HomeMy WebLinkAbout6864APPLICATION [ IPERMIT
FOR APPLICANT TO FILL IN (Print or type only)
COUNTY OF LOS ANGELES
G
DEPARTMENT OF COUNTY ENGINEER
ADDRESS
ADDRES
BUILDING AND SAFETY DIVISION
CITY'PW2
ZIP
NO. OF BLDGS.
BUILDING
SIZE OF LOT
NOW ON LOT
ADDRESS
TRACT g
BLOCK
LOT NO,
LOCALITY Q� vrf�i
-
TEL.
NEAREST
._ OWNER
NO,
CROSS ST.
ASSESSOR
ADDRESS
MAP BOOK
PAGE
PARCEL
DISTRICT GROUP TYPE FIRE
PROCESSED BY
CITY
ZIP
Q ` CONST. ZONE
t
ARCHITECT OR
TEL.
.J—
ENGINEER
NO.
STATISTICAL CLASSIFICATION
SEWER MAP
ADDRESS
CLASS NO. DWELL. UNITS {`
BK PG
'.
TEL.
CONTRACTOR
L„
NO.
USE ZONE MAP
NO.
'r--: ADDRESS
LIC.
NO.
SPECIAL
CONDITIONS
CITY
LIC.
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. NO. OF
NO. OF j CHECK
HIGHWAY + YARD = FRONT PROP. LINE
HIGHWAY WIDTH
�` p
SIZE STORIES G -`
FAMILIES ONE
O
DESCRIPTION OF WORK
NEW
+
ADD ❑
BLDG. SETBACK FROM
(STREET(
SIDE PROP, LINE OF
f F�'- �s�,
Af
ALTER ElTOTAL
4
SETBACK FROM
HIGHWAY + YARD = SIDE PROP. LINE
TYPE OF EXISTING
HIGHWAY WIDTH
REPAIR ❑
USE OF
EXISTING BLDG.
DEMOL ❑
(^„ APPLICANT"" (
TEL
NO.
CORNER CUTOFF YES ®
NO ❑
IPRIN, A*�
IN OPEN SPACE YES ❑
NO ❑
BY (SIGNATURE) A�
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.
Jk
SIGNATURE OF
PERMITTEE
ADDRESS
/�j j%
TEL. "IN' ��i`/ �
DATE EFINAL
BY
y CITY
NO.
FEE
FET
MAKE CHECKS PAYABLE
TO:
'. HARVEY T. BRANDT, COUNTY ENGINEER
6
i
CK. M.O. CASH
/_ 0 1-I .C) 0 "—
PERMIT VALIDATION CK. M.O. CASH
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(P5 76A63BA CE #803 3.75