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APPLICATIO FOR BUILDING PERMlT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN ADDRESS S= - I"G..3�G7
sw�oiN� /�
ADORE55 IV �'� �' LAA'7✓� 7�
N ST /fT�/
CITY Q(A/Lst7'N'A ZIP 5T. c��>G.
NO.OF BLDGS. A ESSOR
SIZE OF LOi ' NOW ON LOT � MAP e00K PAGE PARCEI
DISTRIC7 GROUP TYPE FIRE P ESSED eY
TRAR BLOCK LOTNO. ~ n CONSi.�( ZONE
/- iEl. a /G-� �(,' y�
OWNER v• NO.
STATISTICALCLASSIFI TION SEW MAP
A�ORESS CLASSNO.O DWELL.UNRS BK PG
OTV ZIP (y�j ��,,� y�
ARCMITECfOR TEL VALUATION $ �[/`✓,`� �� P�/r (L O
ENGINEER NO. Q
AODRE55 �C7 BLDG SEiBACK FROM
TEL fRONT PROP.UNE OF ISTREET!
CONTRACTOR NO. HIGHWAY + YARD .= TO1AL SEiBACK FROM TYPE OF E%ISiING
�i� � FRONiPROP.UNE MIGHWAY WIDTH
ADDRESS NO.
LIC. QA� �
CRY CLAS$ �/
CONSTRUCTI N IENDER g��G.SETBACN fROM
NAME ANO 86ANCN SIDE PROP.LINEOF �SiREETI
HIGHWAY + YARD = TO7ALSEfBACKFROM TYPEOF EXISTING �
A�DRE55 CITV SIDE PR07.LINE HIGNWAY WIDTH O
f. Q, NO.OF q NOAF /'_ CHKK + = U
SI (/ STORIES �+� FnMiues C�% owe ��O Q
DESCRiaTfON OF WORK NEW .0 Fee$`}�' �� Pe�mit Fee �
e �J
A�D W
�a Issuance Fee / 'a vi
ALTER K
REPAIR ❑ v � � � Tafal Fee �J�O �
USf OF DEMOL
E%ISTING6LDG. � �/�/ J S� 2
APP�ICANT TEL � �
lPRINTi � O.,5� . i• c T 4�1 Li F;
� �'� .r• •G.�.
BV iSIGNATUkEI � /�
1 HEREBY A NOW DGE 7HAi I HAVE REAO iN15 A7PUCATION AND STAiE V y �� � ��i O
THA7�HE ABO IS C RECf AND AGFEE i0 COMVLY WIiH ALL OROINANCES W
AN�LAWS REG IING WIDING CONSiRUCIION.I CERiIiY iHAi IN DOING iHE = h � I � CS U L�%
WORK AUTMORiZ ' BY I WILI NO�EMVLOY ANY PERSON IN YIOLA710N OF V • .
THELABORCOOEOF MES7AiEOFCALIFORNIAINRELATINGiOWORKMENSWM� p(�,
PENSATION INSURA E. ' � D 7�G L L C'�J
SIGNATUREOF • �� 4 fi L'A
PERMITTEE
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