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COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION
FOR APPLICANT TO FILL IN
BUILDING
ADDRESS
NG
BUILDING
U I LD'
DDRE SS
ADDRESS
LOCALITY
CITY il- zip
ITY
NEAREST
CROSS
NO. OF BLDGS.
SIZE OF LOT NOW ONLOT
ASSESSOR
MAP BOOK
IPAGE
PARCEL
DISTRICT GROUP TTYPE
FIRE
PROCESSED BY
RAF LOT NO
RACT BLOCK
T T T I
C '
ICONST.
ZONE
, -6 __
OWNER �V?,�4 -415
STATISTICAL CLASSIFICATION
SEWER MAP
ADDRESS
CLASS NO. DWELL.
UNITS---!
BK PG
CITY ZIP
USE ZONE MAP
NO.
ARCHITECT OR TEL.
ISPECIAL
ENGINEER NO.
cA`J lCONDITIONS
ADDRESS
ROAD DEPARTMENT APPROVAL REQUIRED
YES ❑ NO
TEL.
CONTRACTOR NO.
BLDG. SETBACK FROM
FRONT PROP. LINE OF
(STREET)
LIC.
ADDRESS NO.
TOTAL SETBACK FROM
HIGHWAY + YARD FRONT PROP. LINE
TYPE OF-
HIGHWAY WIDTH
LIC.
CITY CLASS
+
CONSTRUCTION LENDER
NAME AND BRANCH
BLDG, SETBACK FROM
SIDE PROP. LINE OF
(STREET)
ADDRESS CITY
TOTAL SETBACK FROM
TYPE OF EXISTING
SQ. FT. NO. OF NO. OF CHECK
HIGHWAY + YARD
SIDE PROP. LINE
HIGHWAY, WIDTH
SIZE STORIES FAMILIES ONE
❑
DESCRIPTION OF WORK NEW
❑
CORNER
YES❑
NO
ADD
6,- iAll 14 16
Al
CUTOFF
,
/6 A! L6 ALTER El
1:1
IN OPEN SPACE ,
YES
REPAIR
USE OF r-1
IN COASTAL PERMIT ZONE
YES ❑
NO
EXISTING BLDG. DEMOL
APPLICANT TEL 3
(PRINT) • 9 Al lye "t-fv NO
J
BY (SIGNATURE)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE
THAT THE ABOVE 15 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,
SIGNATURE OF
PERMITTEE
FINAL
DATE
BY
—
ADDRESS L2"' I
TEL.
—NO.'
CITY 7
P.C. Fee $
PermitFee
Issuance Fee
VALUATION $
TotalFee
PLAN CHECK VALI AllUN CK. M.O. CASH
yl
(P)S 76A638A CE #803A 6/76