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HomeMy Public PortalAbout5200-5202-5204-5206 VILLAGE CIRCLE DR_Building__ F APPLICATION FOR BUILDING PERMIT FOR APPLICANT TO FILL IN (Print or type only) Bur_DIRNG COUNTY OF LOS ANGELES ADDESS5200-:2-4-61 DEPARTMENT OF COUNTY ENGINEER CITY r, ZIP BUILDING AND S I FETY DIVISION NO.OF BLD S. BUILDING / SIZE OF 'LOTd r% OW'ON LOT ADDRESS �•'• h'r J. TRACT • 8 LOT NO LOCALITY 29 02 ' TEL. NEAREST •r OWNER -r NO ICROSS ST. ASSESSOR ADDRESS ik - f, MAP BOOK PAGE PARCEL DISTRICT GROUP TYPE FIRE PRO-CfSSED,BY CITY ZIP ,, _.{� .t CONST, �.l_: ZONA /J A R C H I T L. 1 ✓ •- ENGINEER FA 71209pot9l NO. STATISTICAL CLASSIFICATION SEWER MA`P ADDRESSAL w Tn�LASS NO.__.'-._�.;_DWELL,UNITS _�f] BK PG CONTRACTOR NOL• USE ZONE MAP ldwin - LIC. NO. ADDRESS NO" SPECIAL -0017- GV00ft St.CITYraMpl@Cit LIC. CONDITIONS CLASS BMIROAD DEPARTMENT APPROVAL REQUIRED YES❑ NO ❑ d CONSTRUCTION LENDER C NAME AND BRANCHImperial (" BLDG.SETBACK FROM �' c_' FRONT PROP.LINE OF :4 _ - ,•'-UOREET: LL ADDRESS �� CITY TOTAL SETIBACK FROM T'IPE OF EXISTING V' HIGHWAY + YARD SO. FT. O NO. O CK FRONT PROP. LINE HIGHWAYWIDTH } SIZE 581 1 STORIES FAMILIES ONE 1. _ .� a � DESCRIPTION OF WORK NEW + ADD BLDG.SETBACK FROM (STREETI SIDE PROP. LINE OF W ALTER TOTAL SETBACK FROM ~ 1 ^ HIGHWAY + YARD = TYPE OF EXISTING '°"`'' SIDE PROP. LINE HIGHWAY WIDTH REPAIR❑ USE OF + _ EXISTING BLDG, EMOL ❑ APPLICANT EL CORNER CUTOFF YES ❑ NO ❑ (PRINT) Noel U1,410jim NO. BY (SIGNATURE) IN OPEN SPACE YES ❑ NO ❑ Q / IN COASTAL ZONE YES ❑ NO ❑ VALUATION d' 000,00J ,:(' .'': + ( CATEGORICAL EXEMPTION YES❑ NO ❑ I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION ENVIRONMENTAL . ANO STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY IMPACT EXEMPTION DECLARATION SIGNED (DATE) WITHALL ORDINANCES AND LAWS REGULATING BUILDING CON- STRUCTION. I CERTIFY THAT IN DOING THE WORK AUTHORIZED IMPACT REPORT PROCESSED (DATE) HEREBY I WILL NOT EMPLOY ANY PERSON IN VIOLATION OF THE LABOR CODE OF THE STATE OF CALIFORNIA IN RELATING TO WORKMEN'S COMPENSATION INSURANCE. SIGNATURE OF - PERN11 TTEE ADDRESS FINAL iBY TEL. DATE CITY NO. P.C. PMT,C tl.1kF. t./fLl KC f':1).1 f;1.L I Ur FEE FEE W HARVEY T. BRANDT. COUNTY ENGINEER -R... r .. PLAN CHECK VALIDATION CK M0 CASH _ PERMIT VALIDATION CK M O CASH d U ?w w .r.v .c 3 3 .' 76A638A CE#803 7/73 APPLICATION FOR BUILDING PERMIT 400R APPLICANT TO FILL IN (Print or type only) BUILDING r COUNTY OF LOS ANGELES ADDRESS . �% ' C DEPARTMENT OF COUNTY ENGINEER CITY /]1 )/ ZIP V ` BUILDING AND SAFETY DIVISION E' NO.OF BLDG S���ICL 0 ADDRESS BUILDING S ZO CQ �, SIZE OF))LO NOW ON LOT (/ /1� TRACT•0( 601•1 t-*-30 LOT NO. LOCALITY TELNEAREST OWNER j,� NO. . • CROSS ST. ASSESSOR ADDRESS 4 e_ Ci/ ele be, MAP BOOK PAGE PARCEL p A DISTRICT GROUP TYPE FIRE PR ESS BY CITY j ZIP ! CONST ZONE ARCHITECT O f T L. �� 0 ��� ENGINEER Q W em NO. .54m STATISTICAL C,LyASrSIFICATION SEVER MAP ADDRESS �� CLASS NO.�DWELL.UNITS BK G TEL. 'USE ZONE MAP ¢¢�� CONTRACTOR �G!//Y�/Z NO S�/N�- NO, ZO V LIC. L.. `�i1 SPECIAL ADDRESS � NO. L/ LIC. t CONDITIONS CITY (� CLASS 1.�_ ROAD DEPARTMENT APPROVAL REQUIRED YES❑ NO❑ CONSTRUCTION LENDER `' NAME AND BRANCH aN a BLDG.SETBACK FROM ADDRESS [/ CITY FRONT PROP.LINE OF (STREET) HIGHWAY + YARP = ITOTAL SETBA K FROM TYPE OF EXISTING SQ, FT NO. OF NO. OF CHECK i FRONT PRO LINE HIGHWAY WIDTH SIZE 2�L'l� STORIES FAMILIES 'ONE DESCRIPTION OF WORK -f to NEW /"Y + ADD ❑ BLDG.SETBACK FROM SIDE PROP.LINE OF (STREET) C ALTER ❑ HIGHWAY + YARD = O A S TB C FRO TYPE OF EXISTING C~7 REPAIR❑ SIDE P OP. I E HIGHWAY WIDTH USE EXISOT NG BLDG. DEMOL ❑ + Z AP PLICANTNT) )' L ,{ NAL V3 �'°? CORNER C OFF El NO ❑ \ J BY (SIGNATURE) IN OPEN SPACE YES ❑ NO ❑ f IN COASTAL PERMIT ZONE YES ❑ NO ❑ QQ �' VALUATION;�Pp� 7� I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY WITH ALL ORDINANCES AND LAWS REGULATING BUILDING CON- STRUCTION. 1 CERTIFY THAT IN DOING THE WORK AUTHORIZED HEREBY 1 WILL NOT EMPLOY ANY PERSON IN VIOLATION OF THE LABOR CODE OF THE STPTE OF -CALIFORNIA IN RELATING TO WORKMEN'S COMPENSA N INSU SIGNATURE OF PERMITTEE. le- TE ADDRESS t///;,& Q'icG j / CITYf' �1, NOL• /'' DIATE 7 �- Z"� BY C PMT ,%AKE CHECK PAYABLE TO: FEE• 9 FEE"$ ^, © �y v HARVEY T. BRANDT, COUNTY ENGINEER PLAN'CHECK VALIDATION CK. M.O. CASH a PERMIT VALID-A�T,I,O�NN CK. M.O. CASH 7 6 4 Nk)0V 3.2 1 0 9.0 0 e � 76AG38A C6#803 5/74 WORKERS' COMPENSATION DECLARATION I.hereby affir.. that I have r certificate of consent to self APPLICATION FOR BUILDING PE!MI T •insure,'or a certificate of Workers' Compensation Insurance, or a certtfie co yqtherf(Sec. 3800La'b. COUNTY OF LOS ANGELES BUILDING AND SAFETY Ago, oic No. Company �+ BUILDINGCerti ied coereby furnished. ��- a.. FOR APPLICA T TO FI N ADDRESS l� Certified copy is filed with th ty building inspec- BUILDING1(4 tion department. ADDRES / Date I- 7�Applicant CI �r"� ZI LOCAUW NO.OF LDGS. NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NOW ON LOT CROSS ST. COMPENSATION INSURANCE ASSESSOR (This section need not be completed if the permit is for one TRACT BLOCK LOT NO. MAP BOOK P E PARCEL hundred dollars ($100)or less.) TEL. OWNER NO. USE ZONE MAP NO. 1 certify that in the performance of the work for which this �i SPECIAL } permit is issued, I shall note erson in any manner ADDRES 1 (� �`r• ��� CONDITIONS o so as to become suble the Workers' o sation Laws. `� O CITY v ZIP 6 U Date Applicant ARCHITECTPR TEL. DISTRICT GROUP TYPE FIRE P CESSED BY tY NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. 9 CONST. ZONE 0 Exemption, you should become subject to the Workers' �• �uG U ADDRESS w Compensation provisions of the Labor Code, you must forth- a with comply with such provisions or this permit shall beTEL• , STATISTICAL CLASSIFICATION APT. CONDO. Z deemed revoked. CONTRACTOR ONTRALTO NO. _ LICENSED CONTRACTORS DECLARATION LIC. CLASS No.�_DWELL. UNITS - I hereby affirm that I am licensed under p visions of Chapter 9 ADDRESS NO. (commencing with Sectio 7 )of Di can 3 of the Business LIC. SEWER MAP and Professions Cod I' e s in full force ct. CITY CLASS BK PG. VALIDATION SQ. FT. NO. OF NO. OF CH CK License f u�be i . Class SIZE !Ob STORIES FAMILIES ONE JAI JII ,i DESCRIPTION OF OR NEW 1:1 VALUATION Contr r L� to f- $ �(( d !r •� ADD ❑, ► ❑I am exempt uncle Sec. �n J r. it ALTER ❑ $ B.BP.C. for this reason SoTia_ S PAIR ate: US F EXISTING BLDG. 1-1�1OL ❑ Signature APPLICANT TEL. FINAL OWNER-BUILDER DECLARATION (PRINT) NO. IA5r I hereby affirm that I am exempt from the Contractor's License DATE d•-3� Law for the following reason (Section 7031.5, Business and ADDRESS FINAL Professions Code): PRESENT By ElP P Y. or mY emP ADDRESS 91A I, as owner of the ro ert to ees with BUILDING ° - Y 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. •�':�n CONTRACTOR NO. t --.,•• El 1,as owner of the property,am exclusively contracting ; with licensed contractors to construct the project (Sec- ADDRESS F: r - tion 7044, Business and Professions Code.) `Y. sri� ' Cr- 68 REQUIREDTOTAL SETBACK FROM EXIST. ,;, CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH :p-t�is'•, I hereby affirm that there is a construction lending agency for FRONT the performance of the work for which this permit is issued F•L. :lif�+�[ ,f;.•'; (Sec. 3097, Civ. C.). SIDE " P.L. Lender's Name ' t P. �j y:i: z�:7; g �JLDMA Ref. # o` i11u+���'I_+SIJ 3 i; l ii C. Fee$ Permit Fee cls -•� Lender's Address •� 00 1 certify that'l have read this application and state that the Issuance Fee a y LDMA P/C# 3 above information is correct. Iagree to com ly with all County Investigation Fee G� ordinances and State laws relating to •ui ding construction, Total Fee 171'570 4% LDMA Perm. # and her y out ize r resentative o t is County to enter on the ove- ntio arty pec io/n�rposA. e eU-MVn �� SEE REVERSE FOR EXPLANATORY LANGUAGE 141 Will Signature of A icon or Agent Date