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76A688A CE#809..•61 APPLICA`I'I.ON FOR BUILDING PERM01
COUNTY OF:LOS ANGELES BUILDING
DEPARTMENT OF COUNTY ENGINEER• ADDRESS
BU=lNG AND SAFETY DMSION LOCALITY
.JOHN A. LAMBIE, COUNTY ENGINEER NEAREST
WILLIAM A.JENSEN SUPT of BUILDING CROSS ST.
FOR APPLICANT TO FILL IN DISTRICT NO Ou .��E BY/
d CONST:
-BUILDING. p / STATISTICALC CLASSIFICATION BE MAP-
ADDRESS % ��. 6 �JA1� 0o/ K
CLASS.NO>�DWELL.UNITS
LOT NO. a BLOCK 'WATER . NOT REQUIRED, RECEIVED
CERTIFICATE:
TRACT �UZ MAP /� HIGHWAY STATE'MAJOR SECOND, LOCAL
NO,OF BLDGS. ) NO. V 03 (CIRCLE)
SIZE OF LOT NOW ON.LOT / USE zpft, SPECIAL
USE OF CONDITIONS
'EXISTING BLDG.
TEL.
OWNER F_ NO. BUILDING YARD HWY STREET NAME EXIST.
SETBACK WIDTH
ADDRESS FRONT / ,/ 7-
ARCHITECT ORL. P.L.
ENGINEER O L 151 SIDE
P.L. O
ADDRESS TEL. INSPECTION RECORD.
CONTRACTOR '-/FL. O!! NO.,q,
O
ADDRESS
V
DESCRIPTION OF WORK H
• ,os \ z
NEW ADD ALTER REPAIR DEMOLISH' _ �/
SQ.FT. NO..OF NO.OF
IZE STORIES FAMILIES ��
USE OF• /lY7�'I�iC '
STRUCTURE l -�
SIGNATURE OF
APPLICANT
VALUATION$ -
APPROVALS DATE INS.PECTOR'S SIGNATURE
P.C. ! PMT. / FOUNDATION:LOCATION
FE
E FEE $ (/ L! FORMS,MATERIALS
FRAME:FIRESTOPS,
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION BRACING BOLTS
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY FURNACE:LOCATION,
WITH ALL'COUNTV ORDINANCES AND STATE LAWS REGULATING GAS VENT DUCTS-
BUILDING CONSTRUCTION. I CERTIFY THAT IN DOING•THE WORK ,
AUTHORIZED,HERESY 1 WILL NOT EMPLOY ANY PERSON IN VfOLA• LATH,INT.
TION OF THE LABOR CODE OF-VE STATE OF CALIF RMIA RELAT•
INC TO WORKMEN'S COMP 1 S
• - LATH.EXT.
SIGNATURE OF HOUSE NUMBER COR-
PERMITTEE REdT AND POSTED
ADORES FINAL /
�� CLYDE N. DIRL.AM., PRINCIPAL ST RAL ENGINE R
PLAN CIffCg VALIDATION M.o. CASH PERMIT VALIDATIONcK. m.o. cAol!
0 9 1. 2:x:... 4UN28 2 3. D 3.75 ••Q
Y j,AC&O 9 1. 3 ma JW 2.8 1 D .1 5.010
DBPARMWINT OF COUNTY MGIIi= ,
VISION OF BUILD= AND
COUNTY OF LOS ANGE6ffi$A �'Q ,�� "•
+ BUILDING
1rl/ILLIAM J. FOX, COUNTY ENGINEER ` r APPLICATION
BATT D. GRIFFIN, SUP'i OF BUILDING
FOR APPLICANT TO FILL IN FOR OFFICE USE ONLY
DISTRI NO. PLAN CK.oR Rica.No. PERMIT NO.
BUILDING
ADDRESS
LOCALITY Yu �L^-' , EIVED BY DATE OF APPL. DATE ISSUED
NEAREST BT .P
BUILDING
B
ADDRESS
OWNER (� //r0-
MAIL ADDRESS' r O f j� LOCALITY / '
NEAREST
CITY cg'� p••• , �( -- f CROSS ST.
ARCHIENGINEECy OR �^_ ! NOL /��w /" F"1 ZONE I PLANS
G. �,,/� I �,/�P / I GROUPADDRE88l/6J ��E�"
SETBACK LINE �C/ • /�-� ORD. NO.
P ,,, �,,p,,/ TEL
USE / APPROVED
CONTRALTO '6w�' NO ZONE BY PATE
ADDRESS 6 HOUSE NUMBERING
DES LEGAL
NO. a B CK MAP NUMBER_ //� NO- ASSIGNED--
TRACT if 670 C RRECTIONS
SIZE OF LOT, f LG I NOW ON LOT
USE OF NO.OF
EXISTING BLDG. ANit16
D nON OF WORK r-,? A'.>6!r Ir f'pA717 00 -
NEW ALTERATION ADDITION I `A10 J Mr r /9'F• iz e�. Q a
—I PAy 7 z
REPAIR DEMOLITION I -i r
r
8 Q.ZE T, 7NO,OF d ROOMS 6 STORIESEXT. WALL ROOF
COVERING I COVERING ,4 o
WE
USE STRUCTURE 1 ���
Q , T 6/
APPROVALS
INSPECTOR'S SIGNATURE DATE
FOUNDATION:LOCATION •�
FORMS, MATERIALS
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS AP- FRAME: FIRE STOPS. f�
PLICATION. AND STATE THAT THE INFORMATION GIVEN IS BRACING, BOLTS
CORT.
A REE TO COMPLY WITH ALL COUNTY ORDINANCES FURNACE:LOCATION, v
AND STATE LAWS REGULATING BUILDING CONSTRUCTION. GAS VENT, DUCTS
SIGNATURE P RMI ITE O ATH, INT.
e� LATH. EXT,
AD_DRE 7
PLASTER, INT.
AUTHORIZED AGT.
PASTER, EXT.
S % FEE• S -' HOUSE NUMBER COR-
RECT AND POSTED
V
VALUATION (L// l J FEE 4
/ FINAL 30 n
76AGSSA Does S-SS ' 12
� JJMPENSATION DECLARATION
+4V6 „ alaI have certificate 0f consent to $e(f
ora� Comp nsation Insurance,
APPLICATION FOR B U I L D I N G PERMIT CUinsure, a Workers'
or a certified copy thereof Sec. 380D, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. . ompany 6W.9 � BUILDING
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS
❑ Certified copy is filed with the county building inspec- BUILDING
tion epar ment. X V6// ADDRESS
Date Applicant (/�%ze
�•• S CITY ZIP LOCALITY
ERTI CATS OF EXEMPTION FROM ORKERS' 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 � 2 BLOCK LOT NO. MAP BOOK PAGE PARCEL
EL.2/ USE ZONE MAP
I certify that in the performance of the work for which this OWNER O.�J' S NO.
permit is issued, I shall not employ any person in any manner v SPECIAL
so as to become subject to the Workers'Compensation Laws. ADDRESS �- CONDITIONS
Dote Applicant CITY ZIP
NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT ORF T91 DISTRICT I GROUP I TYPE FIRE �SSSED BY G
Exemption, you should become subject to the Workers' ENGINEER NO. CONST./ ZONp,F.
Compensation provisions of the Labor Code, you must forth- ADDRESS `' '—" V �
with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION APT. PDO. V)
deemed revoked. CONTRACTOR + NO� ' )
LICENSED CONTRACTORS DECLARATION s� LIC. //�� CLA55 NO. DWELL. UNITS
—
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS `,0, ♦ NO.O+
(commencing with Section 7000)of Division 3 of the Business and r LIC. SEWER MAP
Professions Code, and my license is in full force and effect. CITY CLASS I BK PGVALIDATION
SQ.FT. NO.OF NO.OF CHECK
License Number Lic.Class SIZE STORIES FAMILIES ONE
• VALUATION
Contractor Date DESCRIPTION OF WORK y
NEW
D ❑❑ $ ;W
I am exempt under Sec. `� ALTER ❑ VV pill.
B.&P.C. for this reason I REPAIR ❑ $
USE OFc` ❑
Date: EXISTING BLDG. & C LZ DEMO"
Signature APPLICANT N L. / FINAL
PRINT O
OWNER-BUILDER DECLARATION DAT cJtO 379. 1 A
I hereby affirm that I am exempt from the Contractor's License /
Law for the following reason (Section 7031.5, Business and ADDRESS" r7 i FI L # o o a o 2 1
Professions Code): PRE5EN❑ ° ° 81.29
I, as owner of the property, or my employees with BUILDING ADDRESS
wages as their sole compensation,will do the work and 2 9=
the structure is not intended or offered for sale ISection LOCALITY , o o a8 1 5
7044, Business and Professions Code). MOVING TEL.
❑ I, as owner of the property,am exclusively contracting CONTRACTOR NO. 01.09-86
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code). REQUIRED TOTAL SETBACK FROMEEEt ;2379.2A
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 0 0 1
the performance of the work for which this permit is issued P.L.
(Sec. 3097, Civ. C.). SIDE
3
Lender's Name
?� WMA Ref. # 0 0 1 0(j, 1 3
P.C.Fee$ r Permit Fee r 3/
- Lender's Address
r I certify that I have read this application and state that the Issuance Fee LDMA P/C# 0 1,09-86
above information is correct. I agree to comply with all County Investigation Fee 2
dinanc nd State laws relating to building construction, Total Fee Q 16 -1 3 WMA Perm.#
reK author! pre ives of this County to enter
upon f bove-mentioned rty fo spection rp ses.
a
o SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature ofLica ArAgent Plate " �"