HomeMy WebLinkAbout7438OR
CA
FOR APPLICANT TO FIL�LlIN (Pr'or tv�on� BUILDING
'fl
BUILDING
COUNTY OF LOS ANGELES
ADDRESS re
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION
CITY 1r04�0,q,4fi ZIP
NO, OF SLOGS.
BUI LD i '�
�SG'Lt'',_
SIZE OF LOT NOW ON LOT
ADDR S ;j ell,, P 6`-
TRACT r� /�U
BLOCK
LOT NO.
LOCALITY E�
TEL
NEAREST
OWNERff=h1 NO, 11
r
CROSS ST.
ADDRESS
ASSESSOR
MAP BOOK �GGROUP
PAGE PARCEL
DISTRICT TYPE FIRE PROCESSED BY
,a�
CITY ,,m•• v j�[.,/'C ZIP
TEL,
CONST, ZONE
ARCHITECT OR p
- �6 �" O• "' /
/�
ENGINEER J e
STATISTICAL CLASSIFICATION SEWER MAP
/P
ADDRESS 7 t/ i'j l (
CLASS NO. ADWELL,UNITS BK PG
CONTRACTOR TEL,
USE ZONE MAP
LIC,
NO,
ADDRESS NO,
SPECIAL
LIC,
CONDITIONS
CITY CLASS
ROAD DEPARTMENT APPROVAL REQUIRED YES ® NO
CONSTRUCTION LENDER
NAME AND BRANCH
BLDG. SETBACK FROM
FRONT PROP, LINE OF (STREET)
ADDRESS CITY
_ TOTAL SETBACK FROM TYPE OF EXISTING
HIGHWAY + YARD -
SQ. FT. NO. OF NO, OF CHECK
RONT PROP, LINE HIGHWAY WIDTH
SIZE STORIES FAMILIES ONE
DESCRIPTION OF WORK / NEW ❑
+
tj."�
L ADD
BLDG,SETBACKFOM
SIDE PROP, LIN OF (STREET)
ALTER ❑
TOTAL SETBACK FROM EXISTING
„ , o
HIGHWAY i YARD -_ TYPE OF
HIGHWAY WIDTH
REPAIR ❑
SIDE PROP, LINE
USE
❑
+
EXISTING BLDG, DEMOL
APPLICANT TEL
CORNER CUTOFF YES ❑ NO
(PRINT) NO.
IN OPEN SPACE YES ❑ NO ❑
BY (SIGNATURE)
Lt .
IN COASTAL ZONE YES ❑ NO
VALUATION $
CATE RICAL EXEMPTION YES ❑ NO
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
ENVIRONMENTAL
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
IMPACT E MPTION DECLARATION SIGNED (DATE)
WITH ALL ORDINANCES AND LAWS REGULATING BUILDING CON-
STRUCTION. I CERTIFY THAT IN DOING THE WORK AUTHORIZED
MPACT REPORT PROCESSED (DATE)
HEREBY I WILL NOT EMPLOY ANY PERSON IN VIOLATION OF THE
LABOR CODE OF THE STATE OF CALIFORNIA IN RELATING TOPL
�r
WORKMEN'S COMPE N. ATION INSURANCE.
7 Y 6�
SIGNATURE OF
P E R M I T T E E
ADDRESS
FINAL BY
TEL,
CITY NO,
DATE
KE CHECKS PAY t31-E TO:
T. BRANDT, COUNTY ENGINEER
=HARVE�
FEE FEE
PLAN CHECK VALIDATION (_-9 M.O. CASH
i� I, o / r,� 5 c-'i ! J JUL j-) 7 7 69f) C
76A638A CE4803 12/72
PERMIT VALIDATION CK. M.O. CASH
C�7
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