deemed revoked.. CONTRACTOR •- ,V S NO. 'C9,77j 'R LICENSED CONTRACTORS DECLARATION q L}C CLASS NO. DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS y3 Lf/• �O��k� /��X10. � a Jj_ (commencing with Section 7000)of Division 3 of the Business and a LIC. SEWER MAP Professions Code, cirriidd my license is in full force and effect. CITY /ilJr �. CLASS G' BK ' VALIDATION p�t/�9LJ� 6'�f SIZES STORIES FAMILILIES CHECK ' License Number Lic.Class - ' ��••�•�� /� /J / VALUATION Contractor L9n'�N J&4 S Date �" ` — DESCRIPTION OF WORK p/� NEW ADD $ I am exempt under Sec. cls ALTER B.&P.C. for this reason T REPAIR" Q $ Date: USE OFDEMOL / J EXISTING BLDG. ®. Signature APPLICANT /�� /J„_a• TEL. r FINAL PRINT (f ��IQiQ NO.(f7p� ��J OWNER-BUILDER DECLARATION /41, �� DATE G � �� -• •- - I hereby affirm that I am exempt from the Contractor's License ADDRESS ,r7.3 L({, Eity/p Law for the following reason (Section 7031.5, Business and FIN C Professions-Code): PRESENT By ❑ ' h BUILDING I, as owner of the property, or my employees with ADDRESS 3 5 8,3_A wages as their sole compensation,will do the work and " the structure is not intended or offered for sale(Section LOCALITY ' # 0 a o d o 7044, Business and Professions Code). MOVING TEL. I, as owner of the property,am exclusively contracting CONTRACTOR NO. I o o60.50 with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). o o 0 6 Q 5 0 5 CONSTRUCTION LENDING AGENCY ' SETT BACK YARD HWY TOTAL SETBACK NEER WIDTH I hereby affirm that there is a construction lending agency for FRONT 12 0 3-8 5 the performance of the work for which this permit is issued P.L. - - (Sec. 3097, Civ. C.). SIDE g P.L. Lender's Name 5-01 LDMA Ref. # Lender's Address P.C. Fee$ Permit Fee /' r I certify that I have.read this application and state that the Issuance Fee 1 /0. LDMA P/C# c above information is correct. I agree to comply with all County Investigation Fee Total F �/ ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter ee V v LDMA Perm. # ( upZonhe above-mentioned property for inspection ur oses. -�, ew los . �vx v tfr SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date - t •;WORKERS;,COMeENSATION DECLARATION ::I hereby a fcthat I •}ravecertificate of consent to self APPLICATION FOR BUILDING PERMIT � insure, or a+cerertificate of Workers'Compensation Insurance, or b,certifigd copy thereof(Sec. 3800, Lab. C.) Policy N'tJ.go 360npany )/SF,Ia 11&. COUNTY OF LOS ANGELES BUILDING AND SAFETY BUILDING ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS Certified copy is filed with the county building inspec- BUILDING tion department. ADDRESS 5545 1/2 Santa Anita Ave. r Date 1© Applicant CITY Tem le Cit ZIP 9178 LOCALITY CERTIFICATE OF EXEMPTION FROM WORKE S' 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 44319BLOCK ASSESSOR ' hundred dollars ($100)or less.) TRACT LOT NO. MAP BOOK PAGE PARCEL TEL. USE ZONE MAP L—O �-7 OWNER J.E. Plount & Co. No.576- J I (.certify that in the performance of the work for which this NO. � permit is issued, I shall not employ any person in any manner �� SPECIAL so as to become subject to the Workers'Compensation Laws. ADDRESS CONDITIONS V CITY ZIP 91776 Qe Date Applicant ARCHITECT OR TEL. NOTICE TO APPLICANT: If, after making this Certificate of DISTRICT GROUP CONST. ZONE pR0 SSED BY Exemption, you should become subject- to the Workers' ENGINEER Neil Esurl:i NO. 576-7456 �j y� W Compensation provisions of the Labor Code, you must forth- ADDRESS `�`� —3 �J � with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION APT. C DO. #A deemed revoked. CONTRACTOR same as owner NO. LICENSED CONTRACTORS DECLARATION LIC, CLASS NO. DWELL. UNITS I hereby off,irm that I am licensed under provisions of Chapter 9 ADDRESS NO. SEWER MAP (commencing with Section 7000)of Division 3 of the Business and LIC. Profession's Code,and my license is in full force and effect. CITY CLASS BK PG 4510 VALIDATION / SQ. FT. NO.OF NO.OF CHECK License Number ��tZ Lic.Class �`/ SIZE 1735 STORIES 2 FAMILIES ONE '�' (/,,,, DESCRIPTION OF WORK NEW under Sec. VALUATION Z 4 3 2 4 A Contractor ��_e•(1O4N -Date ❑ 1 am exemptsingle family detached ADD ❑ ALTER ❑ 0 � v B.&P.C. for this reason condominiums fi SA -m 'a' REPAIR ❑ $ USE OF Date: EXISTING BLDG. DEMOL ❑ Signature APPLPRINTT John Plount TEL 576-8737 FINAL OWNER-BUILDER DECLARATION 1 DATE I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and ADDRESS p Professions Code): PRESENT ❑ BUILDING I, as owner of the property, or my employees with ADDRESS 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. ❑ 1, 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). 2 5 Q a 0 A REQUIRED TOTAL SETBACK FRO CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH '��0 0 0 0 0 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. ( ° 7 5 6 2 5 (Sec. 3097, Civ. C.). SIDE $ P.L. 2 Lender's Name LDMA Ref. # Lender's Address P.C.Fee$ 3,OS- Permit Fee TT - I certify that I have read this application and state.that the Issuance Fee kV 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 r75�. � LD' perm. # and hereby authorize representatives of this County to enter 1 upon;he above-me Toned property for inspection purposes. 7 l7'7J SEE REVERSE FOR EXPLANATORY LANGUAGE 01 Signat a of Applicant or Agent Date -WORKERS:COMPENSATION DECLARATION � A hereby.affirm that I have certificate of consent to self APPLICATION. FOR BUILDING\P E RM I T '1'nFure, or a.,.certificate of Workers'Compensation Insurance, ora certified copy thereof(Sec. 3800, Lab. C.) r Z�'36 p �' COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy Nglww J Company 0��� ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING ��-�� ADDRESS r (� Certified copy is filed with the county building inspec- BUILDING IG�J tion department. � � ADDRESS 5545 Santa Anita Ave. � Date t%oQ"' Applicarit CITY Tembl'e City ZIP 91780 LOCALITY CERTIFICATE OF EXEMPTION FROM WORK S' 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 BLOCK LOT NO. MAP'BOOK• PAGE PARCEL OWNER J.E. Plount c& CO. No. 576-8737 USE ZONE MAP /' I certify that in the performance of the work for which this yp/ NO. /SV �77 } permit is issued, I shall not employ any person in any manner ADDRESS 217 W. Las Tunas Dr. K 3 SPECIAL A. so as to become subject to the Workers'Compensation Laws. Y� CONDITIONS UO CITY el ZIP 1776 Date Applicant ARCHITECT OR TEL. U • NOTICE TO APPLICANT: If, after making this Certificate of Neil Esurki 576-7456 ' DISTRICT G OUP TYPE FIRE P O SSED BY Exemption, you should become subject to the Workers' ENGINEER NO. ?� CONST. ZONE Compensation provisions of the Labor Code, you must forth- ADDRESS ✓'"p _3 V/ IL with comply with such provisions or this permit shall be TEL STATISTICAL C IFI ATION APT. gbNDO. deemed,revoked. CONTRACTOR Same as owner NO-576-8737 / LICENSED CONTRACTORS DECLARATION LIC, CLASS NO. lieDWELL. UNITS't hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS 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 V V VALIDATION', SQ'FT'1613 NO.OF 2 1 NO.OF CHECK —\ License Number 1113 �'/ Lic.Class ,� SIZE STORIES FAMILIES NEW VALUATION U Contractor Xe•/ l–AWWr 7 610' Date DESCRIPTION OF WORK ADD $ D�O� 0 0 3 2 3 A ❑ I am exempt under Sec. single familydetached ❑ 01110 # 23`\ ALTER I ° 6 0 4,3 5 B.&P.C. for this reason EPAIR ❑ $ Date: USE OF EXISTING BLDG. DEMOL ❑ 0 0 6 0 IL 3 510 Signature APPLPRINT) John Plount TEL FINAL 03,31 -86 OWNER-BUILDER DECLARATION DATE I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and ADDRESS F L Professions Code): PRESENT ti ❑ BUILDING I, as owner of the property, or my employees with ADDRESS 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 exclusive) contracting [ADDI TRACTOR NO. ;25029A ❑ P P Y� Y 9 # 000001 with licensed contractors to construct the project (Sec- ESS tion 7044, Business and Professions Code). i CONSTRUCTION LENDING AGENCY TBACK ED YARD HWY TOTAL SETBACK LNEFR M WIDTH ( - 721.50 I hereby affirm that there is•a construction lending agency for ONT o o 6 the performance of the work for which this permit is issued L. �– 7 21.5 0 (Sec. 3097, Civ. C.). E 07. 1 5_86 Lender's NametLDMA Ref. #Fee$ Permit Fee Lender's Address 601, nI certify that I have read this application and state that the Issuance Fee A9 LDMA P/C# above information is correct. I agree to comply with all County stigation Fee f ordinances and State laws relating to building construction, Total Fee ! !V LDMA Perm. # ti and hereby authorize representatives of this County to enter uPon the above-mentioned property for inspection purposes. –7-1;%;"W SEE REVERSE FOR EXPLANATORY LANGUAGE 10n Signature o pplicant or Agent Date