HomeMy WebLinkAbout5340APPLICATION FOR BUILDING PERMIT
FOR APPLICANT TO FILL IN (Print or type only)
BUILDING
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BUILDING
ADDRESS
ADDRESS
CITY ZIP
LOCALITY Z�L
NO, OF BLOGS,
NOW ON LOT
NEAREST
SIZE OF LOT
CROSS ST.
I TRACT IBLOCK I LOT NO Z
ASSESSOR 'A PAGE
MAP BOOK I 1PARCEL
TEL
DISTRICT GROUP TYPE FIRE PROCESSED BY
OWNER
CONST. ZONE
ADDRESS
STATISTICAL CLASSIFICATION SEWER MAP
CITY ZIP I
CLASS NO. _DWELL,UNITS BK PG
* RC-+-+4 T-E-C T-9Rr_ T E L..,
ENGINEER NO.
USE ZONE MOP
ADDRESS
SPECIAL
T EL.
CONDITIONS
CONTRACTOR No.
ROAD DEPARTMENT APPROVAL REQUIRED YES NOE]
LIC*
ADDRESS NO,
BLDG, SETBACK FROM
LIC.
CITY
FRONT PROP, LINE OF (STREET)
CLASS
HIGHWAY + YARD TOTAL SETBACK FROM TYPE OF ;EXISTING
CONSTRUCTION LENDER _
FRONT PROP. LINE HIGHWAY WIDTH
NAME AND BRANCH
+
ADDRESS CITY
SQ. FT. NO. OF NO. OF CHECK
BLDG, SETBACK FROM
SIZE STORIES FAMILIES ONE
SIDE PROP, LINE OF (STREET)
CD
NEW ❑ HIGHWAY + YARD = TOTAL SETBACK FROM TYPE OF EXISTING
DESCRIPTION OF WORK
ADD El
ALTER ❑
SIDE PROP. LINE HIGHWAY WIDTH
+
/w
EPA I R ❑
11EMOL E]
CORNER CUTOFF YES NO
IN OPEN SPACE YES ❑ NO
USE OF
EXISTING BLDG.
APPLICANT TEL
IN COASTAL ZONE YES E] NO
(PRINT) NO.
CATEGORICAL EXEMPTION YES❑ NO
BY (SIGNATURE)
ENVIRONMENTAL
EXEMPTION DECLARATION SIGNED (DATE)
IMPACT
VALUATION 61
$
1
IMPACT REPORT PROCESSED —(DATE)
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 EMPLOY ANY PERSON IN VIOLATION OF THE
LABOR CODE OF THE STATE OF CALIFORNIA IN RELATING TO
WORKMEN'S NS,AT ION IN7SURAKC
FINAL
BY
SIGNA T U OF
L&I
I
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P E R M I T Tg&'g
DATE
ADDRESS
P, C. $
FEE
PMT.$
FEE
TE L.
A, r
CITY NO.
PERMIT VALIDATION -6c. M.O. CASH
PLAN CHECK VALIDATION kiC. M.O. CASH
ro 22 71� 5429 12 0 23
0 122276 1 1 80.0 0
76A6386 CE4803A 5/73