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CE #803 (REV. 11 / 78)
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APPLICATIONIPERMIT
COUNTY OF LOS ANGELES
BUILDING AND SAFETY
FOR APPLICANT TO FILL IN
BUILDING
ADDRESS
BUILDING
ADDRESS
LOCALITY `;
NEAREST
CITY q yr l C j j ZIP P,1765
CROSS ST.
NO, OF BLDGS.
ASSESSOR
SIZE OF LOT NOW ON LOT ``'
MAP BOOK
PAGE
PARCEL
DISTRICT GROUP TYPE FIRE
PROCESSED BY
TRACT BLOCK LOT NO. n
CONST. ZONE
. el � TEL
OWNER e a e d J, T3 T T "-� m _ q�, er j / r,, .
@ a Y a! �. ? w T ,, E'
ATISTICAL CLASSIFICATION
SEWER MAP
ADDRESS 7 r
DI?1` � 1 € , C 176
CLASS NO. DWELL. UNITS
BK PG
CITY ZIP
ARCHITECT OR TEL
VALUATION t
NO ENGINEER °a"i n,
1j,
a'
ADDRESS
BLDG. SETBACK FROM
�
L^ 1� TEL 61
FRONT PROP. LINE OF (STREET)
CONTRACTOR NO
TOTAL SETBACK FROM
TYPE OF EXISTING
LIC.
HIGHWAY + YARD = FRONT PROP. LINE HIGHWAY
WIDTH
ADDRESS O 1 ;. n r NO ? _ 'O ? 7,
LIC. e: J —.
+ _
CITY DL 4 �01,71D BAP,CLASS
CONSTRUCTION LENDER
BLDG. SETBACK FROM
SIDE PROP. LINE OF
(STREET)
NAME AND BRANCH
HIGHWAY + YARD = TOTAL SETBACK FROM
TYPE OF EXISTINGQ.
ADDRESS, CITY
SIDE PROP. LINE HIGHWAY WIDTH 0
SQ. FT. ,,t NO. OF NO. OF CHECK
+ _
ZE STORIES FAMILIES ONE
y x .,�
DESCRIPTION
USE ZONE MAP
NO.
OWORK NEW
❑
SPECIAL
UA
ADD
CONDITIONS
!.LNwl Fd� LK' Eta L ° i'a ALTER
FINAL BY
REPAIR ®
DATE
USE OF 4 a DEMOL
EXISTING BLDG,
Z
APPLICANT TEL
(PRINT) ss � - s Ili NO
r
BY (SIGNATURE)
� >
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE
s,
THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL ORDINANCES
eea
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-
Z
PENSATION INSURANCE."
J
SIGNATURE OF
PERMITTEE
ADDRESS ? 3 f'. 5 A a gT;:7 L a^ t?
itJ-1 ND BAR ' � e . £ P ,.!.f
CITY NO.
d L
P.C. Fee $ A Permit Fee
J
Q
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F
Issuance Fee
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m
Total Fee