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76A638A CE#803 662APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDIADDRE S
DEPARTMENT OF COUNTY ENGINEER ADDRESS C`
BUILDING AND SAFETY DIVISION LOCALITY
JOHN A LAMBIE COUNTY ENGINEER NEAREST
WILLIAM A JENSEN SUP T OF BUILDING CROSS ST
DISTRICT N G PR SSED BY
FOR APPLICANT TO FILL IN �Q coNsr
BUILDING STATISTICAL CLASSIFICATION S ER MAP
ADDRESS `-04Q i G
CLASS NO DWELL UNITS
LOT NO z d_ 3 BLOCK WATER ❑
Q. CERTIFICATE NOT REQUIRED RECEIVED
TRACT ( MAP �,,.+ a HIGHWAY STATE JOR COND LOCAL
�y NO OF BLDGS NO o�/L/S� (CIRCLE)
SIZE OF LOT $ a NOW ON LOT USE ZONE SPECIAL
USE OF CONDITIONS
EXISTING BLDG I
OWNER O-el/ TEL,/
W� NO BUILDING YARD HWY STREET NAME EXIST
SETBACK WIDTH �
ADDRESS 5GF171yFRONT �..�—
ARCHITECT OR TEL P L /__T r
ENGINEER NO SIDE �-
P L d
ADDRESS ol0 O
CONTRACTOR _S�tl_22 e_ NO 5
�� N
ADDRESS
O
DESCRIPTION OF WORK
W
/ i a
NEW ADD ALTER REPAIR DEMOLISH / H
S FT NO OF NO OF r/dIT �` ��G�w
CJ RIES FAM
SIZE STO
ILIESd x % ''I b��
STR UUSE OCTU E Q, �� ` } f
SIGNATURE OF
APPLICANT
VALUATION �Cl
I APPROVALS -"DIA INSPECTOR SISIGNA RE
P C PMT FOUNDATION LOCATION
FEE FEE $ Q �� FORMS MATERIALS
# FRAME FIRE STOPS
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION BRACING BOLTS
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY FURNACE LOCATION
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING GAS VENT DUCTS A i
BUILDING CONSTRUCTION I CERTIFY THAT IN DOING THE WORK
AUTHORIZED HEREBY I WILL NOT EMPLOY ANY PERSON IN VIOLA
TION OF THE LABOR CODC OF THE STATE OF CALIFORNIA RELAT LATH INT
ING TO WORKMEN MPENSATION ZINSU /jy,GE LATH EXT
SIGNATURE OSI HOUSE NUMBER COR
PERMITTEE """r' RECT AND POSTED
ADDRE FINAL
PLAN CHECK VALIDATION cK M o cnsH _ JOHN F LEWIS PRINCIPAL ST TURAL ENGINEER
PERMIT VALIDATION CK M o CASH
L1 �o0935w IEB1423 D 3G251 1
U 1Lo 1 4 1 0 I EB 1 D 6 0 5 Ci`
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