HomeMy WebLinkAbout1109APPLICATION FOR BUILDING PERMIT
FOR APPLICANT TO FILL IN (Print or type only)
BUILDING
BUILDING
COUNTY OF LOS ANGELES
ADDRE 0 -
S S
DEPARTMENT OF COUNTY ENGINEER
i
el
BUILDING AND SAFETY DIVISION
CITY
7, 7
NO OF BLOGS
NO BLIGS,
BUILDING
N LOT
N&V ON LOTS
OF LOT NOW
ADDRESS
TRACT 0
I BLOCK
LOT NO.
LOCALITY
TEL
OWNER No
NEAREST
CROSS ST.
ASSESSOR
r
ADDRESS J
MAP BOOK "s
PAGE
PARCEL
DISTRICT GROUP TYPE FIRE PROCESSED BY
CONST,_
CITY Z I P
/7-- Z?NE
ARCHITECT Ofk TEL
ENGINEER NO .
STATISTICAL CLASSIFICATION SEWER MAP
ADDRESS "
ca 1-,59 /s
CLASS NO.a-OWELL.UNITS'L � BK/Z&G
EL.
CONTRACTOR A"t-J112' NO,
USE ZONE MAP
NO.
LIC.
ADDRESS NO,
SPECIAL
LIC.
J17
b �9 CONDITIONS
CITY
CLASS
ROAD DEPARTMENT APPROVAL REQUIRED YES NO
CONSTRUCTION LENDER
AND BRANCH
BLDG. SETBACK FROM
-NAME
FRONT PROP, LINE OF (STREET)
ADDRESS CITY
HIGHWAY + YARD TOTAL SETBACK FROM TYPE OF EXISTING
SQ. F NO. OF NO OF CHECK
FRONT PROP. LINE HIGHWAY WIDTH
SIZE STORIES -FAMILIES ONE
[
+
JSC&RIPTION
OF WORK NEW A I
ADD
BLDG, SETBACK FROM
SIDE PROP. LINE OF .(STREET)
ALTER
HIGHWAY + YARD = TOTAL SETBACK FROM TYPE OF EXISTING
HIGHWAY WIDTH
REPAIR❑
USE OF
SIDE PROP. LINE
+
t_u
EXISTING BLDG, DEMOL
APPLICANT
(PRINT) _�V 0-0 -10)
CORNER CUTOFF YES ❑ NO
BY (SIGNATURE)
IN OPEN SPACE YES ❑ NO ❑
IN COASTAL PERMIT ZONE YES ❑ NO
VALUATION, $ q- q
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-
ERTIFY THAT IN DOING THE WORK AUTHORIZED
STRUCTION . I CERTIFY
HEREBY I WILL HOT EMP ANY PERSON IN VIOLATION OF THE
�X
LABOR CODE .1 THE I` - E OF -CALIFOR'NIA IN RELATING TO
VIN WORKMEN'S COMPENSA,TINSJ/RA
SIGNATURE OFJ/
PERMITTEE
ADDRESS
FINAL BY
TEL,
CITY
DATE
MAKE CHECKS PAYABLE TO:
P'C*PMT.:
FEE '$ FEE $
HARVEY T. BRANDT, COUNTY ENGINEER]
PLAN CHECK VALIDATION rc M.O. CASH
PERMIT VALIDATION (810y M.O. CASH
1
2 1
1 9
76A638A CE:#803 5/74