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..•....tta... l APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELESBUILDING1-14Z zlZ
DEPARTNT OF COUNTY ENGINEER ADDRESS
ME
BUILDING�AND SAFETY DIVISION LOCALITY t
JOHN A LAMBIE COUNTY ENGINEER NEAREST
WILLIAMA JENBEN SUPTOFBUILDINO CROSSST
FOR APPLICANT'TO FILL IN DISTRICT NO GROUP TYPE I ESS ED BY /
S' t CONST \ r L
BUILDING 1 STATISTICAL CLASSIFICATION SEWER MAP
AD RESS v__ E //� SK PO
'C'_ASS NO DWELL UNITS �/
L BLOCK WATER
I CERTIFICATE NOT REQUIRED RECEIVED
A13
TRACTS a 1 p L.pUb E.O. Ll Li
MAP HICHWAT
JJ.�. NO OF BLDGS NO (<Iflclel STATE MAJOR SECOND LOCAL
SIZE OP LOT fl/ X NOW ON LOT USE ZONE SPECIAL / /
of
USEOF CONDITIONS
EXISTING BLDG i I,I , , , I
OWNER b. " V C7IJI NOLI. (s$S BUILDING EXIST
.1 SETBACK YARD HWY STRE iIAME WIDTH
ADDRESS t. Si. E 1_ FRONT
ARCH V ITECT
ENGINEER . ! NO SIDE
ADDRESS INSPECTION RECORD
CONTRACTOR M11L. A",EJ;L.L7 t2 P ,o
'ADDRESS 28 :; Lom A
DESCRIPTION OF WO %� ° 1 .•t f O
NEW ADD ALTER ' REPAIR DEMOLISH ' •1 v T
SO FT y� NO OF NO OF �' Ml_ 6-.,
6-.,' i4`ol ?
IZE STORIES 1 FAAMILIES Ate " t, Yh. I
SUSE OF,
TRUCTURE IatV C LL-k 1. c1 -
G ��big;W _.
SIGNATURE'OF / '�l 1 �,p��✓.l�� `R. A 9 I.
APPLICANT i' I rLLa'L I/YLrs �•'�I��•v A ty`rt'L''� 1'ul
VALUATION$ C) - ,
`Y APPROVALS /D
ATEOI_ INSPPECTORRS"SIGNATURE '
PC 7—S PMT J + / ✓ n P,SFO
UNDATION LOCATION I,
FEE S FEE FORMSMATERIALS � /h
FRAME FIRE STOPS ,
HER SGT ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION) BRACING BOLTS
ANO STATE THAT THE ABOVE 19 CORRECT AND AGREE TO COMPLY FURNACE LOCATION
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING GAS VENT,
ENT DUCTS !
GU ILDING CONSTRUCTION I CERTIFY THAT IN DOING THE WORK I ,
AUTHORIZED HEREBY I WILL NOT EMPLOY ANY PERSON IN VIOLA LATH INT
TION OF THE LABOR CODE OF THE STATE OF CALIFORNIA R[LAT
ING TO WORKMENS COMP 18[.T ON INSURANCE
SIGNATURE OF HOUSE NUMBER COR-
PERMITTEF RECT AND POSTED
y
FINAL 1
ADDRESS
CLYDE N DIRLAM, RINCIPAL STURAL ENGINEER '1
PLAN CHECK VALIDATION c L N o cAGH • ,. ' PERMIT'VALIDATION F No wH
Lr _:;2 0 C 0 2 ; D 1 9.7 5,J� n � '_
•�D ' L!i'JlI.SCJ 3 G 'O U�!`I / .L D _J =... 5 C '
APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGLES BUILDING AND SAFETY
WORKER S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS
Bl1ILLyy ✓ 40 A STiPEET
I hereby OttoRate that I have a certilimpen ate n consent to self insure Coil —I—EMN E `C-I f f_ C� / �a
or a certnlrcate of Workers Compereatpn Insurance or a certified
copy thereof (Sec 3800 Lab C) CITY .i.._I. nP
Polcy No Company, LOCALITY
SIZE Fk T /J NO O B NOW ON LOT
13 Certified Copy re hereby fumahed (J �J��' NEAREST CROSS ST /O1 )_ ST �,D�,G oil'
ff
❑ Certified copy Is filed with the county building Inspection TRACT BLOCK LOT NO CT !J '�
department I USE ZONE MAP NO
Date Applicant ASSESSOR MAP BOOK PAGE PARCEL
SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER TEL NO
COMPENSATION INSURANCE WITHIN 1000 FT OF SCHOCLI YES No
ADDRESS O rfD ^I / P IDPE PROCESSED BY
(This section Reed not be completed If the permit Is for one hundred / J '/
dollars 1$1001 a less) DISTRICT GROUP TYONST FIRE_
I certify that In the performance of the work for which the permit
issued I shall not employ any person In any manner So as to CCITY- `�' �, LP
e 9�9 pD ar /�1_/, g
J
beoorre Subject t0 the Workers Compensation Latae ARCHITECT NGINE TEL NOO •
STAR"CAL CLASSSSIF CATION APT CONDO
Date Appkcam ADDRESS I / - CLASS NO .�J— DWELL UNITS
NOTICE 70 APRL/G1NT h after making the Certificate of V REQUIRED TOTAL SETBACK FROM EXIST
should become subject to the Workers CONTRACTOR TEL
Exemption, you r� N�
SET BACK YARD FM'V PROP UNE WIDTH
Compensation prosnsNCn of the Labor Cade you must forthwAh /
coney,With such pnrierDre or this Permit stall be deemed rewkatlFRONT
ADDRESS uc �
PL
LICENSED CONTRACTORS DECLARATIONSIDEt— F P L
_
I hereby affirm that am licensed underprwCITYLIC CL
epns of Chapter B {/
(commencing with Section 7000)of DN=n 3 of the Business and SO FT SIZE NO CF 4TORIV NO OF FAMILIES -SEWER MAP 1
Profession Code and my license IS In lull force and effect NEW gr BK PG , O
U
Lcanse Number - LIC Cass DESCRIPTION OF WORK IADD ❑ VALUATI
contractor Date ALTER C1 $ /i d00• to 0
o
❑ I em REPAIR ❑ F-
eXempt under Sec $
M
BARG for e reason O
DEMOL ❑ W
LDMA P/c. fi
Data USE ISnNG B URM ❑ 1 to
_ 2
11I1asSOwrer of the APPLICANT( 1 Q / /i e�r TEL NO LDMA Perm♦ = r,I.c T.Av
property n ((
IGwrerrk-eYwpaWG6m_w111 do the world and the structure is ADDRESS qp 70 — .'14 - s Et"r 0 . _TJ�J �
rpt Intended! or offered for sale (Section 7044 Business and 7 1/ ��/Z PIS DAT" _�t/ rR
v ] Q
PrOfeB9gnS Code) WILL THE APRJGVR OR FLMURE BJuDN0 C UP NT IIANDI£A Iw7MDn11S MNERYL i ITEM
❑ I ars OMRer Of to property am exclusively Contracting WIM OR A WXTUVE LOfRA➢Oq A IN[M0.'Yle IMTERDL EIX TO OR NEATER THAN THE
licensed Oantractara to construct the project (Sectcn 7044 "MN"`S SPEaF D ON THE Iw.wD«,s MATERI4S IFORI.ATON GLADE, tINAL eY TOTAL - 89 - 2-5
BuenasProfessor
ns and Professos Code) YES 1:1No /y� C
W11 THE MENDED USE OF TME 3WNJ G WTIE ARiM.M'T OR RTTL E BULDND r:HE'.T\ 29.25
OccUR1M REQUIRE A PER FOR DONSTRUDTpN OR M001MATDN FROM THE SCUTH W.tTI'B7UC , )
CONSTRUCTION LENDING AGENCY GUIDELINES ow+nY MANAGEN.ENT DSTRIm IS !))SEE PERNFTTING CHEOMUST FOR IS-/t�IF� QC.(_ r(�(
I hereby affirm that Mere Is a Construction lerdug agency for YES❑ No I
the performance of the work for which this permit Is asied(Sec
mIHN£�/p TIE INZAADDl151MTEIWLLSINFDRAUTK.W auDE AND TME SCAQp PERIAmN3
3OB7 CN C) CHECKUST I UNDERSTAND MY REOUREMENTS UNDER THE LOB MGFLES CCUNTV CODE NST-1,1, { {
Lender a Name •. a W JE TITLE 2 CHAPTER 220 BECTIDNa 220 100 TIe H 120 IAO LONLERNMG HAZARDOUS OOV V-V VO1 lO�15/91-A
FNTERULS REPDRPNO AND FOR CSPNI 3 A PERMIT FROM THE SCAeI.p yN +
Larders Address 2157 1 AM J•L
g I certify that I hairs read the appllcatGn and state under penalty PC FEE PERk4T FEE
of perryry, that the abcxe Information Is corect I agree to canpty / p
�. with all c Rty ordinances and State Taws ws mlebrg to budding /w.:xO
construction and hereby authorize representatives of the County ISSUANCE FEE
q propsry Inspection purposes 101 7�
ro enter ins r fa
m ��/ .i/O ��7� INVESOGATION FEE TOTAL FEE
�rlMr..aµpar w ion � cr
SEE REVERSE FOR EXPLANATORY LANGUAGE