HomeMy Public PortalAbout5843 TEMPLE CITY BLVD_Building - S APPLICATION FOR BUILDING PERMIT
FOR APPLICANT TO FILL IN (Print or type only)
BUILDING I COUNTY OF LOS ANGELES
ADDRESS DEPARTMENT OF COUNTY ENGINEER
CIT ZIP BUILDING AND SA' TY DIVISION
NO.OF BLDGS.' BUI-LDING
SIZE OF LOT-,WK/;7,5� NOW ON LOT ADDRESS 31f
TRACT� � BLOCK LOT NO. ?j/ LOCALIT
o TEL. NEAREST
OWNER NO. CROSS ST.
ASSESSOR
ADDRESS J MAP BOOK PAGE RCEL
DISTRICT GROU TYP FIRE RO SSED BY
CITY ZIP V ST• ZONE
ARCHITECT OR I TEL.
ENGINEER NO' STATISTICAL CLASSIFI TION s
SEWER MAP
ADDRESS CLASS NO. ? 2 DWELL•UNITS BK PG
CONTRACTOR NpL�r 077 USE ZONE MAP
ADDRESS INO. Zq, SPECIAL
LIC. CONDITIONS
CITY CLASS
ROAD DEPARTMENT APPROVAL REQUIRED YES❑ NO❑
CONSTRUCTION LENDERSw t
AME AND BRANCH Gds BLDG, TBACK FROM
FRON PROP,LINE OF (STREET) C
ADDRESS CITYK TB
L-- TASETBACK FROM TYPE OF EXISTING C
HIGHWA {• YARD OTC-
SQ.,
SQ.,FZ.yA� NO. OF NO. OF CHECK FRONT PROP. LINE HIGHWAY WIDTH p
SIZE STORIES ' FAMILIES ONE F
DESCRIPTION OF WORK NEW p
a�0I ADD ❑ BLDG.SETBACK FROM = a
SIDE PROP.LINE OF - (STREET)
tiALTER ❑ HIGHWAY t YARD = TOTAL SETBACK FROM`TYPE OF EXISTING
REPAIR❑ SIDE PROP. LINE HIGHWAY WIDTH
USE OF Q
EXISTING BLDG. DEMOL E] +
APPLICAN TE (��. CORNER CUTOFF YES ❑ NO ❑
(PRINT �i N0�"
BY (SIGNATOR IN OPEN SPACE YES ❑ NO ❑ `�
IN COASTAL ZONE YES ❑ NO ❑
VALUATION$ � CATEGORICAL EXEMPTION YES❑ NO ❑
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION ENVIRONMENTAL
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY IMPACT EXEMPTION DECLARATION SIGNED (DATE)
WITH ALL ORDINANCES AND LAWS REGULATING BUILDING CON-
STRUCTION. I CERTIFY THAT IN DOING THE WORK. AUTHORIZED IMPACT REPORT PROCESSED (DATE)
HEREBY I WILL NOT EMPLOY ANY PERSON IN VIOLATION OF THE
LABOR CODE OF THE STATE OF CALIFORNIA IN RELATING TO
WORKMEN'S COMPENSATI RANCE.
SIGNATUR OF
PERMITTEE
ADDRESS 11// J.G6'] Ff A
TEL DIATE tlA�-fi/F ! BY� UE"=a=tj
CITY NO. Q
)lilKE CHECKSPA}'ABLE TO: FEE $ FEE F
HARVEY T. BRANDT, COUNTY ENGINEER
PLAN CHECK VALI TIPN CK. M.O. CASH PERMIT VALIDATION CK. M.O. CASH
A f; 1 3 3 673 Y .9 2 D 9.0 D-4
' 1 Ar, 1 8 4 073, JUN 22 1 D 1 55.0 0 a
75A63BA CE#803 12/72