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76A641.T-CE07 - APPLICATION
I
COUNTY OF LGS ANGELES SITE ,I
DEPARTMENT OF COUN'TY-ENGINEER ADDRESS
BUILDING AND SAFETY' DIVISION LOCALITY
JOHN A. LAMBIE, COUNTY ENGINEER ZAK
CASSATT D. GRIFFIN, SUP'T OF BUILDING. NEAREST
CROSS ST.
FOR APPLICANT T FILL IN MAP No STATE HWY. PRQC
jjBY
DI TRICT NO.
SITE
YES NO XI
ADDRESS USE ZONE SPECIAL
LOT CONDITIONS
NUMBERS - BLOCK
TRACT eO " N U M B E R-ws
s
s -t
SETBACK YARD : HWY..STREET NAME. WIDTHOWNER
till ;
a FRONT P.L. AMAIDDRESS 8( /
S
CITY , F N SIDE P.L
y STATE SURETY $ ;;: BONDENGINEERREG. NO, BOND t °" &' NO.
j _`: - SURETY"° aADDRES .. & COMPANY
E
ENGINEERR :s—' REGTNO. 1-- DATE
E F
LED"BYC ADDRESS
s til DEPOSIT $
BYC D DATE GRADING
TEL CONTRACTOR
c'°: NO. ADDRESS`,.
DESCRIPTION
OF WORK CHECK
IFSUPERVI GRADING SIGNATURE
OF.
APPLICANT ADDRESS&
XV15: NO.
OF CUBIC YDS. HANDLED' P.
C. $ FEE
1
HEREBY ACKNOWLEDGE THAT^. 1 HAVE READ THIS WORK TO BE COMPLETED WITHIN DAYS APPLICATION
AND STATE THAT THE ABOVEOS CORRECT AND. AGREE
TO COMPLY WITH ALL COUNTY RDINANCES FINAL CONTOUR
DATE INSPECTORS SIGNATURE AND STATE
LAWS REGULATING EXCAVATING AND ,GRAD-' MAP FI
LED ING. T
t FINALCERTI F. A OF
ENG'R. REC'D. SIGNATURE OF
Ta woRKDIS"R ICT ENG,PN E qR PERMITTEE . COMPLETED,- SURETYBONDADDRESS"
A. RELEASED
P" en,' icf C13
CL' N. DIRLIA..( PRINCIPAL STRUCTURAL ENGINEER' - PLAN CHECK VALIDATION
CK. ,; M.O. CASH PERMIT VALIDATION - CK.,` M.O. CASH 6 w 5
I )
