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HomeMy Public PortalAbout4857 ENCINITA AVE_Building__ APPLICATION FOR BUILDING PERMIT FOR APPLICANT TO FILL IN (Printortypeonly) 1 .1COUNTY OF LOS ANGELES ' BUILDING ADDRESS #8 4771 t' DEPARTMENT OF COUNTY ENGINEER CITY / C/�1 L �'' ZIP 9/7S 0B�U/ILD�I7NG AND SAFETY DIVISION rV NOW ON LOT J ADDRESS LDING SIZE OF LOT pp,,,, //^^ TRACT BLOCK !a �� LOT NOR0 ;2 LOCALITY LC V[ NEAREST OWNER // NO .2B��S CROSS ST ADDRESS 5'7 £yZ C / p2 A ASSESSOR MAPBOOK PAGE PARCEL �'� Z ZIP 6 �w DISTRICT GROUP TYPE- FIRE P ESE CITY ' f �C! © ��F CONST e ZON ARCHITECT OR TEL / ENGINEER �'�� C NO STATISTICAL CLASSIFICATION SEWER MAP ADDRESS CLASS NO DWELL UNITS K OPG TEL CONTRACTOR NO US ZCNE NOP LIC — ADDRESS NO SPECIAL EC 1;17 r CONDITIONS LIC Sp CITY CLASS ROAD DEPARTMENT APPROVAL REQUIRED YES ❑ NO ❑ CONSTRUCTION LENDER NAME AND BRANCH BLDG SETBACK FROM _ FRONTPROP LINEOF (STREET( ADDRESS - CITY HIGHWAY + YAR=TOTAL SETBACK FROM TYPE OF EXISTING SQ FT NO OF f NO OF CHECK FRONT PROP LINE HIGHWAY WIDTH SIZE STORIES ! FAMILIES ONE a } DESCRIPTION OF WORK Ow/yr 2j00 NEW ❑ + O ADD BLDG SETBACK FROM /� a oc O� /SAA Tv be;v ��� SIDE PROP LINE OF - ((STREET) O /F7�� ALTER HIGHWAY + YARD = OTAL SETBACK FROM TYPE OF EXISTING PAIR ❑ SIDE PROP LINE HIGHWAY WIDTH- + N = r Z_ DEMOL ❑ - - APPLICANT �Lv a� TEL CORNER TOFF YES ❑ NO E] (PR INT) � GQ NO IN OPEN SPAC YES ❑ NO ❑ BY(SIGNATURE) 1_;Y/ Q „r IN COASTAL ERMIT ZONE , YES ❑ NO ❑ VALUATION .P � Th!!q3 LDR BY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE �3/7� ABOVE IS CORRECT AND AGREE CT COMPLY WITH ALL ORDINANCES /n`/ .r•U lN�vi. ' G! S REGULATING BUILDING CONSTRUCTION I CERTIFY THAT IN DOING THE !/fC THORIZEDTHE LABOR CODE 0,HEREBY I WILL NOT EMPLOY ANY PERSON IN VIOLATION OF �y N INSURANCETHE LABOR CODE OF STATE OF CALIFORNIA IN RELATING TO WORKMEN SCOM v RE OF E ' -7 ^ ;r j • iD�1 C * NOL DATEFINABY v MAKE CHECKS PAYABLE TO FEE $ FEET $ HARVEY T BRANDT•COUNTY ENGINEER PLAN CHECK VALIDATIONcK M o CASH PERMIT VALIDATION cK M o cases 5 9 4mFEB 8 P1 2-8.5 03 76A638A CE#803 3 75 DEP I R NT OF-BUILDING AND SAFETY ' "k Ll%.E'111ViV r WK& X'&-."a as• �COUwTY OF LOS ANGELES �' t ® 1 y--'' WM. J. FOX, CHIEF ENGINEER NG FOR APPLICANT TO FILL IN _ FOR OFFICE USE ONLY �j /� '''7 DISTR1 N0. PLAN CK.NO. PERMIT NO. BUILDADDRESS /(�/ C`/ /� J.� 1�/VGl A/! �J// ---- F5 r LOCALITY _�� RE t D BY DATE OF APPL. - DATE IBSULE�DNEARE7 ES CROSS �D"Ay�� /D�� F BUILDING OWNER ADDRESS IQ O / a7, �' /CI Ll N/ 7-/=7 � I I I AMAIL DDRESS • ® a l OCALITY T 97'-M pL C 1 tt NEAREST- - CITY pb.I I '. CROSS ST. i E 4✓ t� e FIRE NO.OF'I I TYPE ( ORO P O �ARCHITECT R TEL. 70NE PLANS ENGINEER \� NO. I TBLDG. - I -L✓'1 I / ��I" ORD.NO. ADDRESS 'SETBSETBACK LINE I I ' 4PPROVED TEL I - - - CONTRACTOR - (NOS pT 4BY 'I - - i I DATE ( ,., \ USE ��}} IAPPROVF`D a ADDRESS` ZONE fY'/ BY DATE DESCRIPTION LOT NAL O. I BLP d4' / - I - - 1 CORRELEG CTIONS TRACTills{y� - ` - -- - �[.Cil/L-�I `:h� ►'C� SIZE OF No OF LOT I t., X��C' c� NOW ON LOTS�/V `� U 3 Q T S T 'I USE OF NO OF m NO EXISTING BLDG FAMILIES ROOMS- - - - DESCRIPT-ION-OF WORK NEW ALTERATIONI ADDITIONi GT I T 4 ,I REPAIRMOVING DEMOLISH- f / 17 - GI FTS f NO. O SIF 4 r�`q ' P ! d R ? r SIZE ROOMS STORIES L- WALL " � J ROOF COVERING f I COVERING rr 4. a .4 USE OF NEW el BUILDING" r d A'cr...f�da 61 I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPROVALS APPLICATION AND STATE THAT THE ABOVE IS CORRECT FOUNDATION LOCATION INSPECTOR DATE y AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES FORMS, MATERIALSG_ .2 2 l AND STATE LAWS REGULATING BUILDING CONSTRUCTION FRAME FIRE STOPS, SIGNATURE OF BRACING,BOLTS OWNER. 11 ®. Clan � .1 � LATH,INT.: �C AUTHORIZED AGT. f� --� LATH,EXT oeS-3 25M GETS 1-47 $ P C PLASTER. INT. 1 FEE !B A FEE PLASTER, EXT. / VALUATION /- �-' FINAL DEPARTMENT OF BUILDING AND SAFETY APPLICATiON tFOR-P�T COUNTY OF LOS ANGELES ` p WM. J. FOX, CHIEF ENGL INEER 7 FOR APPLICANT TO FILL IN FOR OFFICE USE ONLY DISTRICT NO PLAN CK NO PERMIT NO BUILDING G /� ADDRESS LOCALITY REC IVE Y DATE OF APPL DATE ISSUED NEAREST 8-� CROBSI BT BUILDING OWNER ADDRESS C>G7 Fi✓G .v MAIL ® © LOCALITY .� ADDRES NEAREST TEL CROSS ST CITY NO FIRE NO OF TYPE 13 ARCHITECT OR TEL ZONE PLANS ENGINEER NO. (/ -- BLDG � "� ORD ANO ADDRESS SETBACK LINE L--e.;7 9� APPROVED TEL. BY DATE CONTRACTOR (zzw-)� INO.t _ USE APPROVED ADDRESS o r - ZONE BY DATE LEGAL 'p Zo�7 CORRECTIONS DESCRIPTION LOT NO.57 CORRECTIONS BLOCK f TRACT�/Il 1,/ T� / S �-- �6 .C? NO OF SLOGS. I SIZE OF LOT /�/� Y�df^� I NOW ON LOT USE � `� FAI FA OF / I NO OF a�..i EXISTITI LDNG BG MILICB ROOMS ' DESCREPTION OF WORK P NEW ALTERATION ADDITION _ O A REPAIR MOVING DEMOLISH 1 O Sq FT NO OF j Z SIZE ROOMS STORIES 1 D WALL ROOF r COVERING I COVERING j. USE OF NEW BUILDING r I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS, APPROVALS t�T APPLICATION AND STATE THAT THE ABOVE IS CORRECTINSPECTOR DATE t FOUNDATION: LOCATION FORMS,MATERIALS 'r AND AGREE TO COMPLY WIT ALL COUNTY ORDINANCES, �v R� AND, AT LAW REOULATI BUILDING CONSTRUCTION FRAME:BRACING,RBOLTSS, SIGNATURE OF 1 PERMITTEE LATH,INT.: it AUTHORIZED A T i LATH,EXT.' DSS-3 SOM SETS 7-47 $ low P C PLASTER,INT. c FEE pLASTER,EXT. VALUATION FEE ��,, FINAL R APPLICATION FOR BUILDING PERMIT FI�R APPLICSANT TO FILL IN (Print or type only) am COUNTY OF LOS ANGELES BUILDING 85-7 RnG/ ADDRESS 1(j 1774 DEPARTMENT OF COUNTY ENGINEER CITY Tg mp L€' C /r' zip 9./ 7 80 BUILDING AND SAFETY DIVISION G , SIZE OF LOT 9 J&�O�Q" 'NOW ON LOT ADIDRESS TRAC S BLOCK LO z�� LOCALITY OWNER / J mr �+ ,C -7-7'm4 TEL Oda87J3/ CROSS ST ADDRESS S7 ,c� f /�/�/r ASSESSOR. MAP BOOK PAGE PARCEL DISTRICT GROUP TYPE- FIRE -PROCESSED BY CITY -77 �7m Le C/ ZIP / / 80 �` CONST _ ZONE ARCHITECT OR TEL f DB `lAj` ENGINEER NO STATISTICAL CLASSIFICATION SEWERP ADDRESS TEL CLASS NO ^ / DWELL UNITS BK PG CONTRACTOR 0 W YO 9.Q NOZI NE NO �� LIC ADDRESS NO /a SPECIAL LIC CONDITIONS - - CITY CLASS ROAD DEPARTMENT APPROVAL REQUIRED YES ❑ NO ❑ CONSTRUCTION LENDER �� NAME AND BRANCH BLDG SETBACK FROM FRONT PROP LINE OF (STREET) ADDRESS CITY TOTAL SETBACK FROM TYPE OF EXISTING SQ FT pA NO OF ��� NO OF O CHECK HIGHWAY + YARD = FRONT PROP LINE HIGHWAY WIDTH SIZE / / STO ES FAMILIES ONE } DESCRIPTION O NEW ❑ + OU ADD BLDG SETBACK FROM Q� SIDE PROP LINE OF (STREET) O ALTER TOTAL SETBACK FROM TYPE OF I EXISTING w HIGHWAY + YARD = SIDE PROP LINE HIGHWAYI WIDTH N USE OF REPAIR ❑ EXISTING BL GRA � GAn� G � DEMOL + - Z APPLICANT �cl� NL CORNER CUTOFF YES NO P IN OPEN SPACE YES NO BY(SIGNATURE) IN COASTAL PERMIT ZONE YES NO VALUATION $ c,Jr- 5 IHEREBY ACKNOWL ZE THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL ORDINANCES AND LAWS REGULATING BUILDING CONSTRUCTION I CERTIFY THAT IN DOING THE WORK AUTHORIZED HEREBY WILL NOT EMPLOY ANY PERSON IN VIOLATION OF THE LABOR CODE OF THE STATE OF CALIFORNIA IN RELATING TO WORKMEN S COM PENSATION INSURANCE - - SIGNATURE OF PERMITTEE ADDRESSAVS FINAL BY 1 CITY AE' •+ NO 7� DATE -2— S 7- - MAKE CHECKS PAYABLE TO- FEE v F Er HARVEYT BRANDT,COUNTY ENGINEER PLAN CHECK VALIDATION CK M o CASH PERMIT VALIDATION (Z K' mc, CASH 4 4 8 MAY 23 l 6, 2 8.5 0 rya ®3 76A638A CE#803 3 75 1 ,/ APPLICATION FOR BUILDING PERMIT FOR APPLICANT TO FILL IN (Print or type only) BUILDING `/ 5-7�7 COUNTY OF LOS ANGELES ADDRESS '18 !7 C!rl! T'�9 4✓F DEPARTMENT OF COUNTY ENGINEER CITY7; C 17' zip 9/790 BUILDING AND SAFETY DIVISION NO OF BLDGS BUILDING SIZE OF LOT f j 30 S �1" NOW ON LOT "T W 19 ADDRESS (� ✓t TRACT BLOCK LOQA Z LOCALITY TEL OWNER-I—,4/, ,��7.C�7� No 07" r".? CROSS ST ASSESSOR ADDRESS "/(S'S !/ / n 7�/�J MAP BOOK PAGE PARCEL /� DISTRICT GROUP TYPE FIRE �2CE!SEDfY-CITY -7-Ely[ LamC' Jt j ��,GZIP ,r CONST ZO/ ARCHITECT OR TEL ENGINEER 97 NO STATISTICAL CLASSIFICATION SEWERXP ADDRESS CLASS NO -,::221DWELL UNITS BCb Pc�- TEL CONTRACTOR CEJ n NO ZONE NO LIC ADDRESS NO .Jj SPECIAL LIC 11 CONDITIONS CITY CLASS ROAD DEPARTMENT APPROVAL REQUIRED YES ❑ NO ❑ CONSTRUCTION LENDER A4 0'"'e NAME AND BRANCH BLDG SETBACK FROM FRONT PROP LINE OF (STREET) ADDRESS CITY TOTAL SETBACK FROM TYPE OF EXISTING SQ FT NO OF NO OF CHECK HIGHWAY + YARD = FRONT PROP LINE HIGHWAY WIDTH SIZE j 9 STORIES I FAMILIES ONE y DESCRIPTION OF WORK 4 p jo TQ4t,pNEW ❑ + O BLDG SETBACK FROM - D ADD J SIDE PROP LINE OF (STREET( O fvChg� ALTER ❑ TOTAL SETBACK FROM TYPE OF EXISTING Y 1704 g te Ano U0d2 us HIGHWAY + YARD = SIDE PROP LINE HIGHWAY WIDTH N USE OF <�AR�pQ REPAIR ❑ Z EXISTING BLDG R ,/�Q G? DEMOL ❑ + APPLICANT�/ - 1 ' � EO CORNER CUTOFF YES ❑ NO (FIR NIT) LhN ❑ B 7 /�I IN OPEN SPACE YES ❑ NO ❑ BY(SIGNATURE( IN COASTAL PERMIT ZONE YES ❑ NO ❑ VALUATION.Q p �QZZ Qy- IHEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE I, J THAT THE ABOVE ISCORRECT AND AGREE TO COMPLY WITH ALL ORDINANCES !y rL.v ./ AND LAWS REGULATING BUILDING CONSTRUCTION I CERTIFY THAT IN DOING THE !7iq LIJAL- /Ns" �/✓♦•iy d/�. WORK AUTHORIZED HEREBY I WILL NOT EMPLOY ANY PERSON IN VIOLATION OF THE LABOR CODE OF THE STATE OF CALIFORNIA IN RELATING TO WORKMEN S COM ,n- L PENSATION INSURANCE Z3 t{er}f' yivA8 L 7 a SIGNATURE OF PERMITTEE 3'7 ADDRESS e �' n «� p FINAL 2- \ BY / CITY -72 L _ No- ! / DATE MAKE CHECKS PAYABLE TO FEE FET $ HARVEYT BRANDT,COUNTY ENGINEER D PLAN CHECK VALIDATION CK M o CASH PERMIT VALIDATION M o CASH '22 cK->1� � Q p a�� ®S 76A638A CE#803 3 75 1 ?MORKERCC PENSATION DECL�?ATION p - �insur her-,oraffirm a certificate of Workers' omte of consent to pensation Insurance, A■ PLICATION FOR BUILDING PERMIT or a certified copy thereof (Sec 3800 Lab C ) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No Company Certified copy is hereby furnished FOR APPLICANT TO FILL IN BUILDING ADDRESS j Certified copy is filed with the county building inspec- BUILDING q C tion department ADDRESS O S �!7C I hi ICL U Lk G4 Date Applicant CITY, 2 G CL ZIP I�p U LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' i NO OF BLDGS NEAREST r COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS ST cye11e J(� (This section need not be completed if the permit is for one LOT NO TRACT BLOCK ASSESSOR hundred dollars ($100)or less ) MAP BOOK PAGE PARCEL OWNER 6 LSf7 CD NO zit 7-�So USE ZONE MAP I certify that in'the performance of the work for which this NO permit is issued, I'shall not employ any person in any manner ADDRESS S7 6,17( n SPECIAL ' so as to become subject to the Workers'CompensationLaws !i7 all e- CONDITIONS U Date 1 O Apphcont x��L1Ft1�� ,0 G&Z CITY ? !P ZIP U NOTICE YO APPLICANT If, after making this Certificate of ARCHITECT Ok TEL DISTRICT G UP TYPE FIRE SSED BY O Exemption, you should become subject to the Workers - ENGINEER NO 5- CONST E U Compensation provisions of the Labor Code, you must forth- ADDRESS J `� ­7E � with comply with such provisions or this permit shall be deemed revoked L STATISTICAL CLASSIFICATION APT CO. DO to CONTRACTOR NO Z LICENSED CONTRACTORS DECLARATION LIC CLASS NO DWELL`UNITS - I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO (commencing with Section 7000)of Division 3 of the Business and LIC SEWER P Professions Code, and my license is in full force and effect CITY CLASS BK PG VALIDATION SQ FT NO OF NO OF CHECK License Number Lic Class SIZE STORIES FAMILIES ONE VALUATION S,0 DESCRIPTION OF WORK NEW ❑ Contractor Date y' $ am exempt under Sec 00 e G(l— 0 n� ADD ALTER ❑ ® �8 4 S 9 A B&P C for this reason REPAIR $ # o e o a e,1 USE OF Date EXISTING BLDG DEMOL ° 1 99.88 Signature _ - ' APPLICANT TEL FINAL OWNER-BUILDER DECLARATION PRINT NO�� - DATE/,o 1 hereby affirm that I am exempt from the Contractor's License _ ­199.886 Law for the following reason (Section 7031 5, Business and L ADDRESS C FINA I Professions Code) By 1.30-87 1, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and ; the structure is not intended or offered for sale(Section LOCALITY 7044, Business and Professions Code) I MOVING TEL 1, as owner of the property, am exclusively contracting CONTRACTOR NO w y with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code) CONSTRUCTION LENDING AGENCY ED SETT BACK YARD HWY ED TOTALSETBACK WIDTH t I hereby affirm that there is a construction lending agency for FRONT i the performance of the work for which this permit is issued P L (Sec 3097, Civ C ) SIDE PL Lender's Name ` LDMA Ref # m P C Fee$ Permit Fee I ' Lender's Address I certify that I have read this application and state that the Issuance Fee l O : S(/ LDMA P/C# g above information is correct I agree to comply with all County Investigation Fee Q 0 ordinances and State laws relating to building construction, Total Fee r�(� LDMA Perm # , $ and hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE o Signature of Applicant or Agent Date -. I APPLICATION FOR BUILDING PERMIT COUNTY OF LOS ANGELS BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDR S G /)fie I hereby affirm that I have a Certificate of consent to self Insure, BUILDINGADDRESS Q� aOcli C//I or a certificate of Workers' Compensation Insurance,or a certified S "_# " " copy thereof(Sec 3800,Lab C) CITY ZIP /1 V a'l— / LOCALITY Policy No Company SIZE OF LOT NO OF BLDGS NOW ON LOT ❑ Certified Copy is hereby furnished I NEAREST CROSS ST ❑ Certified copy Is filed with the county building Inspection TRACT BLOCK LOT NO department USE ZONE MAP NO Date ' Applicant ASSESSOR MAP K_0 P�/ PARC O C(/ SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS', EOWNER r o COMPENSATION INSURANCE �c77 WITHIN 1000 FT OF SCHOOLS YES No (This section need not be completed if the permit is for one hundred AD DISTRICT GROUP TYPE CONST FIRE ZONE PROCESSED BY dollars($100)or less) CITY ZIP G I certify that m the performance of the work for which this permit �� aL� � /�O IS issued, I Shall not employ any person In any manner SO as t0 ARCHITECT OR ENGINEER TEL NO � U �'r�'�' become/ubt t to the Workers mpensatlon Laws STATISTICAL CLASSIFICATION APT CONDO Dat Applicant �/¢YLrUsS J ADDRESS CLASS NO val DWELL UNITS NOTICE TO APPLICANT If, after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST Exemption, you should become Subject 4o the Workers C �ACTOIj� NO SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith LI�I..II//►►- ITZ7/ FRONT comply with such provisions or this permit shall be deemed revoked Ap�q f' LIC O P L C LICENSEDCONTRACTORS DECLARATION IT �.�^'17Y ITYsrs- SIDE I hereby affirm that I am licensed underprovlslons of Chapter 9 CLL_ �"" ''�� A te! SEWER MAP ciO (commencing with Section 7000)-Of Division 3 of the Business and SO FT SIZE- NO-OF STORIES NOF FAMI S (O '- Professions Code,and s Is in full force and effect NEW ❑ BK PG d License Nu ber LIC CIdSS DESCRIPTION OF W / ADD VALUATION , O Contractor Date ALTER .❑ jlflE ❑ I am exempt under Sec A' lb tarREPAIR El0 B&PC for this reason DEMOL ❑ LDMA P/C# W Date USE OF EXISTING BLDG URM ❑ CL Signature APP ANT(PRINT) 19117b LDMA Perm# Z El 1, as owner of the property,'or my employees with wages as 6 _>1 z DCCT°s their sole compensation, will do the work and the structure is ADD R ��w' O cE_ cf not Intended or offered for sale (Section 7044, Business and �� V/�/VYA_, FINAL DATE �j Q 3, 07 , LIC (3 ° Professions Code) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL 5-49— OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE J El 1 as owner of the property, am exclusively contracting AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDES FINAL BY / 5 8 licensed contractors to construct the protect (Section 704444,, )/ Business and Professions Code) YES❑ NO❑ /Y _ WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING �4`I,�� i°�AI.f OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH CONSTRUCTION LENDING AGENCY COASTAIRGUIDELINEUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FOR 2 ITEMi I hereby affirm that there is a construction lending agency for YES 11 NO El } t C i 1 N the performance of the work for which this permit Is Issued(Sec TOTAL �_ 2 ® �0 � I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING 1I I w 10 3097,CIV C) CHECKLIST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE H�f L � ° !`I TITLE 2 CHAPTER 2 20 SECTIONS 2 20 100 THROUGH 2 20 140 CONCERNING HAZARDOUS LL l - 5. Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD 3 o I` E °.31� Lenders Address OWNER OR AGENT O 0 1 certify that I have read this application and state under penalty PC FEE PERMIT FEE of perjury that the above Information Is correct I agree to comply i( / o with all county ordinances and State laws relating to building �J a� D c� or 0q_C100 c/ _/Oy u m construction, and hereby authorize representatives of this County ISSUANCE FEE rc-i 1 AM .III to Qat upon thea a 10 prop rt for Insp n p oses i y i1 1 1 t+l t '�°j'- a INVESTIGATION FEE TOTAL FEE SEE REVERSE FOR EXPLANATORY LANGUAGE