HomeMy Public PortalAbout9217 OLIVE ST_Building__ VyORKERS'COMPENSATION DECLARATION
insure,or afcertif cat to of Worke s''Compensat on Insurance, APPLICATION F®R BUILDING PERMIT
Vr 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
DD Ess
Certified copy is filed with the county building inspec- BUILDING
1 tion department. ADDRESS got / 7 r:. QL/yC q6f.
Date Applicant CITY I MPLa dr r y ZIP //79 LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. / NEAREST
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS ST.
(This section need not be completed if the permit is for one TRACTBLOCK LOT NO. �� ASSESSOR
PAGE PARCEL
hundred dollars($100)or less.) MAP BOOK
u� TEL. / USE NE MAP
I certify that in the performance of the work for which this OWNER /y/iiQ(S'�JQL—� N NO. 3 7 NO.
permit is issued, I shall not employ any person in any manner q0Q l 7 _ QLI WSJ SPECIAL
so as to be orae ubject to the Workers'Compens ADDRESS A IIUII CONDITIONS O
o� - CITY I�I�j/o4E d4% Zip 917e�0
Date Applicant ARCHITECT OR TEL.
NOTIC TO PLICANT: If, after maki ! ificate of ENGINEER L F NO. DISTRICT GR UP TYPE FIRE PROCESSED BY O
Exemption, you should become sub ct to the Workers' A, CONST.I ZONE U
Compensation provisions of the Labor Code, you must forth- ADDRESS
with comply with such provisions or this permit shall be �.
deemed revoked.
TEL. STATISTICAL CLASSIFICATION APT CONDO. fn
CONTRACTOR SC L 9 NO.
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. DWELL. UNITS
—
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. SEWER MAP
(commencing with Section 7000)of Division 3 of the Business and LIC,
Professions Code,and my license is In full force and effect. CITY CLASS BK PG VALIDATION
SQ.FT INC.OF NO.OF CHECK
License Number LIc.Class S1ZE STORIES FAMILIES ONE VAL TIOJ4 ds}
DESCRIPTION OF WORK NEW ® / T/t/
Contractor Date �, .� $ t%O L (�
1 am exempt under Sec. ; ,8' Fi4�jLY ADD
ALTER PLO
B.&P.C. for this reason -o REPAIR $ 09521 A
Dote: USE OF DEMOL #-o 0 0 0 0 1
EXISTING BLDG.
,,d �— I I�
Signature APPLICANNTT I-i�FACSRK.G! -�D/i/�NO(FR . �'% FINAL � ( o ] 2[�,$$
OWNER-BUILDER DECLARATION DATE
I hereby affirm that I am exempt from the Contractor's License ADDRESS FIN 0 0 1 2 k 5 g c'
Law for the following reason (Section 7031.5, Business and
Professions Code): PRESEMTBY ,
BUILDING 0 (400-88
I, as owner of the property, or my employees with ADDRESS
wages as their sale compensation,will do the work and
the structure is not Intended or offered for sale(Section LOCALITY
7044, Business and Professions Code). MOVING TEL.
I,as owner of the property,am exclusively contracting CONTRACTOR NO.
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY SETT BACK YARD HWY TOTAPROP.LINE WIDTH
I hereby affirm that there is a construction lending agency for FRONT
the performance of the work for which this permit is issued P.L.
(Sec. 3097, Civ. C.). SIDE
P.L.
C.:
Lender's Name y !� LDMA Ref. #
P.C.Fee$ Permit Fee )
Lender's Address /�
I certify that I have read this application and state that the Issuance Fee i'le % LDMA P/C#
above information is correct. I agree to comply with all County Investigation Fee Q
i ordinances and State laws relating to building construction, Total Fee 4.21(g () LDMA Perm.#
and hereby authorize representatives of this County to enter r..:
upon the above-mentioned pr for inspection urposes.
/ ell ��J _'� SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of 'ent obate
• . • APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS
2 1
I hereby affirm that I have a certificate of consent to self insure. BUI 7
�2 F.
�L,/ �/�
ING ADDRESS 57,
or a certificate of Workers'Compensation Insuran ,or a certifie CITY ZIP
copy thereof Sec.3800,Lan.C.) /�I✓� 9�7�0 LOCALITY
Policy No. v Compakd SIZE OF LOT NO OF BLDGS.NOW ON LOT
❑ Certified copy is hereby furnished. —170 XOR. / PUf�f r e NEAREST CROSS ST
❑ Certified copy is filed with the county uilding in pection TRACT BLOCK LOT NO. 1�
depart nt. L� USE ZONE MAP NO.
Date S f ASSESSOR MAP BOOK PAGE PARCEL
Applicant /3'C) SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER TEL NO. S
COMPENSATION INSURANCE �� �/��
WITHIN 1000 FT.OF SCHOOL? YES NO
(This section need not be completed if the permit is for one hundred ADD ESS
dollars($100)or less.)
2 f dL/ 1- $"r DISTRICT GROUP TYPE CONST. I FIRE ZONE PROCESSED BY
CITY PL� A, ZIP `
I certify that in the performance of the work for which this permit T� Cil `3 3
is issued, I shall not employ any person in any manner so as to ARCHITECT OR ENGINEER TEL NO.
become subject to the Workers'Compensation Laws. v/ /W;. / STATISTICAL CLASSIFICATION APT' CONDO
Date Applicant ADDRESS ,V ,1 CLASS NO. DWELL UNITS
NOTICE TO APPLICANT If, after making this Certificate of 3.S ozae� ve �-h` X027 REQUIRED TOTAL SETBACK FROM EXIST
Exemption, you should become subject to the Workers' CONTRACTOR TEL NO. SET BACK YARD HWY PROP LINE WIDTH
Compensation provisions of the Labor Code, you must forthwith �lo"Ar 7ia0/� �0� FRONT
comply with such provisions or this permit shall be deemed revoked. ADD S SIDE D LIC.NO. PL
LICENSED CONTRACTORS DECLARATION CITYA LIC.CLASS PL C
I hereby affirm that I am licensed underprovisions of Chapter 9 s% D Yl
lf2 SEWER MAP C
(commencing with Section 7000)of Division 3 of the Business and SO.FT.SIZE NO.OF STORIES NO OF FAMILIES 0
Professions Code, d I'cense is in full force and I. NEW ❑ BK PG C
License Num r �� ��� Lic.Class DESCRIPTION OF WORKADD VALUATION ® F
Contractor ` Date ALTER ❑ $
O
U
❑ e
❑ i am exempt under Sec. REPAIR $
B.BP.C.for this reason DEMOL ❑ LDMA P/C#
Date: USE O� 7}N� G BL �� w�/ URM ❑
Signature APPLICANT fPPo T) /,�- c_ TEL NO. LDMA Perm# ?�
❑ I, as owner of the property, or my employees with wages as /+'V L� V/1/D z ACCT.v
their sole compensation, will do the work and the structure is ADORES b O �_
not intended or offered for sale (Section 7044, Business and 3 lB V/� �V,, S� d�/�S FINAL DATE a 3303 50.50
Professions Code.) WILL THE APPLICANT OR FUTURE _!d O 1
BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIALd
❑ I, as owner of the property, am exclusively contracting With OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE JQ
AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE?
licensed contractors to construct the project (Section 7044, FINAL BY ^ > ACCT°v
Business and Professions Code.) YES 11 No❑ ,U`h
��yy3 142.20 WILL THE INTENDED USE OF THE BUIDUNG BY THE APPLICANT OR FUTURE BUILDING r''rJ'Ll�1 142°s_
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH
CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMDI SEE PERMITTING CHECKLIST FOR ITEMS
GUIDELINES i
I hereby affirm that there is a construction lending agency for YES❑ No❑ TOTAL 192-70
the performance of the work for Which this permit IS Issued(Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING �/
3097,CIV.C.) CHECKUST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, CHECK 192.70
GH 2 20 140
Lender's Name MATERIALS REPORTITLE 2.CHAPTER TING AND FOR OBTAIN NG20 SECTIONS 2 20.100THRA PERM T FROM THEOSCAOMD.G HAZARDOUS
Lender's Address HANE °�d
OWNER OR AGENT
3 I certify that I have read this application and state under penalty
y P.C.FEE 7, PERMIT FEE 3000-0001
p of perjury that the above information is correct.I agree to comply �!'Q Q )/1 /$b
with all county ordinances and State laws relating to building
m construction and her by authorize representatives of this County ISSUANCE FEE R O 4900 1 Ph 6:42
O to en u the ab entioned property for inspection urpo es. p!
dg ` %---, � 9-Az ,� INVESTIGATION FEE TOTAL FEE
N ,vu a Am*=ffl a Agee Oa1e r
SEE REVERSE FOR EXPLANATORY LANGUAGE
WORKERS'COMPENSATION DECLARATION
i r
I hereby affirm that I have a certificate of consent to self P LIC T i F®Q 1 ®� PERMIT
insure, or a certificate of Workers', Lob. Cstion Insurance,or L1O jjlm
a certified copy thereof(Sec. 3800, Lab. C.) � C04JFIYY OF (OS � �� ILDI111G A►ND SAFETY
Policy No. 55501 CompanyState CnI11M-at70 e� r
F-1Certifiedcopy is hereby furnished. Ins . Fund FOR APPLICANT TO FILL IN AooRE"
® Certified copy is filed with the county building inspec- BUILDING
tion department. ADDRESS LOCALITY
NEARE
Date 4-1 _RQ Applicant 1 CO CITY ZIP CROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGAI 7 8 0 ASSESSOR
COMPENSATION INSURANCE I SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL
(This section need not be completed if the permit is for one USE ZONE ESPECIAL
hundred dollars ($100)or less.) TRACT BLOCK LOT NO. y,
TEL. tLI certify that in the performance of the work for which this OWNER NO DITIONS 0
permit is issued, I shall not employ any person in any manner DISTRICT GROUP TYPE FIRE PROFASSED BY U
so as to become subject to the Workers'Compensation Laws. ADDRESS CONST. JZ�F,
CITY Tem 1 e Cit ZIP 91780 0,?
Date B-26-20 Applicant U n w a r d I D�n1 C O ARCHITECT OR TEL. STATISTICAL CLA ICATION APT. CONDO. V
NOTICE TO APPLICANT: If, after making this Certificate of w
Exemption, you should become subject to the IL
Workers' ENGINEER NO. CLASS NO. J DWELL. UNITS
Compensation provisions of the Labor Code, you must forth- ADDRESS SEWER MAP g
with comply with such provisions or this permit shall be �u�
deemed revoked, CONTRACTORF10 ward L .R a n d o l %'0 2 BK. PG,0�OQ
VALIDATION
LICENSED CONTRACTORS DECLARATION LIC. =
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS. NO. VALUATION
(commencing with Section 7000)of Division 3 of the Business and LIC.
Professions Code, and my license is in full force and effect. CITY San iel CLASS $
Uln
SQ. FT. NO.OF NO.OF CHECK
License Number -186G86 Lic.Class C-39 SIZE STORIES FAMILIES ONE
Contractor Howard L .Rand�Le Cos 8-26-,8(
DESCRIPTION OF WORKRe-roof house NEW ❑ $
❑ I am exempt from the licensing requirements as I am a only ADD ❑ -
licensed architect or a registered professional engineer ALTER ❑ FINAL
acting in my professional capacity (Section 7051, REPAIR DATE ®- 3�a
SE
Business and Professions Code). USE OF e'SFINAL P
EXISTING BLDG. DEMOL ❑ By
Lic.or Reg.No. _Date APPLICANT TEL.
OWNER-BUILDER DECLARATION (PRINT) _ /
I hereby affirm that I exempt from the Contractor's License
Law for the followingg r reason (Section 7031.5, Business and ADDRESS
Professions Code): PRESENT
F1BUILDING
I, 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). MOVING TEL.
❑ 1, as owner of the property, am exclusively contracting CONTRACTOR NO.
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code).
i REQUIRED TOTAL SETBACK FROM EXIST. 41 9 5 9 A
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH
I hereby affirm that there is a construction lending agency for FRONT # o 0 0 0 0 1
the performance of the work for which this permit is issued P L
(Sec. 3097, Civ. C.). SIDE
P.L. 2 0 0 3[L C C
Lender's Name .,,.y:r... 1•. _ 0 0
- 34. 005
41 C C
P.C. Fee$ Permit Fee $27.00 U
Lender's Address
04.C2-80
I certify that I have read this application and state that the Issuance Fee
7 00
tabove information is correct. I agree to comply with all County Investigation Fee $34.00
3 or nd tate laws relating to building construction,
3 and here a nz representative f this County to enter Total Fee
= upon ab -m t' ed p ert r inspect' pur s
R
gZIFJF- ZIP SEE REVERSE FOR EXPLANATORY LANGUAGE
D
Signaty of Applicant or gent Date ®s
1,
r" COUNTY OF LOS ANGELES TEMPLE CITY # 0508 BUILDING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 BL 0508 1301300022
PHONE: (626) 285-0488 EXT:
ILEGAL ID: I N0. OF CONST NEW I BUILDING ADDRESS: I
ON FILE SQ. FT STORIES TYPE OCCUP GROUP[ 9217 OLIVE ST I
(STRUCTURE: 30 1 V-B R3 [ TEMP CA 917803126 [
[ASSESSOR INFORMATION NUMBER: I GARAGE: I NEAREST CROSS STREET: [
18588-031-020 OTHER: I THOMAS PAGE: 596 GRID: H4 LOCALITY: TEMPLE CITY CAI
(TENANT (EXIST BLDG USE: REBID TISSUED ON: PROCESSED BY:
EXIST OCC GRP: R3 01/30/13 SR
(OWNER: TEL. NO: IBLDGS. NOW ON LOT: VALUATION: (FINAL DATE FIN BY: CODE:
IABDELSHEMID, SAMEH (626) 652-5084- 1 8,000 I
19217 OLIVE ST 1 /
ITEMP 917803126 I FEES PAID TMSd-RIPTIfOkf OF WORK v [
I I REPLACE APPROXIMATELY 30 LF FOUNDATION, RETROFITTING (LA 1
I IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT:ICITY STANDARD PLAN) BEAM, PIER & POST W/PADS 1
1APPLICANT: TEL. NO: I I
ICANTA, ARTHUR (323) 254-8800- IAA BLDG PERMIT ISSUANCE 27.80 I_ I
15728 YORK BLVD IAB STATE GREEN BLDG FEE 8000.00 VAL 1.00 [SPECIAL CONDITIONS: [
ILOS ANGELES 90042 IAC STRONG MOTION RESID 8000.00 VAL 0.80 [ [
I IDI PLANCHECK W/O EN-HC 8000.00 VAL 155.60 I I
I ID2 PERMIT W/0 EN-HC 8000.00 VAL 183.00 1
(CONTRACTOR: TEL. NO: I TOTAL FEES 368.20 (APPROVALS DATE INSPECTOR SIGNATURE I
IL C GENERAL CONSTRUCTION INC (323) 254-8800- I 1-
15728 YORK BLVD LIC. NO I ILOCATION AND SETBACKS [ I I
ILOS ANGELES CA 90042 837030 1 I
I I ISOILS ENGINEER APPROVAL [ I I
[ARCHITECT OR ENGINEER: TEL. NO: [ IFOUNDATION/TRENCH FORMS [ I
I -
LIC. NO: I (SLAB/UNDER FLOOR I [
(RAISED FLOOR FRAMING I I
I I I
IMAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP:[ (UNDERFLOOR INSULATION [ I I
1147H265 K 52 3 001 1 [ I I
I I 11ST LEVEL FLOOR SHEATH I I I
INO. OF FAMILIES: DWELLING UNITS: APT/COND: STAT CLASS: 1 I [ I I
1 0 NO 20 I 2ND LEVEL FLOOR SHEATH
I I I
SCHOOL WITHIN HAZARDOUS I IROOF SHEATHING [ I
[AIR QUALITY: 1000 FEET MATERIALS [ I
NO NO NO I (FIRE DEPT. FRAME INSPECT[ I
[ [BLDG DEPT. FRAME INSPECT[ I [
I I ISHEAR PANELS I I [
I I I
[ i IINSULATION/WEATHER STRIP[ I I
[ IINTERIOR LATH/DRYWALL I I I
[ I (EXTERIOR LATH I I I
I ILOT DRAINAGE [
[ [SMOKE DETECTION DEVICES I [
I I IFIRE DEPARTMENT APPROVAL[ I I
I I I I I I
I (REPORT ID: DPR261 ROUTE TO: BS0508 [ I I [
APPLICATION FOR BUILDING PERMIT
• •.COUNTY OF LOS ANGELES s • 'W w BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN
[LI1.LDING ADDRESS
I hereby affirm that I have a certificate of consent to self insure, LD G ADDRESS 2/7 ,� Q�/Y/ ST.or a certificate of Workers'Compensation Insurance,or a certified ?— � � � �� 7B�
copy thereof(Sec.3800,Lab.C.) CITY ZIPPolicy No. Company 7i� FUND '��LE � ' �/78® O+CA�LI,TYY /� �SIZE OF LOT / NO.OF BLDGS.NOW ON LOT l •PL0 '"'1❑ Certified copy is hereby furnished. �� X I Tio ���• //pl/S� t NEREST CROSS ST.
11 Certified BLOCK LOT NO
Certified copy is filed with the county building inspection
departUSE ZONE MAP No.
ment. I
Date �� /0 ApplicantASSESSOR MAP BOOK PAGE PARCEL
V-29— SPECIAL CONDITIONS
�
CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER ✓��� TEL NO. 2-D YES NO
COMPENSATION INSURANCE WITHIN 1000 FT.OF SCHOOL?
(This section need not be completed if the permit is for one hundred ADDRESS
IV� ST, DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY
dollars($100)or less.) 92/7 A, 4V4
CITY ZIP
I certify that in the performance of the work for which this permit �,0C&7 L'/T $P17
is issued, I shall not employ any person in any manner so as to ARCHITECT OR ENGINEER TEL NO.
become subject to the Workers Compensation Laws. V A1471-W,1141(1
471-W ��/Y(1 213��6�>f3 STATISTICAL CL SIFICATION APT CONDO
Date Applicant ADDRESS 7�/Tr //5y �/� �,! CLASS NO. DWELL UNITS
NOTICE TO APPLICANT.- If, after making this Certificate of 2/ BL.BD/e0 Y�s + v�`� ��a�7 REQUIRED TOTAL SETBACK FROM EXIST
Exemption, you should become' subject t0 the Workers' CONTRACTOR _ TEL NO.-7 SET BACK YARD HWY PROP LINE WIDTH
Compensation provisions of the Labor Code, you must forthwith ,¢,gam 4:!AV7X19 L/OR f g-/ j! O FRONT
comply with such provisions or this permit shall be deemed revoked. A✓RESEl7 ��� y �v n^' uC.NO. P L
LICENSED CONTRACTORS DECLARATION �� �v of x-56 SIDE
CITY LIC. LASS P L
1 hereby affirm that I am licensed underprovisions of Chapter 9 5 ®�S�
SO.Fr.SIZE NO.OF STORIES NO.OF FAMILIES SEWER MAP
(commencing with Section 7000)of Division 3 of the Business and � a
Professions Code,and my`Ii nssee is in full force and effect. .4VaiN•5'9f0 NEW ❑ BK PG AQQT°Tr d
License Number ��` S•^' Lic.Class DESCRIPTION OF WORK App VALUATION ,Tj303 7 ,17 Q
Contractor�E e-Q& /'./= ate b /D ,/J�/i/f7/(/ O— L/!//N!� �'/�,
ALTER ❑ — J� 1 ITEMS cc
cc
L' T (R/ON REPAIR ❑ a°-� TOTAL �L o � ''
❑ 1 am exempt under Sec. �Q BBQ. _ C O
BAP.C.for this reason J�?U�� JET DEMOL ❑ A P/C# CHECK 781.19
W
LDM
Date: USE OF EXISTING BLDG. 11
Signature %V 415415 !G Os`t/�'LL7 URM ❑ IAhIGE oQQ C0
Si
g APPLICANT(PH/ T)�"NO TEL NO. C� D LDMA Perm# X23 a z
El 1, as owner of the property, or my employees with wages as ,- W (J 7 Z
their sole compensation, will do the work and the structure is ADDRESS / O 10/10/95
not intended or offered for sale (Section 7044, Business and /Y 4'V FINAL DATE a �5
Professions Code.) WILL THE APPLICANT OR -1g-q4
FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIALJ
OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE
I, as owner of the property, am exclusively contracting with
❑
AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDES FINAL BY 0ACCTJL
contractors to construct the project (Section 7044, YES 11 NO� °'0'
Business and Professions Code.)
WILL THE INTENDED USE OF THE BUIDUNG BY THE APPLICANT OR FUTURE BUILDING 3303 1115.25
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH
CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FOR ITEMS
GUIDELINES
I hereby affirm that there is a construction lending agency for YES❑ NOW
rnthe performance of the work for which this permit is issued(Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING TOT/A+L�/. 1249°89
T3097,CIV.C.) CHECKLIST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE. f"'E4f, 1249.89
a TITLE 2,CHAPTER 2 20 SECTIONS 2 20 100 THROUGH 2 20 140 CONCERNING HAZARDOUS CHANGE
Lender's Name MATE PORTING FOR OBTAINING A PERMIT FROM THE SCAOMD. `''A�l7E °00
In Lenders Address //
0 O��'kER OR AGENT
o I certify that I have read this application and state under penalty
c of perjury that the above information is correct.I agree to comply P.C.FEE PERMIT FEE 0000-000 1 11/27f95
ccv with all county ordinances and State laws relating to building !�
C0 constrU to , and h eby authorize representatives of this County ISSUANCE FEE // 3435 1 PM12008
� to ent On he a /p-mentioned property for inspection rpose . /
I ��- `"�—L�- l� 2 S INVESTIGATION FEE
� TOTAL FEE � 1
SEE REVERSE FOR EXPLANATORY LANGUAGE
1