HomeMy WebLinkAbout1143APPLICATION UI i 1
FOR APPLICANT TO FILL IN (Print or type only)
BUILDIN
COUNTY OF LOS ANGELES
ADDRES . .
b DEPARTMENT OF COUNTY ENGINEER
ell 47
BUILDING AND SAFETY DIVISION
CITY
ZIP 7
NO, OF BL GS.
BUILDING
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SIZE OF LOT
NOW ON LOT
ADDRESS r,-� - � � � �J'df�°'f',�`
TRACT��j
BLOCK
LOT NO.
LOCALITY
OWNER S
TEL
NO.
NEAREST
CROSS ST. - `/ �-� L
-
ASSESSOR Y d
ADDRESS J
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MAP BOOK r=
PAGE PARCEL
3
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DISTRICT GROUP TYPE FIRE PROCESSED BY
CONS T. ZONE �i"
CITY
ARCHIT CT
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OR
,
ENGINEER-
NO
STATISTICAL CLASSIFICATION SEWER fv1 P
ADDRESS
CLASS NO. DWELL,UNITSy BfpG
CONTRACTOR
No.
USE ZONE MAP
L I
m N O.!,
ADDRESS
NO e
!% C f CONDIIT ONS
CITY
LIC.
CLASS
ROAD DEPARTMENT APPROVAL REQUIRED YES ❑ NO
CONSTRUC ION LENDER
NAME AND BRANCH
BLDG. SETBACK FROM
STREET)
FRONT PROP, LINE OF'"
ADDRESS
CITY
HIGHWAY } YARD -_ TOTAL SETBACK FROM TYPE OF EXISTING
.. SQ. FT NO. OF
NO. OF CHECK
FRONT PROP. LINE HIGHWAY WIDTH
SIZE STORIES
FAMILIES ONE
DES'CR PT N-'6F'WO K "' ' `
ytI NEW
Cw�
❑
BLDG, SETBACK FROM_-j
y i
2
ADD
SIDE PROP, LINEOF ' ` °} -- (STREET)
tom;
t'
ALTER ❑
HIGHWAY } YARD = TOTAL SETBACK'- ROM TYPE OF EXISTING
HIGHWAY WIDTH
7
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REPAIR❑
SIDE PROP. LINE
Lrt
USE OF
t
EXISTING BLDG.
DEMOL ❑
?
APPLICANT
(PRINT)
TEL
, NO
CORNER CUTOFF YES NO
IN OPEN SPACE YES ❑ NO ❑
BY (SIGNATURE)
IN COASTAL PERMIT ZONE YES ❑ NO ❑
w VALUATION,$ f ) 3
1 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 1 WILL NOT EMPLOY ANY PERSON IN VIOLATION OF THE
OF
LABOR CODE OF THE ST E OF •CA IFORNIA IN RELATING TO
WORKMEN'S COMPE NSATI INS
e-
4F..
SIGNATURE OF
PERMITTEE
ADDRESS
FINAL
BY
TEL.
DATE
CITY NO.
MAKE CHECKS PAYABLE 7'0:
HARVEY T. BRANDT, COUNTY ENGINEER
FEE
FEEL'
::IFEEMT,;$
PLAN CHECK VALIDATION K.y M.O. CASH
PERMIT VALIDATION
CK.4 M.O. CASH
!t
u.
L
76AG38A CE#803 5/74