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HomeMy Public PortalAbout5128 ARDEN DR_Building__ DEPARTMENT OF COUNTY ENGINEER BUILDING DIVISION OF BUILDING AND SAFETY COUNTY OF LOS ANGELES WILLIAM J. FOX, COUNTY ENGINEER APPLICATION CASSATT D. GRIFFIN, SUP'T OF BUILDING FOR APPLICANT TO FILLIN FOR OFFICE USE ONLY BUILDING /,''� DISTRICT NO. PLAN CK.OR REC.No. PERMIT NO. ADDRESS �- '2�'/8/,?1 'F LOCALITY RECEIV D BY DATE OF APPL. DATEISSUED NEAREST CROSS ST BUILDING OWNER ' ADDRESS MAIL LOCALITY ADDRESS TEL. OSSST CITY O — S BOSS 3T. �r/�6J H�/2 ARCHITECFIRE NO. OF TYP9 GRO%��}%,P•J -ENGINEERT OR NO• ZONE I PLANS � J -dam^ ADDRESS BLDG. ORD. NO. SETBACK LINE TEL. USE 4 APPROVED CONTRACTOR NO. ZONE BY PATE ADDRESS HOUSE NUMBERING LEGAL © O. MAP NUMBER NO. ASSIGNED BY DESCRIPTION I LeT �A I BLOCK CORRECTIONS' TRACT / ✓y SIZE OF LOT ! c;2NO. OF BLDGS. 1s n OW ON LOT USE OF NO. OF EXISTING BLDG. FAmiLtE DESCRIPTI NOF WORK o - z NEW —I ALTERATION —I ADDITION I Z REPAIR DEMOLITION Z D r SO. FT. NO. OF SIZE ROOMS STORIES EXT. WALL ROOF COVERING COVERING USE STRUCTURE / ✓" C:> APPROVALS INSPECTOR'S SIGNATURE DATE FOUNDATION: LOCATION FORMS, MATERIALS 1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS AP- FRAME: FIRE STOPS, PLICATION AND STATE THAT THE INFORMATION GIVEN IS BRACING, BOLTS CORRECT. IAGREE TO COMPLY WITH ALL COUNTY ORDINANCES FURNACE: LOCATION, AND STATE LAWS REGULATING /BUILDING.CONSTRUCTION. GAS VENT, DUCTS SIGNATURE OF .� n/ LATH, INT. PERMITTEE LATH. EXT. ADDRESS �O ✓`�( (�(i: PLASTER, INT. AUTHORIZED AGT. �/.�1 r^ PLASTER, EXT. FEE S HOUSE NUMBER COR- RECT AND POSTED VALUATION FEE $ ^�� FINAL 4 70ASSSA DBS 3 9-5A DEPARTMENT OF BUILDING AND SAFETY APPLICATION FOR PERMIT COUNTY OF LOS ANGELES WM. J. FOX, CHIEF ENGINEER BUILDING1 NO. OF BLDG. ORD.NO. DISTRICT NO. PLAN CK. NO. PERMIT NO. PLANS SETBACK LINE FIREAPPROVED O v �`'� / A ZONE � BY DATE RECEIVED BY DATE OF APPL. DATE ISSUED USE // q APPROVED ��' ZONE/�/ BY TE APPLICANT FILL IN HEAVILY OUTLINED PORTION ONLY BUILDING O NAME ADDRESSILI ,O�/�•t /.� ;�,,/�,�j �- W Z ADDRESS LOCALITY Z NEAREST U U W CITY CROSS 3T. Ir Q STATE �NEL LICENSE NO. /a � NAME It MAIL 7O NAME / 3 ADDRESS UO ' / TEL CIT / �-(Y/ Q ADDRESS NO. �/ 6 m , I HEREBY ACKNOWLEDGE THAT 1 HAVE READ, THIS Z CITY O APPLICATION AND STATE THAT THE ABOVE IS CORRECT U STATE TEL. AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES LICENSE NO. NO. 7 AND STATE LAWS REGULATING B ILDING CONSTRUCT.1 N. joa'?, 2 g /63 SIGNATURE OF Z LOT NO. ^� SIZE OF LO o2 OWNER NO. OF BLDGS. Q IL BLOCK NOW ON LOT AUTHORIZED AG ` p C � ,f( �'.y/ t} F CORRECTIONS N TRACT ✓ u .�!"� - W D USE OF BLDGS. ,f / l �f `k f NOW ON LOT "J,�.'�/6"I. '/fAv.rs•'\T si3iiA� /'1i �`"'�i-'"✓4-^Sl`) B�r$ !: DESCRIPTION OF WORK USE OF I V - IY BUILDING v O NEW TYPE GROUP /VM NO. OF NO. OF ALTERATION_ �� ROOMS, FAMILIES f �tM !/LIWWtiLC+t •-"y"i ADDITION SIZE �✓ ✓//� - REPAIR STORIES J MOVING WALL COVERING �� L����s DEMOLISH ROOF COVERING / F/1� J Y04- P. $ FEE FINAL APPRROVAL S �,f1/� �0�I il INSPECTOR'S • ' VALUATION �9� FEE�,/ DATE NAME @�]j 7BAd 38A D6.5-3 3-55 APPLICATION FOR BUILDING PERMIT DIVISION OF BUMDING AND SAFETY BUIL°'NG I✓,,\\ C A O � L� Department of County Engineer ADDRESS County of Los Angeles LOCALITY Tem.pI eCi i-� WM.J. FOX. COUNTY ENGINEER NEAREST I CASSATT D.GRIFFIN, SUP•TOFBUILDIN43 CROSS ST. La RCSB DISTRICT NO. GROUP ITYPESEWrR „MAP FOR APPLICANT TO FILL IN '1i O B y� �i CONST. BUILDINGf) MAP STATE YES- ADDRESS�-�Je t'V NUMBER HWY CO LOT NO. 9 .. BLOCK USE ZONE SPECIAL ,ts CONDITIONS TRACT San Francisqulto X 18V X 174 NO: OF BLDGS. NG EXIST. SIZE OF LOT I NOW ON LOT Non SETBACK YARD HWY: !`STREET NAME WIDTH BUILDI EX STT NG BLDG.USEF FRONT OWNERC'- 1'enneth n Williams SIDE. P. L. MAIL ADDRESS j 0111 F 01 i ITA St 5 INDUSTRIAL - O TRACT DWELL: - t UNIT TEL. 1 DWELL. . Du NIT CITY C' NO 6 PUBLIC BLDG. ' 2 DUPLEX 1 UNIT ARCHITECT OR TEL. ! 7 ADDN.,ALT., ETC. ENGINEER NOtIA NO. 3 APT. --L-UNITS .. 8 MISCEL. ADDRESS 4 COMMERCIAL CONTRACTOR Above NO. � � -�4 INSPECTION RECORD ADDRESS1k, + DESCRIPTION OF WORK /off �.�� f- /���`i, • � � NEW 7TADD ALTER REPAIR DEMOLISH .'�� -- / ✓ s I - _ SO. FT. NO. OF NO.OF -� � ` ' SIZE l 300 STORIES 1 FAMILIES USE OF STRUCTURE Home SIGNATURE OF AX APPLICANT RRG'SOALS ADDRESS DATE •�INSkCTOR*S SIGNATURE FOUNDATION: LOCATIONS P.C. $ FORMS, MATERIALS 1 I� FEE / FRAME- FIRE STOPS.BRACING, BOLTS -A- VALUATION FEE $-/7// "�� FURNACE: L CATION. .r�i /+q GAS VENT, DUCTS I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS - ✓ / APPLICATION AND STATE THAT THE ABOVE IS CORRECT' AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES LATH, INT. Aj AND STATE LAWS REGULATING BUILDING CONSTRUC- LATEXT. TION. H, SIGNATURE OF HOUSE NUMBER COR- PERMITTEE -ECT AND POSTED - �--• re? ADDRESS sl� FINAL WM.J. FOX,COUNTY ENGINEER -� VALIDATION C. N. DIRLAM, Cc LPG. INSPECTOR IACo2758N APR 101 6 A 20.50 ..2 L;C 2 8 2 4 O. .APS 11 1 A 4 1 .0 0 M APPUCAMON FOR BULONG PERNT COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS I hereby affirm that I have a certificate of consent to self insure, BUILDING ADDRESS 5 1 2.5C �or a certificate of Workers'.Compensation Insurance,or a certified •_ copy thereof(Sec.3800,Lab.C.) CITY ZIP Giv. t LOCALITY Policy No. O3G 4s Company sT� Tx� SIZE OF LOT NO.OF BLDGS.NOW ON LOT ❑ Certified copy is hereby furnished. NEAREST CROSS ST. L)Si Certified copy is filed with the county building inspection TRACT BLOCK LOT NO. USE ZONE MAP NO. depart Ent. C®�,1ot ASSESSOR MAP BOOK PAGE PARCEL SPECIAL CONDITIONS Applicant pplicant CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER TEL NO. YES NO COMPENSATION INSURANCE WITHIN 1000 FT.OF SCHOOL? This section need not be completed if the permit is for one hundred ADDRESS ( P S12-0 /� ��� DISTRICT GROUP P E ZONE P/RSO/®C�IESSED BY dollars ($100)or less.) !� r1 C-� CITY ZIP I certify that in the performance of the work for which this permit Q1'� _ j. is issued, I shall not employ any person in any manner so as t0 ARCHITECT ORE GINEER TE�N �� become subject to the Workers'Compensation Laws. STATISTICAL CLAS IFICATION APT CONDO Date Applicant ADDRESS CLASS NO. DWELL UNITS NOTICE TO APPLICANT If, after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST Exemption, you should become subject t0 the Workers' CONTRACTOR (( ` TEL NO. o��/7b� SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith (Sss�+.` ��,� g7.--4Gc5 FRONT Comply with such provisions Or this permit shall be deemed revoked. ADDRE S LIC.NO. P L LICENSED CONTRACTORS DECLARATION r� , PILE CITY /�_ LIC.CLA19P L I hereby affirm that I am licensed underprovisions of Chapter 9 T 4 SEWER MAP (commencing with Section 7000)of Division 3 of the Business and SQ.FT.SIZE NO.OF STORIES NO.OF FAMILIES Professions Code,and my license is in full force and effect. NEW fl BK PG a License Number 1352!9_7 Lic.Class I. DESCRIPTION OF WORK ADD VALUATION O Contractor 46-fok'a,/ Date 2!"T rG !*x IS ALTER ❑ $ :51 abD. d0 U Cc El am exempt under Sec. A �� REPAIR 13 $ BAP.C.for this reason DEMOL LDtu1A P/C# W Date: USE OF EXIS71-G BLDG. — URM ❑ f I U) Signature' APPLICANT(PRINT) TEL NO. :LDMA Perm# ❑ I, as owner of the property, or my employees with wages as 2�i�-17a O ( �.�: T their sole compensation, will do the work and the structure is ADDRESS _ not intended or offered for sale (Section 7044, Business and i0.6,y-18� �s FINAL DATE Q '30 i?,',•'I j Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL Y.� i J } ITEMS ❑ I, as owner of the property, am exclusive) contracting with OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE <' S I 1 i 1 P y. Y g AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? Q licensed Contractors t0 construct the project (Section 7044, YES[I No� FINAL BY > i I+ITAL �17 m 90 Business and Professions Code.) I t WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING CHECK �1�a f ' OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH CONSTRUCTION LENDING AGENCY COAST AIR QUAUTY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR GUIDEUNES. CHANGE .If I hereby affirm that there is a construction lending agency for YES 1:1 Nor 1t cu the performance Of the Work for which this permit IS Issued(Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING 3097,CIV.C.) CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, r,r' / TITLE 2,CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING HAZARDOUS ��uV�� f a.c/ Lender's Name MATERIALS AND FOR OBTAINING A PERMIT FROM THE SCAQMD. o Lender's Address13464 1 AN R l! OWNER OR AGENT o I certify that I have read this application and state under penalty 0 of perjury that the above information is correct.I agree to comply P.C.FEE PERMIT FEE N with all county ordinances and State laws relating to building �TsJ construction, and hereby authorize representatives of this County ISSUANCE FEEco to enter upon the above-mentioned property for inspection urpo es. INVESTIGATION FEE TOTAL FEE r` Sqn „ // re of Apclic t o.Agent Date O SEE REVERSE FOR EXPLANATORY LANGUAGE _ ,APPUCAT1qN [FOR BULIMNIG. PERNT COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR-APPLICANT TO FILL IN BUILDING ADDRESS I hereby affirm that I have a certificate of consent to self insure, BUILDIN DDfRE / �J'/ or a certificate of Workers' Compensation Insurance,or a certified ) " " " V� copy thereof(Sec.3800,Lab. C.) CITY M011940 4-17"-1 ZIP ����Q ��,yL y <4 �J1 !/1� LOCALITY Policy NO. Company SIZE OF LOT �^ NO.OF BLDGS.NOW ON LOT El Certified copy,is hereby furnished. -(N NEAREST CROSS . Certified Copy is filed with the county building inspection TRACT 'BLOCK LOT NO: depart e t. n USE ZONE MAP NO. Date— Applicant �.agi; � ASSESSOR M�[jpy BOOK PAG E PARCEL V 66 6 a� SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER TEL TEL NO. QJ� COMPENSATION INSURANCE � eldwk c� w3 WITHIN 1000 FT.OF SCHOOL? YES NO (This section need not be completed if the permit is for one hundred ADDRESS'/ /,, AW 05-`(� DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY dollars ($100) or less.) I certify that in the performance of the work for which this permit CITY ./,d ZIP /-7 is issued, I shall not employ any person in any manner so as to ARCHITECT OR ENGINEE TEL NO#'/8' Oy become subject to the Workers'Compensation Laws. L', " �1 Q STATISTICAL CLASSIFICATION ,;_ APT CONDO 282'�J�/�7 � DWELL UNITS Date �Applicant ADDRE S p� C CLASS NO. �,.,. $ NOTICE TO APPLICANT.' If, after making this Certificate of 'i�Js� ��• J�� �l�Ol g REQUIRED TOTAL SEjtp FROM EXIST Exemption, you should become subject to the Workers' CONTRACTOR TEL NO. SET BACK YARD HWY PRQP..tICI WIDTW:`s;1,Y,C, Compensation provisions of the Labor Code, you must forthwith /W �1rZ�ls �� FRONT TT •1 comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC.NO. P L .. y I 1}E• LICENSED CONTRACTORS DECLARATION P.0 136 SIDE TOTAL 4'i'i`,�fL '8330 o 0 CITYn LIC. ASS P L I hereby affirm that I am licensed underprovisions of Chapter 9 CA SEWER MAP (commencing with Section 7000)of Division 3 of the Business and SO.FT.SIZ NC5.OF STORIES NO.OF FAMILIES Professions Code,and my license is in full force and effect. 6 SC NEW ❑ BK PG �MANGE =i 31 s 0- License License Number 13M20-2 Lic.Class DESCRIPTION OF WORK ADD VALUATION "" Q Contractors*ft-_ A KNe:7 Date / ALTER J 7O� 1 _ . . U —I l �'i_r'. _ 0 ❑ I am exempt under Sec. REPAIR D $ - Y`'= _� _. #mac' ( i �y B.&P.C.for this reason f�/I�HNV Q1/y1 DEMOL ❑ ti`=3; _fz =i U J � LDMA P/C# _ Date: USE OOOFFF ) G URM ❑ 71`L' f 1 i Signature�Z,�—�'— APPLICANT'(PRINT) �` ( TEL NO.. 1 LDMA Perm# - � ,_ j�E� , _ El 1, as owner of the property, or my employees with wages as asAw � 98& 3`97 Z O I, 'H their sole compensation, will"do the work and-the structure is A DRESS uu y��� not intended or offered for sale (Section 7044, Business,and 33 /7� Sl y FINAL DATE Q t `_HT CK + Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL — - ` t OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE ❑ 1, as owner of the property, am exclusively contracting With AMOW SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY > licensed contractors to construct the project (Section 7044, YES 4�J No❑ '` Business and Professions Code.) _th GE WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING a OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH LS CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR GUIDELINES. t U.S;[•} I hereby affirm that there is a construction lending agency for YES❑ Nve N the performance Of the Work for which this permit IS ISSUed(Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING Lfft„'L_i' m + d AN �•_ 3097, CIV.C.) CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, TITLE 2,CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING HAZARDOUS 3 Lender's Name MATERIALS REPORTING ANDD FOR OBTAINING A P- MIT E@OM THE SCAQMD. o Lender's Address O OWNER OF AGENT oI certify that I have read this application and state under penalty O of perjury that the above information is correct.I agree to comply P.C.FEE PERMIT:FEE with all county ordinances and State laws relating to building �/�• !O o ��j �� < construction, and hereby authorize representatives of this County ISSUANCE FEE toenter up n the above-mentioned property for inspection ur oses. 1� `a INVESTIGATION FEE TOTAL FEE maw.or Aponwm or Am Dale V SEE REVERSE FOR EXPLANATORY LANGUAGE APPLICATION FOR BUILDING PERMIT COUNTY 012'�LOS ANGELES BUILDING AND SAFETY _WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS ASS �� � ` . � I hereby affirm that I have a certificate of consent to self insure, BUIG DDR �. !sj,— or a certificate of Workers' Compensation Insurance,or a certified L copy thereof(Sec. 3800,Lab.C.) L+- CITY ZIP Policy No. ��63�� Company ` r'^ 610 P,C? LOCALITY . SIZE OF LOT NO,OF BLDGS.NOW ON LOT ❑ Certified copy is hereby furnished. NEAREST CROSS ST. Certified copy is filed with the county building inspection TRACT BLOCK LOT NO. USE ZONE MAP NO. department. /.� 4tZ� Applicant �-- ASSESSOR MAP B O PAGE PARCEL Date t1 y r- SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' OWNERT L O. COMPENSATION INSURANCES - Z ® WITHIN 1000 FT.OF SCHOOL? YES NO (This section need not be completed if the permit is for one hundred ADDRESS A ZG. krvG, �P DISTRICT GROUP TYPE CONST, FIRE ZONE PROCE D BY dollars ($100)or less.) C� c�+ I certify-that in the performance of the work for which this permit CITY ` ZIP�� S �'� i is issued, I shall not employ any person in any manner so as to Gs Al yy� TV mil r become Subject to the Workers'Compensation Laws. ARCHITECT OR LINGINEER' TEL NO. STATISTICAL CLASSIFICATION APT CONDO Date Applicant ADDRESS CLASS NO. DWELL UNITS NOTICE TO APPLICANT.' If, after making this Certificate Of EFRONT TOTAL SETBACK FROM EXIST Exemption, you should become subject to the Workers' CONTRACTOR - TEL NO. / YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith, E�j2� �'Z' 227 rycomply with such provisions or this permit shall be deemed revoked. ADDRESS LIC.NO.LICENSED CONTRACTORS DECLARATION CITY LIC.CM } I hereby affirm that I am licensed underprovisions of Chapter 9 SEWER MAP (commencing with Section 7000)of Division 3 of the Business and SQ.FT.SIZE NO.OF STO S< NO,OF FAMILIES d Professions Code,and my license is in full force and effect. °--�- NEW X BK PG U License Number �$34Z` ? Lic.Class -Pb- DESCRIPTION OF WORK ADD E] VALUATION Contractor --n•r�\VU ✓ - Date gjZ_7''*h3 ALTER 1:1s 4 Irl o>6 cc J J O El am exempt under Sec. I t REPAIR ❑ $ U BAP.C.for this reason DEMOL ❑ W LDMA P/C# d Date: USE OF EXISTING BLDG. URM ❑ (msseCe..cz s i Z Signature APPLICANT(PRINT TEL NO. LDMA Perm# S CSI El 1, as owner of the property, or my.employees with wages as ADDRESS � Z.� (� � �':i•, a� their sole compensation, will do the work and the structure is cz not intended or offered for sale (Section 7044, Business and FINAL DATE 41 Q :_uiL• tr s Professions Code. // �%/l�, WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL ! v J = i~EI f-.1 ORA MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE - ❑ I, as owner of the property, am exclusively contracting with AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? Q FINAL BY licensed contractors to construct the project (Section 7044, �{ i ;i i^t� 1+�'g-'�' - 35 YES❑ NO P Business and Professions Code.) /' _, - , WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING i-�••� �_{'., 5+�. a OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH " CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCACMD)SEE PERMITTING CHECKLIST FOR - GUIDELINES. r� '_HH'11{1,�(`„`' I hereby affirm that there is a construction lending agency for YES❑ NO Int the performance of the work for which this permit Is Issued(.Sec. I HAVE READ THE HAZARDOUS MATERALS INFORMATION GUIDE AND THE SCAQMD PERMITTING 3097,Giv.C.) CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, ` TITLE 2.CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING HAZARDOUS !01 1) !—%,0 I°,,, %j J,�j,�f;'. Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD. - - �^ o Lender's Address —���J���S7 �� i7=''r jt ,°_i'�` 0 OVJN2ff Oq AGENT _ 0 1 certify that I have read this application and state under penalty 0 of perjury that the above information is correct.I agree to comply P.C.FEE PERMIT FEE , - N with all county ordinances and State laws relating to building 74 S construction, and hereby authorize representatives of this County ISSUANCE FEE to enter upon bove-mentioned property for inspection urpo es. + Z7 INVESTIGATION FEE TOTAL FEE r` 1req a. Mo-1 w�gen, oat, SEE REVERSE FOR EXPLANATORY LANGUAGE