HomeMy WebLinkAbout6852 (12)APPLICATION I I I
FOR APPLICANT TO FILL IN (Print or type only)
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BUILDING
ADDRESS
DEPARTMENT OF COUNTY ENGINEER
`,-
BUILDING AND SAFETY DIVISION
CITY ZIP
NO. OF BLDGS.
BUILDING
SIZE OF LOT NOW ON LOT
ADDRESS
TRACT BLOCK LOT NO.
LOCALITY p
A TEL.
NEAREST
OWNER NO.
CROSS ST.
ASSESSOR
ADDRESS
MAP BOOK
PAGE
PARCEL
DISTRICT GROUP TYPE FIRE
PROCESSED BY
;. -CITY ZIP
ARCHITECT OR TEL.
CONST. ZONE
lit
1 V
m�
ENGINEER NO.
STATISTICAL CLASSIFICATION
SEWER MAP
ADDRESS
CLASS NO. DWELL. UNITS
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 1 STORIES FAMILIES ONE
DESCRIPTION OF WORK NEW
+
ADD
BLDG. SETBACK FROM
SIDE PROP. LINE OF
(STREET)
/ ALTER ❑
(% `
TOTAL SETBACK FROM
HIGHWAY + YARD =
TYPE OF EXISTING
,
❑
SIDE PROP. LINE
HIGHWAY WIDTH
USE OF REPAIR
EXISTING BLDG. DEMOL ❑
+
APPLICANT ` fty TEL
CORNER CUTOFF YES ®
NO ❑
IPRINTI �A NO.
_
IN OPEN SPACE YES ®
NO ❑
�" BY (SIGNATURE) '- t
`
IN COASTAL PERMIT ZONE Y!L�
NO
VALUATION $ `J � 0x`
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
f
WORK AUTHORIZED HEREBY 1 WILL NOT EMPLOY ANY PERSON IN VIOLATION OF
THE LABOR CODE OF THE STATE OF CALIFORNIA IN RELATING TO WORKMEN'S COM-
PENSATIONINSURANCE.
,
SIGNATURE OF
PERMITTER''
ADDRESS
FINAL BY
TELp/
DATE
CITY NO,
MAKE CHECKS PAYABLE TO:
FEE' F ET
HARVEY T. BRANDT, COUNTY ENGINEER
CK. M.O. CASH
PERMIT VALIDATION CK. M.O. CASH
i `I r -T , ' 3
®5 76A638A CE #803 3J5