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7GA638A CE#6031187 APPLICATION FOR BUILDING PERMIT 1
COUNTY OF LOS ANGELES BUILDING
DEPARTMENT OF COUNTY ENGINEER A111ESS
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JOHN A LAMBIE COUNTY ENGINEER NEAREST
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1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS AP LATH INT
PLICATION AND STATE THAT THE ABOVE IS CR T AND
AGREE TO COMPLY WITH ALL OUNTY ORD A ES AND
STATE LAWS REGU ILD &TION LATH EXT
SIGNATURE OF
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T RECT AND POSED
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76A63BA CE#803 I1 S7 APPLICATION FOR BUILDING PERMIT Z
COUNTY OF LOS ANGELES BUILDING
DEPARTMENT OF COUNTY ENGINEER ADDRESS
BUILDING AND SAFETY DMSION LOCALITY
JOHN A LAMBIE COUNTY ENGINEER NEAREST
CASSATT D GRIFFIN SUP T OF BUILDING CROSS ST
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FEE ^ GAS VENT DUCTS
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS AP LATH INT
PLICATION AND STATE THAT THE ABOVE IS CORRECT AND
AGREE TO COMPLY WITH ALL COUNTY DIN NCES AND
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SIGNATURE OF HOUSE NUMBER COR
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APPLICATION FOR BUILDING PERMIT
FOR APPLICANT TO FILI! IN (Print or type only)
COUNTY OF LOS ANGELES �
BUILDING
DEPARTMENT OF COUNTY ENGINEER
ADDRESS —
dd /� ' i BUILDING AND SAFETY DIVISION
CITY ` 0 i li IP �` -y
NO OFBLDGS C7 BUILDING
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ADDRESS /m0 W NO/ (p SPECIAL
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CITY ` b a— CLASS 13— 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 NO OF NO OF CHECK HIGHWAY + YARD = FRONT PROP LINE HIGHWAY WIDTkI
SIZE STORIES FAMILIES ONE }
DESCRIPTION OF WORK NEW + O
ADD BLDG CK FROM Q�
SIDE P OPBLINEOFF (STREET) O
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AP%CAN TEL CORNER CUTOFF YES ❑ NO ❑
(PRINT) �,ha- ��}/S'J�a'Y� NO 3 fl"
IN OPEN SPACE YES ❑ NO ❑
BY(SIGNATURE( tr
IN COASTAL PERMIT ZONE YES ❑ NO ❑
VALUATION $ 3 0 `y/ T>
THAT THE ABOVEHEREBY (ISOWLEDGE CORRECT THAT AND( HAVE AGREE TOAD THIS COMPLY WITH ATION AND STATE
ALLL ORDINANCES a� ' ^J ��L ./�
AND LAWS REGULATING BUILDING CONSTRUCTION I CERTIFY THAT IN DOING THE AA 4 b(�i
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 c /� 31
PENSATION INSURANCE (.
SIGNATURE OF /(IIS ���t/ ' GoL✓��N
PERMITTEE
ADDRESS
'per ��<^ FINAL B
,/� 7 TEL r6a, DATE J {
CIT, '�� NO
MAKE CHECKS PAYABLE TO FEE $ P FET
HARVEY BRANDY COUNTY ENGINEER 2/
PLAN CHECK VALIDATION < K M o CASH PERMIT VALIDATION <Fr— M o cAsH
3 4 0 ti 711L 49 2 6.533 4 1 r--,PJL 29K 1 0 21.75,
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