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COUNTY & LOS ANGELES
DEPARTMENT OF'COUNTY ENGINEER ADDRESS V'`J
BUILDING AND 1SAFETY DMSION LOCALITY
JOHN A. LAMBIE. COUNTY ENGINEER
COLEMAN W.JENKINS SUPT. OF BUILDING NEAREST
CROSS ST.
FOR APPLICANT TO FILL IN DIS ljlCTONO. GRO TYP
CONST. Y
BUILDING ��jtr MAP HIGHWAY
ADDRESS N0. ♦� (/ (CIRCLE) STATE MAJOR SECOND LOCAL
� .
LOCALITY yS �LQ,u,�,p,d) USE ZONE SPE LAL CONDITION'S
NEAREST
CROSS ST. -
LEGAL REQUIRED YARD HWY STREET NAME EXIST.
DESCRIPTION LOT NO. BLOCK SETBACK WTIDH
FRONT
NO. OF BLDGS. P.L.
TRACT NOW ON LOT SIDE
USE OF L.
SIZE OF LOT t7 1 ��� EXISTING-BLDG.
191a Fef�
OWNER a -
MAIL.. Q
ADDRESS �3S y�f63/� ter/
CITY NO.
- QC C �fl AL2
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APPLICATION FOR � -- C
OCOUPANCY p
INSPECTION SAFETY PERMIT F
C
TRAILER USE u
p
v
USE OF STRUCTURES OR DEVICES s
LIMITED TIME. USE
DATE DATE
FROM: TO:
APPROVALS DATE INSPECTOR'S
SIGNATURE
OCCUPANCY APPROVAL
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS GROUP OCC. LOAD
APPLICATION AND STATE THAT THE ABOVE IS COR-
RECT AND AGREE TO COMPLY WITH ALL COUNTY TRAILER USE
ORDINANCES AND STATE LAW R UL SUCH
WORK AS INDICATED H I
SIGNATURE OF SAFETY PERMIT
PERMITTEE TEMPORARY
�� . STRUCTURE APPROVED
ADDRESS 'TEMPORARY
STRUCTURE REMOVED
FEESL�l V FINAL APPROVAL
APPLICATION VALIDATION 'JOHN F. LEWIS, PRINCIPAL STRUCTURAL ENGINEER
(NOT A PERMIT) CK. M.O. cases PERMIT VALIDATION CK. M.O. CASH
I �'� 0 d �t 5!;" JbL '7 � � D a