HomeMy WebLinkAbout0937APPLICATION FOR BUILDING1
FOR APPLICANT TO FILL IN (Print or type only)
ING
COUNTY OF LOS ANGELES
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DEPARTMENT OF COUNTY ENGINEER
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BUILDING AND SAFETY DIVISION
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ROAD DEPARTMENT APPROVAL REQUIRED
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APPLIC NT
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CORNER CUTOFF YES
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IN OPEN SPACE YES ❑
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IN COASTAL PERMIT ZONE YES ®
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VALUATION
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I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL ORDINANCES AND LAWS REGULATING BUILDING CON-
STRUCTION, I CERTIFY THAT IN DOING THE WORK AUTHORIZED
HEREBY I WILL NOT EMPLJPY ANY PERSON IN VIOLATION OF THE
LABOR CODE OF THE S p,TE OF CALIFORNIA IN RELATING TO
WORKMEN'S COMPENSAT ON INSUR CE.
SIGNATURE OF
PERMITTEE
ADDRESS
CITY -�- f N� a
FINAL
DATE
BY
MAKE CHECKS PAYABLE TO:
FEE
FEE'
FEE
HARVEY T. BRANDT, COUNTY ENGINEER
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0011L
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PLAN' CHECK VALIDATION M.O. CASH
PERMIT VALIDATION
093 7 5 1 575 2 1 5 5.8 0
(193 8 5 1575 1
76A638A CEI#803 5/74 s
7
PMT.'$
FEE PP p
C K. M.O. CASH