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APPLICATION FOR BUILDING PERMIT_
COUNTY OF LOS ANGELES BUILDING AND SAFETY
ING
FOR APPLICANT TO FILL IN 'ADD RESS C/TI !
BUILDING /�
ADDRESS LOCALITY Q
i + + NEAREST
CITY ZIP CROSS ST G
- —NO OF BLDGS= _ + ASSESSOR
SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL
TRACT BLOCK LOT NO DISTRICT G�REOUP CONST
OWNERAA=aNO ZIORIEJ PROCESSED BY
TEL ��° K 3
STATISTICAL CLASSIFICATION SEWER MAP
ADDRESS CLASS NO L/ DWELL UNITS BK PG
CITY ZIP
ARCHITECTO TEL $ LlsvV
ENGINEER NO = VALUATION v V
ADDRESS BLDG SETBACK FROM
TEL FRONT PROP LINE OF ISTREETI
CONTRACTO NO HIGHWAY + YARD _ TOTALSETBACKFROM TYPEOF EXISTING
UC 1" FROM PROP
LINE HI GH WAV WIDTH
ADDRESS NO
LIC +
CITY CLASS
CONST ON LENDER BLDG SETBACK FROM
NAME AND BRANCH SIDE PROP LINE OF ISTREETI
HIGHWAY + YARD TOTAL SETBACK FROM I TYPEOF 1EXISTING
ADDRESS CITY SIDE PROP LINE 1HIGHWAYI WIDTH O
SO FT S OF NO OF CHECK + - Y
SIZE STORIES FAMILIES ONE 0
O
DESCRIPTION OF WORK NEW P e$ Permit Fee {XJ L:
ADD Issuance Fee /O(J
y� ALTER �
REPAIR Total Fee V
USE
EXISTING BLDG
APPLICANT TEL I F
IPRINTI 0maklu
O JM If
BY ISIGNATUREI yy(//WeF > @0953A
I HEREBY AIX O DGE THAT I HAVE READ THIS APPLICATION AND STATE r {m
THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY WtTH ALL ORDNANCES ` O ld w # • • • •'a 1
AND TAWS REGULATING BUILDING CONSTRUC hON I CERTIFY THAT IN DOING THE J /T
WORK AUTHO l NOT ENIA ANY PERSON IN VIOLATION OF M
THE TABOR OF THE STATf 0 FORMA RELATING WORKMEN SCOM Z • • 6'1 O O
PENSATION I RANCE
• • • 61006
SIGNATURE OF _
PERMITTEE ` 6Q24-78 _
ADDRESS
Z
TEL
CITY NO �� Q
O
0ONE OP Zo/ 7
70— SPECIAL
CONDITIONS
FINAL BY
DATE