HomeMy WebLinkAbout6856.. APPLICATION 1 I I
FOR APPLICANT TO FILL IN (Print or type only) .. Pr
BUILDING
DEPARTMENT OF COUNTY ENGINEER
ADDRESS
BUILDING AND SAFETY DIVISION
CITY ZIP
NO. OF BLDGS.
BUILDING
SIZE OF LOT NOW ON LOT
ADDRESS
TRACT v
BLOCK J.
LOT NO.
LOCALITY
TEL.
NEAREST
OWNER NO.
CROSS ST.
ASSESSOR
ADDRESS
MAP BOOK
PAGE
PARCEL
DISTRICT GROUP TYPE FIRE
PROCESSED BY
-CITY ZIP
i '�[� CONST. ZONE
ARCHITECT OR TEL
l s
ENGINEER NO.
STATISTICAL CLASSIFICATION
SEWER MAP
ADDRESS
CLASS NO. DWELL. UNITS "�
BK PG
TEL.
CONTRACTOR NO.
USE ZONE MAP
NO.
LIC.
ADDRESS NO.
SPECIAL
CONDITIONS
LIC.
CITY P 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
SQ. FT i f NO. OF NO. OF CHECK
HIGHWAY + YARD = FRONT PROP. LINE
HIGHWAY WIDTH
SIZE 1 s Q i STORIES FAMILIES ONE,
DESCRIPTION OF WORK NEW
+
ADD
BLDG. SETBACK FROM
SIDE PROP. LINE OF
(STREET)
ALTER ❑
TOTAL SETBACK FROM
TYPEOF EXISTING
❑
HIGHWAY + YARD = SIDE PROP. LINE
HIGHWAY WIDTH
REPAIR
U E OF
EXISTING BLDG. DEMOL ❑
+
APPLICANT .Ilt TEL !
CORNER CUTOFF YES ®
NO ❑
(PRINT( �� NO. _.
IN OPEN SPACE YES ❑
NO ❑
BY (SIGNATURE)
IN COASTAL PERMIT ZONE YE
NO
y VALUATION
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI ATION AND STATE
THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL ORDINANCES
AND LAWS REGULATING BUILDING CONSTRUCTION. 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 COM-
PENSATION INSURA E.
�
SIGNATURE O,F
PERMITTEE
.
ADDRESS
®
1.
FINAL BY
E 7 9
DATE
CITY NO.
P.C. PMT.
MAKE CHECKS PAYABLE TO:
FEE FEE
HARVEY T. BRANDT, COUNTY ENGINEER
'le �r z'
CK. M.O. CASH
7 L1, 0 .2 0
PERMIT VALIDATION CK. M.O. CASH
®5 76A638A CE #803 3-75'