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7LAnSA CIE#803 P./so APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING
DEPARTMENT OF COUNTY ENGINEER ADDRESS
BUILDING AND SAFETY DMSION LOCALITY
JOHN A LAMBIE COUNTY ENGINEER NEAREST
WILLIAM A JENSEN SUP T OF BUILDING CROSS ST
DISTRICT NO GROUP ITYPEP
SSED BY
FOR APPLICANT TO FILL IN
� CONST
BUILDING �/ /J���Q�v STATISTICAL CLASSIFICATION SE KR MAP
ADDRESS (�ff�
CLASS NO DWELL UNITS —
LOT NO p BLOCK MAP q a STATE YES
NUMBER o.�G
TRACT USEZONE SPECIAL
NO W OF BLDGS CONDITIONS
SIZE OF LOT NOON LOT /
USE OF
EXISTING BLDG Gu / BUILDING EXIST
TEL SETBACK YARD HWY ST EET NAME WIDTH
OWNER < S ///GN'�� NO FRONT
ADDRESS -o CL2 ,, ,�(J P L
SIDE
ARCHITECT OR TEL P L
ENGINEER NO I INSPECTION RECORD
ADDRESSTEL
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CONTRACTOR
�C,�cv� S NO L W
ADDRESS /J Z L�NS�h L� g �t ' / O C-19-S O!� V
" DESCRIPTION OF WORK 0
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NEW ADD ALTER REPAIR DEMOLISH as a W
SQ FT NO OF NO OF
SIZE STORIES FAMILIES -
USE OF -
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STRUCTURE 11V Cl'- v! C� �S� �/(/ �dI q
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SIGNATURE OF
APPLICANT
VALUATION$ O d U
APPROVALS DATE INSPECTOR S SIGNATURE
PC PMT FOUNDATION LOCATION
FEE FEE $ FORMS MATERIALS
FRAM BRS
P.CING BOLTS
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS AP r
PLICATION AND STATE THAT THE ABOVE IS CORRECT AND FURNACE LOCATION I
AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND GAS VENT DUCTS
STATE LAWS REGULATING BUILDING CONSTRUCTION
1 CERTIFY THAT IN DOING THE WORK AUTHORIZED 1 LATH INT
WILL NOT E��-OY ANY PERSON IN VIOLATION OF THE
WORKMEN S/G9 LA FLIFO NIA LATH EXT
SIGNATURE LO FF f HOUSE NUMBER COR
PERMITTEE
RECT AND POSTED
ADDRESS yNr/ FINAL,
PLAN CHECK VALIDATION CK M O CASH CLYDE PERMIT VALIDATIONQSTRUCTURAL ENGINEER
1�0�'
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