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COUNTY O: LOS ANGELES BUILDING AND SAFETY
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FOR APPLICANT TO FILL IN
BUILDING
ADDRESS ` $.( r �
BUILDING
ADDRESS G�
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LOCALITY
CITY7Zf i- ,Lr; r ZIP
NEAREST
CROSS ST.
NO. OF BLDGS.
SIZE OF LOT NOW ON LOT
ASSESSOR
MAP BOOK
PAGE
PARCEL
DISTRICT GROUP TYPE
TRACT BLOCK/ LOT NO.,
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OWNER( NO.S 5 / r',
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STATISTICAL CLASSIFICATION
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ADDRESS S i7 L-�,tJ /
CLASS N06 DWELL. UNITS
CITY j j e?4 ZIP
' ARCHITECT OR f� TEL. ._-
NO.
VALUATION f
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ENGINEER` 1::11 { Z>�aL
ADDRESS
BLDG. SETBACK FROM
(STREET)
TEL.
FRONT PROP. LINE OF
CONTRACTOR NO.
HIGHWAY + YARD = TOTAL SETBACK FROM
FRONT PROP. LINE HIGHWAY
TYPE OF EXISTING
WIDTH
LIC.
ADDRESS NO.
_
+
LIC.
' CITY CLASS
BLDG. SETBACK FROM
CONSTRUCTION LENDER
SIDE PROP. LINE OF
(STREET)
NAME AND BRANCH
TOTAL SETBACK FROM
TYPE OF EXISTING
HIGHWAY + YARD = SIDE PROP. LINE HIGHWAYI
WIDTH
ADDRESS CITY
SQ. FT. NO. OF NO. OF CHECK
+ _
SIZE STORIES FAMILIES ONE
USE ZONE MAP
DESCRIPTION OF WORK NEW ElNO.SPECIAL
/ ADD ❑
P
CONDITIONS
ALTER ❑
FINAL BY
REPAIR ❑
DATE
USE OF DEMOL
EXISTING BLDG.
®
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APPLICANT / TEL
PRINT( f/� j NO.G �7G,6 12
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BY ISIGNA �cL'
I HERE ACKNOWLEDGE THAT IIHA E READ THIS APPLICATION AND STATE,
THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL ORDINANCES
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AND. LAWS REGULATING BUILDING CONSTRUCTION. I CERTIFY THAT IN DOING THE
WORK AUTHORIZED HEREBY I WILL NOT EMPLOY ANY PERSON IN VIOLATION OF
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' THE LABOR CODE OF THE STATE OF CALIFORNIA IN RELATING TO WORKMEN'S COM•
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PENSATION INSURANCE.'
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SIGNATURE OF
E PERMITTEE
ADDRESS
O
TEL.
CITY NO._
'- P.C. Fee $ T ,> r Permit Fee
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Issuance Fee
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Total Fee
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