HomeMy WebLinkAbout6863APPLICATION I IPERMIT
FOR APPLICANT TO FILL IN (Print or type only)
COUNTY OF LOS ANGELES
x, BUILDING ADDRUS DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION
E%3 CITY ZIP
O. OF BLDGS.
BUILDING
SIZE OF LOT NOW ON LOT
ADDRESS
TRACTS
BLOCK
LOT NO.
LOCALITY t 1 CA W, IN
TEL.
NEAREST
OWNER NO.
CROSS ST.
ASSESSOR
ADDRESS
MAP BOOK
PAGE
PARCEL
DISTRICT GROUP TYPE FIRE
PROCESSED BY
CITY ZIP
[ADDRESS
L � ,,.,�, CONST. ZONE
i I
ARCHITECT OR TEL.
_
ENGINEER NO.
STATISTICAL CLASSIFICATION
SEWER MA
CLASS NO. DWELL. UNITS ` n
BK PG
TEL.
ONTRACTOR NO.
USE ZONE MAP
NO.
LIC.
DDRESS NO.
SPECIAL
LIC.
[NAME
CONDITIONS
ITY CLASS
ROAD DEPARTMENT APPROVAL REQUIRED
YES ❑ NOONSTRUCTION
LENDER
AND BRANCH
BLDG. SETBACK FROM
FRONT PROP. LINE OF
(STREET)
ADDRESS CITY
_ TOTAL SETBACK FROM
HIGHWAY YARD
TYPE OF EXISTING
SQ. FT at''` NO. OF �'" _ NO. OF % CHECK
SIZE Q STORIES FAMILIES E ON
FRONT PROP, LINE
HIGHWAY WIDTH
DESCRIPTION OF WORK NEW
+
ADD
BLDG. SETBACK FROM
SIDE PROP. LINE OF
(STREET)
a ALTER ❑
TOTAL SETBACK FROM
HIGHWAY + YARD = SIDE PROP. LINE
TYPE OF EXISTING
IHIGHWAY WIDTH
REPAIR ❑
. USE OF
EXISTING BLDG. , DEMOL ❑
{- _
` APPLICANT TEL
CORNER CUTOFF YES ❑
NO ❑
` IPRINTI NO.
IN OPEN SPACE YES ❑
NO ❑
BY (SIGNATURE) ,
_
IN COASTAL PERMIT ZONE YES ®
NO
�
'* VALUATION
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 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 INSURANCE.
SIGNATURE OF
' PERMITTEE dd��
ADDRESS
FINAL '
BY
TEL "` }
DATE
CITY N
MAKE CHECKS PAYABLE TO:
P.C.
FEE
PMT.
FEE
HARVEYT. BRANDT, COUNTY ENGINEER
VA �
I UN 1101,71
CK. M.O. CASH
nU
PERMIT VALIDATION CK. M.O. CASH
Os 76A638A CE #803 3-75'