HomeMy Public PortalAbout5029TEMPLE CITY BLVD_Building APPLICATION FOR BUILDING PERMIT
FOR APPLICANT TO FILL IN (Pnm or type mlvl
Bul.zo)Nci COUNTY OF LOS ANGELES
ADDRESS /Mrla' C' T d7�yO DEPARTMENT OF COUNTY ENGINEER
CITY �(c� L' zlP BUILDING AND SAFETY DIVISION
O OF BLDG BUILDING �/
SIZE OF LOT .fX7f NOW ON LOT / ADDRESS 00
TAAC 3 6
BLOCK LOT NO 0 LOCALIT
TEL NEAREST
OWNER NO - CROSS ST
ADDRESSASSow MAPFSSOR BOOK PAGE PARCEL
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CITY /�L� // ZIP Q ^ CONST ZON T
ARCHITECT OR - TEL
ENGINEER NO
STATISTICAL CLIA S,SIFICA TION ER MAP
ADDRESS CLASS NO�.DWELL UNITS BK3 G
CONTRAC70R 6,�s '40,TEL ,y D� USE ZONE OP O/
ADDRESS J .tY�F .rT- NO ^ �� SPECIAL
CITY LIC
CONDITIONS
/l LENDER CLASS ROAD DEPARTMENT APPROVAL REQUIRED YES❑ NO❑
CONSTRUCTION LENDER y
NAME AND BRANCH ^ >t1/� _ IL
BLDG SETBACK FROM tl
FRON PROP LINEOF (STREET)
S OGRESS CITY
HIGHWA } YARD -_ TOTAL SETBACK FROM TYPE OF EXISTING C
SI FT NO OF NO OF_ CHECK FRONT PROP LINE HIGHWAY WIDTH F
SIZE STORIES FAMILIES/ ONE C.
_ LL
DESCRIPTION OF WORK NEW ❑
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®DD BLDG SETBACK Z
KX/ SIOEPROP LINEOF TREETI
LTER ❑ HIGHWAv } YA RO - TOTAL SETBACK FROM TYPE 0 EXISTING
EPAIR❑ SIDE PROP LINE HIGHWA WIDTH
USE OF + _
EXISTING BLDG ENOL ❑
A PIPRI CANT 0 6�/(L NOL 8�6 CORNER CUTOFF YES ❑ NO ❑
49
'BY (SIGNATURE) _ /✓ ��� IN OPEN SPACE YES El NO
�j IN COASTAL ZONE YES [:] NO ❑
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VALUATIONS 10 --
CATEGORICAL EXEMPTION YES[] NO ❑
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS AARLICAT IOM ENVIRONMENTIL
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO CO MR LY IMPACT EXEMPTION PTION DECLARATION SIGNED (DATE)
WITHALL ORDINANCES AND LAWS REGULATING BUILDING CON
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TION I CERTIFY THAT IN DOING THE WORK AUTHORR ED IMPACT REPORT PROCESSED (DATE)
HEREBY I WILL NOT EMPLO ANTPERSON IN VIOLATION OF T—
LABOR CODE OF THE ST OF CALIFORNIA I LATING TO ��V( �/ L
WORKMEN S COMPENBATI SURANCE �♦ L/
SIGNATURE OF i���
PERMITTEE -fLlvj e6 4e-441
ADDRESS O .4-�I Y Q
TEL ��SEE FINAL ( BY f
CIT NO y DATE
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MAKr CHECKS PAYABLL TO PC
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HARVEY T 13RANDT COUNTY ENGINEER ` r �T
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PLAN CHECK VALIDATION GH MC, GASH , 1 PERMIT VALIDATION GK .. GAeH
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7GA538A CER803 7/73