HomeMy Public PortalAbout10114 RANDWICK DR_Building__ APPLIGATIUN FUR BUILDING PERMIT
FOR APPLICANT TO FILL IN (Print or type only)
FADORESS
COUNTY OF LOS ANGELES
t`�11 �� W�c-�. DEPARTMENT OF COUNTY ENGINEER
e� ZIP BUILDING AND SAFETY DIVISION
T rp ` OW ON LOTS ADDRESS / / ^ �.
�� BLOCK LOT NO
NEAREST
h? (� NOL, ` GROSS ST.
ASSESSOR
0d� • ' v s`� MAP BOOK PAGE PARCEL
DISTRICT GROUP TYPE FIRE, ESSED BY
^ Q t ZIP a 1 ,/�. CONST. ZONE
ARCHITECT OR TEL. 5-.be L
ENGINEER NO.
STATISTICAL CLASSIFICATION WER P
ADDRESS CLASS NO.s�/ ff�DWELL,UNITS / YByK,;2�;PG
TEL.
CONTRACTOR S CL C_ NO. ZONE NMAOP
LIC.
ADDRESS NO, U SPECIAL
LIC. CONDITIONS
CITY CLASS ROAD DEPARTMENT APP R L REQUIRED YES❑ NO❑
CONSTRUCTION LENDER
NAME AND BRANCH BLDG.SETBACK FROM
FRONT PROP.LINE OF �' �' (STREET! c
ADDRESS CITY _ TOTAL SETBACK FROM TYPE OF EXISTING
q HIGHWAY + YARD - L
S ZE SO TI,S 3O STORIES I FAMILIES I CHECK
FRONT PROP. LINE HIGHWAY WIDTH `
DESCRIPTION OF WORK NEW + ♦! ` CCiF
(.] ADD ❑ BLOG.SETBACK FROM
t: ��� �p�yS �✓� SIDE PROP.LINE OF (STREET)
4- a � REPAIR�� ALTER ❑ HIGHWAY + YARD = TOTAL S DESETBAK FRPROPCLINEOM HIGHWAY TYPE OFEXIS IN
W DTHG
❑
USE DEMOL ❑ +
EXISTING BLDG. y
AP PRICANT C `I (�� NEL r t1� CORNER CUTOFF YES ❑ NONT) ❑
BY (SIGNATURE) �- a\n IN OPEN SPACE YES ❑ NO ❑
IN COASTAL ZONE YES ❑ NO ❑
VALUATION�Y 3� 2S CATEGORICAL EXEMPTION YES❑ NO ❑
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION ENVIRONMENTAL
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY ,IMPACT EXEMPTION DECLARATION SIGNED (DATE)
WITH ALL ORDINANCES AND LAWS REGULATING BUILDING CON-
STRUCTION. I CERTIFY.THAT IN DOING THE WORK AUTHORIZED IMPACT REPORT PROCESSED (DATE)
HEREBY I WILL NOT EMPLOY ANY PERSON IN VIOLATION OF TME f
LABOR CODE HE OF CALIFORNIA IN RELATING TO
WORKMEN'S COMM TPENSATIONION INSURANCE. A
SIGNATURE OF ,� .> .�/a✓t�l f��
[v
PERMITTEE / f�'� _
ADDRESS L JAG �C/rL11�
.!` TEL �ry �y t FINAL �} BY
CITY S dLV�. Cis G\ V�'�_ NO. ? 1'•"111 DATE
MAKE CHECKS PAYABLE TO: PEE $ FEE
/5z;HARVEY T. BRANDT• COUNTY ENGINEER %� f,a, /
PLAN CHECK VALIDRAON �K., .O. CASH _ PERM�VALIDATION CK. M.O. CASH
4 7 1 i•1RY -12 D 156.6 &"ti i/
76AG38A CE4803 7/73 / 8 7 5vnJUN 2 1 D 2 6 1.0 0 A93