HomeMy WebLinkAbout6853APPLICATION 1 IPERMIT
FOR APPLICANT TO FILL IN (Print or type only)
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BUILDING
DEPARTMENT OF COUNTY ENGINEER
ADDRESS
BUILDING AND SAFETY DIVISION
CITY ZIP
NO. OF BLDGS.
BUILDING
SIZE OF LOT NOW ON LOT
ADDRESS
s. TRACT, -
BLOCK
LOT NO.
LOCALITY
TEL.
NEAREST
w OWNER NO.
CROSS ST.
ASSESSOR
ADDRESS
MAP BOOK
PAGE
PARCEL
DISTRICT GROUP TYPE FIRE
PROCESSED BY
-CITY ZIP
` CONST. ZONE
j
ARCHITECT OR TEL.
` !_
t®aC_ of
ENGINEER NO.
STATISTICAL CLASSIFICATION
SEWER MAP
ADDRESS
fs
CLASS NO. DWELL. UNITS 'i '
BK PG
TEL,
CONTRACTOR NO.
USE ZONE MAP
LIC.
NO,
ADDRESS NO.
SPECIAL
LIC.
CONDITIONS
CITY 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
HIGHWAY + YARD =
TYPE OF EXISTING
SQ. FT NO. OF NO. OF CHECK
FRONT PROP. LINE
HIGHWAY WIDTH
' SIZE `' 0 STORIES FAMILIES z ON
DESCRIPTION OF WORK NEW
+
ADD
BLDG. SETBACK FROM
SIDE PROP. LINE OF
(STREET)
a ALTER ❑
} -
= TOTAL SETBACK FROM
TYPE OF EXISTING
r
❑
HIGHWAY + YARD SIDE PROP. LINE
HIGHWAY WIDTH
' USE OF REPAIR
EXISTING BLDG. DEMOL El+
APPLICANT, J�+ ITJELL r , `�%
i
CORNER CUTOFF YES ®
NO
IPRINTI
IN OPEN SPACE YES ®
NO Cj
F BY )SIGNATURE) / l _
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
) s
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 , f
\_
PERMITTEE
n
ADDRESS
e
n
FINA BY
L•
DATE
CITY NO.
MAKE CHECKS PAYABLE TO:
=HARVEY
FEE' F ET
T. BRANDT, COUNTY ENGINEER
-pee� s-e.
ram` �J
CK. M.O. CASH
?(10 ;(fir
PERMIT VALIDATION CK. M.O. CASH
®5 76A63BA CE #803 3-75