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APPLICATION FOR COUNTY OF LOS ANGELES
-DEPARTMENT OF COUNTY ENGINEER
, BUILDING PERMIT BUILDING AND SAFETY DIVISION
BUILDING
FOR APPLICANT TO FILL IN ADDRESS
BUILDING 5I �- f
ADDRESS V LOCALITY
NEAREST
CITYTEMrLF- QjTf ZIP IQ 1-7gO CROSS ST
41 . JZ`Z NO OF BLDGS I - ASSESSOR
SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL
Q^ DISTRICT I TE
GROUP TYPE FIRE CESSED BY
\JAIA
TRACT 4st BLLOCK ^C LOT NO �Qt��p '1 CONST ZpNE
OWNER �j pGE AWWL NOL 26SVLCI
`` `` ` ` (� STATISTICAL CLASSIFICATION SEWER AP
ADDRESS �"� N_ GIv A C CLASS Nc�,,ZLDWELL UNITS ` E BK PG
CITY l eM _0- YT\f Zlp 1 1 USE ZONE NADP
ARCHITECT OR NOL
SP IAL
ENGINEER f CONDITIONS (�
ADDRESS ROAD DEPARTMENT APPROVAL REQUIRED YES C:] NOD
TEL t
CONTRACTORNO BLDG SETBACK FROM
_ LIC FRO TPROP LINEOF (STREET)
ADDRESS NO HIGH Y + YARD = TOTALSETBACK FROM TYPEOF EXISTING
CITY LIC
FRONT PROP LINE HIGHWAY WIDTH
CLASS _
CONSTRUCTION LENDER +
NAME AND BRANCH BLDG SET 0.CK FROM -
ADDRESS CITY SIDE PROP L OF z A (STREET)
SQ FT NO OF NO OF CHECK HIGHWAY + YARD = T AL FROM TYPE OF EXISTING 9=SIZE STORIES FAMILIES ONE SIDE PROP LIN HIGHWAY WIDTH U
DESCRIPTION OF WORK NEW ❑ + a
ADD- ❑ CORNER CUTOFF YES ❑ NO C Z
I, t� ALTER ❑ �
'� Sv REPAIR IN OPEN SPACE YES ❑ NO C3
USE US
EXISTING NG BLDG ` - DEMOOL ❑ IN COASTAL PERMIT
QZONE
� yYES ❑ NO
APPLICANT 1,�r Npwztz.NOL���V��L
(PRINT) v `el'-sTe,f�p
BY (SIGNATURE) Uw ' `
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL ORDINANCES AND LAWS REGULATING BUILDING CON
STRUC TI ON II CERTIFY THAT IN DOING THE WORK AUTHORIZED
HEREBY I WILL NOT EMPLOY ANY PERSON IN VIOLATION OF THE
LABOR CODE OF THE STATE OF CALIFORNIA IN RELATING TO
WORKMEN SfCOMPENSATION INSURANCE -
SIGNATURE OF J ti��- FINAL 77 BY
PERMITTEE 7777 DATE
ADDRESS- 5/130 ���5
CITY jeMt 1,.� ��T� NOL (•U Z PC Fee$ Permit Fee
Q I 012 Issuance Fee
VALUATION
Total Fee
PLAN CHECK VALIDATION �_y�s�—M O CASH _ PERMIT VALIDATIOPCZZ ,`�o CASH
1 1 9'r—'JAN 12 2 3 U 5 G 0 ,&,j 1 2 0,--JAN 12 1 6 0 0 A�ft
76A638A CEM503B 1275 - y
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