HomeMy Public PortalAbout6323 SALTER AVE_Building__ ENT OF BUEMW AND SAFETY APPLICATION FOR PERMIT
COUNTY OF .oS ANGELES Q V 8 � ' 0
WM. J. FOX, CHIEF ENGINEER �V�� �/ r�
NG
FOR APPLICANT TO FILL IN FOR OFFICE USE ONLY
DISTRICT NO. PLAN CK.-NO. - PERMIT NO.
BUILDING/ f, 'I ��'_ p r/ Q _ +
ADDRESS(^.5 7� i; 7/) / //
�-+
LOCALITY �/ "m- &Jv/ RECNEARESTEIVED BY DATE orr ,P-PL`L.. DATE ISSUED
'ROBBST. �C'/./1��.new Q� ` C�.5.5/l /��-+ �`-
BUILDING
/. �Slp.A® ADDRE98 / /7
OWNER �/�y'rG�7 (/,�T
MAIL
ADDREBS��f Cn i"�/I� � L,.,- LOCALITY • C!
NEAREST La /�p /
CITY �. TEL yy�� r� C CROSS ST. E !
NOQr.I�IV`°�i� FIRE NO.OF TYPE GROUP�r.
ARCHITECTOR � � EOL ZONE PLANSz�
ENGINEER �y U r� 3�S'7r}
BLDG. y / RD. NO.
ADDRESS 17/JId SETBACK LINE ;2-e
APPROVED
CONTRACTORS NPL BY DATE
USEAPPROVED
ADDRESS ZONE �SY DATE
LEGAL
DESCRIPTION LOT NO. BK CORRECTIONS
TRACT e !/LO37
C
NO. OF BLDGS. '' r�
SIZE OF LOT, _ �� NOW ON LOT id y
USE I OF I ISO.OF
EXISTITI FANG BIDS. FAMILIES ,ZOOMS
DESCRIPTION OF WORK ;
NEW ALTERATION ADDITION 2-
3 / ��• "� �� r
REPAIR MOVING DEMOLISH /a��dT a-�'A'a X'oG�q�l o Gi ,r�!J(��a •� -
91).FT. NO.OF l _
SIZE 1? f.�f) ROOMS STORIES /pr -)-9
r
WALL '
COVERING , �//� aGA� RCOOF
OVERINO (�/}J� ,�/�,(i a t7 wIE!
USE OF NEW -�" Gf�CaTl� G//✓dam• .��T �•oY G�
BUILDING
LL
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS = 7 ✓ 4,'?�A'pPROVAL6
APPLICATION AND STATE THAT THE ABOVE 18 CORRECT
AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES —QUNDATION.- LOCATION I BPECTOR DATE
FORMS, MATERIALS / ss..,__ ,♦e +t F;fj!
AND STATE LAWS REGULATING BUILDING CONSTRUCTION.
D FRAME.- FIRE STOPS,
SIGNATURE or 1 p "MBRACING,BOLTS
PERMITTEE ���////���� I'a!•.ASC.ti ! / a :4V'
f LATH, INT. ,.
AUTHORIZED AST. `
LATH, EXT.
76A6313A-3 10-513 .gf' / V L/ P.C.$ 6'..' O PLASTER, INT.
FEE PLASTERr EXT. /
VALUATION
FEE FINAL
78A888A CE 980811-87 APPLICATION FOR BUILDING PERMIT �••
COUNTY OF LOS ANGELES BUILDING
DEPARTMENT OF COUNTY-ENGINEER ADDRESS 0 3 3 A-7-&X
X
BUILDING AND SAFETY DIVISION LOCALITY�L
JOHN A.LAMBIE,COUNTY ENGINEER NEAREST
CASSATT D.GRIFFIN,SUPT OF BUILDING - CROSS ST. fF M YL
DISTRI T NO. - GROUP SEWER MAP
FOR APPLICANT TO FILL IN. coNsr. I BK P6
BUILDING g �� P a STATISTICAL CLASSIFICATION l""
ADDRESS e J .i
LOT.NO. BLOCK CLASS.NO DWELL.UNITS
MAP �� STATE YES NO
3
e / ' NUMBER HWY.
TRACT / .• USE 7,ONE SPECIAL
NO.OF
SIZE OF LOT f/J +w7_ CI t I NOW ON LOTS ' rl� CONDITIONS
USEOF
.p J
EXISTING BLDG. BUILDING YARD HWY STREET NAME EXIST.
SETBACK WIDTH
OWNER / A- 4 1XI �iJ l�/� FRONT 9 � c �L
ja
MAIL /. 1V
ADDRESS 6_r,LJ N S,4 d. fs/2.. SIDE
TE
CITY /► r. No%r 7p
ARCHITECT OR TEL. INSPECTION RECORD
ENGINEER NO.
ADDRESS � U /J �� _ C l��ddF
TEL.
CONTRACTOR gLl NO.
ADDRESS ,.J i`i-J rJ 6 /V
DESCRIPTION OF WORK �) '
SQD ALTER NO.OFNO.OF REPAIR DEMOLISH. - j
SIZE f3O SiFi STORIES FAMILIES
USE rA R�7 e/ /7/(-,�1,7/)Ap"=/4 C''=•.11 lhl(r p
SIGNATURE OF - APPROVALS
APPLICANT _ -_• � md.
DATEINS TOR'S SI NATURE
ADDRESS FOUNDATION: LOCATION / + �yJ
FORMS,MATERIALS b 'J e lI
P. FRAME: FIRE STOPS, / r
$ VLc) FEE $ BRACING.BOLTS
VALUATION $ FURNACE:'LOCATION.
FEE t , GAS VENT,DUCTS ��1
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS AP- LATH,INT. ! ',�%'!�� 7.+/; '.16"LJ��?
PLICATION AND STATE THAT THE ABOVE IS CORRECT AND -
AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND
STATE LAWS REGULATING BUILDING CONSTRUCTION. LATH,EXT.
SIGNATURE OF
S - yrsiHCOR-
RECT AND POSTED
�:v ,
ADDRES "� ��'/�-^ FINAL
CLYDE N.DIRLAM,PRINCIPAL STRUCTURAL ENGINEER
PLM1N CHECK VALIDATION CiL M.O. cASH PERMIT VALIDATION cfc M.O. CASH
LG 4 5 2 2°° SEP 5 1 A 8.50 M ®.
76A63BA'CE#803 9-68
68 .9'
APPLICATION FOR BUILDING' PERMIT
r-'.COUNTY OF LOS ANGELES BUILDING
DEPARTMENT OF COUNTY ENGINEERADDRESS n .y oe ,.
Ll � ,a xa, e
BUILDING AND SAFETY DMSION .LOCALITY Minmnln
JOHN A. LAMBIE, COUNTY ENGINEER NEAREST
COLEMAN W. JENKINS, SUPT OF BUILDING CROSS ST.
FOR:APPLICAI�IT TO FILL N DIS««T�-,.., cT Noy GR TYPE"' ,P'. OCESSED BY
(Print or type only) ru r CONSTrr
BUI DING j STATISTI CA L_gLASSI FICA TION .-SEWER MAP
AD RESS C37 77 jq CLASS NO. !_ DWELL,UNITS B ) P
LOT NO. BLOCK USE ZONE MAP ,�•+-+,
TRACT �r SPECIAL
NO.OF BLDGS. )fid CONDITIONS
SIZE OF LOT NOW bN LOT
USE OF
'EXISTING BLDG. BLDG.SF.,TBACK FROM
OWNER I$(),_ NOL. FRONT PROP"LTIQE"O —(STREET)
TYPE OF EXISTING SETBACK IGHWAY + YARD — TOTAL
ADDRESS63 HIGHWAY WIDTH FROM G.L.
_ ��pp City
CITY � ld.® irY. + —
BLDG.SETBACK FROM
ARCHITECT OR TEL. SIDE PROP.LINE OF (STREET)
ENGINEER NO. TYPE OF EXISTING SETBACK I HIGHWAY + . YARD = TOTAL
ADDRESS HIGHWAY WIDTH FROM C.L. pr•,
TEL. + v
CONTRACTORtt a {I ,� NO.d7sg /� /Xvg �• W
ADDRESS �aA-rlri (1,""' h ;d1 'Al .NO L.C. I , CORNER CUTOFF YES ❑ NO ❑ J
u
CITY SRM; Gebrio 3'` A CLASS C-39 SEE REVERSE SIDE FOR SPECIAL APPROVALS a
CONSTRUCTION LENDER 1 a
NAME AND BRANCH a
ADDRESS s LL
SQ. FT. ' NO. OF NO. OF NEW ❑
SIZE STORIES FAMILIES ❑
USE OF ADD
STRUCTURE sA ,
ALTER ,❑
REPAI Q
SIGNATURE OF •s
APPLICANT DEMOL ❑
VALUATION APPROVALS '• DATE INSPECTOR'S SIGNATURE
• P.C. PMT. FOUNDATION: LOCATION
`FEE S FEE FORMS, MATERIALS
FRAME: FIRE STOPS,
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION 'BRACING BOLTS
AND STATE THAT THE ABOVE 18 CORRECT AND AGREE TO COMP FORNACE: LOCATION,
*ITH ALL ORDINANCES AND LAWS REGULATING BUILDING CO - GAS VENT, DUCTS
STRUCTION. I CERTIFY THAT IN DOING THE WORK AUTHORIZE
FIEREBY I WILL NOT EMPLOY ANY PERSON IN VIOLATION OF THk LATH, INT.
"BOR CODE 01 THE STATE OF -CALIFORNIA IN RELATING TO
WORKMEN'S COMPENSATION INSURANCE. LATH, EXT,
" �` HOUSE NUMBER COR-
SIGNATURE OF __, /''
PERMITTEE. ' ' `'"�"""'` A RECT AND POSTED
ADDRESS-- �` "� 'moi 5' FINAL
JOHN F. LEWIS. PRINCIPAL STRUCTURAL ENGINEER
PLAN CHECK VALIDATION CK. M.O. CASH PERMIT VALIDATION cK. M.O. CASH
3 '� Ct lti:!'y.S'•' ':I
APPLICATION FOR BU ILDI N .PyyE�� `u
FOR APPLICANT TO FILL IN (Print or tyae only) �'®®
BUILDING COUNTY OF LOS ANGELES
ADDRESS Y&325 Sf)L-T�� DEPARTMENT OF COUNTY ENGINEER
c114 T GE G/Ty z I P /)80 BUILDING AND SAFETY DIVISION
NO.OF B BUILDING /
SIZE OF LOT(p•S rf�' NOW ON LOT
� ADDRESS J'�40-3�
TRACTA//C�ANNA BLOCK LOT NO.
/ LOCALITYTEL
NEAREST
OWNER/�040JE&• g11jT NO. 7'0��7 CROSS ST.
ASSESSOR
ADDRESS (p82_ � �' � MAP BOOK PAGE PARCEL
CITY / MAW-4i 6177; ZIP 9170 v D T GR CONST ZONE PROC Y
ARCHITECT OR TEL.
ENGINEER • NO.
STATISTICAL CLASSIFICATION SEWER M P
ADDRESS - CLASS NO. DWELL..UNITS ler-OFOG
CONTRACTOR TEL.NO USE ZONE MAP r��
LIC. ,/� NO. 7W01
ADDRESS NO, f+ SPECIAL
LIC CONDITIONS
CITY CLASS
ROAD DEPARTMENT APPROVAL REQUIRED YES[] NO❑
CONSTRUCTION LENDER
NAME AND BRANCH L nw BLDG.SETBACK FROM C
FRONT PROP.LINE OF (STREET) c
ADDRESS I w 1mg6jang CITY qHIGHWAY + YARD = TOTAL SETBACK FROM TYPE OF EXISTING C
SQ. FT9 NO. OF NO. OF CHECK FRONT PROP. LINE HIGHWAY WIDTH F
SIZE STORIES FAMILIES / ONE C
+ _ 1 c
D ❑
DESCRIPTION OF WORK NEW G
BLDG.SETBACK FROM
ADD SIDE PROP.LINE OF (STREET)
ALTER ❑ HIGHWAY _+ YARD = TOTAL SETBACK FROM TYPE OF EXISTING
REPAIR❑
SIDE PROP. LINE HIGHWAY WIDTH
USE DEMOL ❑ +
EXISTING BLDG.
APPLICANTTEL n6G CORNER CUTOFF YES ❑ NO ❑,
(PRINT) ��FALAQW0. vOv 7.
BY (SIGNATUREIN OPEN SPACE YES ❑ NO ❑
) -
VU ov
IN COASTAL ZONE -YES ❑ NO ❑
VALUATION "�
CATEGORICAL EXEMPTION YES❑ NO,❑
I HEREBY ACKNOWLEDGE THAT I HAVE HEAD THIS APPLICATION ENVIRONMENTAL
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY IMPACT EXEMPTION DECLARATION SIGNED (DATE)
WITH ALL ORDINANCES AND LAWS REGULATING BUILDING CON-
STRUCTION.
ON- IMPACT RE PROCESSED (DATE)
STRUC TI ON. I CERTIFY THAT IN DOING THE.WORK AUTHORIZED.
HEREBY I WILL NOT EMPLOY ANY PERSON IN VIOLATION OF THE ��
LABOR, Co• DE OF THE STATE OF CALIFORNIA IN RELATING TO A _vw
WORKMEN'S COMPENSATION INSURANCE. �/ CL
SIGNATURE OF kdL
PERMITTEE
egin
ADDRESS) Z �/rM
NAL
Y.
CITY/ �(�:r Com/% NO. DIA TE B�
TEL.
MAKE C//ECKS PAYABLE TO:
FEE $ FEE
HARVEY T. BRANDY, COUNTY ENGINEER
PLAN CHECK VALIDATION CK. M.O. CASH PERMIT VALIDATION CK. M.O. CASH
R.6.2:-4 SEP 1 1 D 2 .5.5 0 amt
7GA638A CE#B03 7/73 _ .
- ,err
APPLICATION FOR BUILDING PERMIT
„ COUNTY OF LOS ANGELES BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT T FILL IN BUILDING A4DRESS „
(7 y
I hereby affirm that I have a certificate of consent to self insure, BUILDING ADDRESS .t ' LC 4J
or a certificate of Workers'Compensation Insurance,or a certified
copy there+off Sec.3800,Lab.C.) clTv r ZIPS.
Policy No.-/� Cp � Company!Ecp t� �A "'0 �.7� LOCALITY
SIZE OF LOT NO.OF BLDGS.NOW ON LOT
❑ Certified copy is hereby furnished. NEAREST CROSS ST
/Certified copy is filed with the county building inspection TRACT BLOCK LOT NO.
USEZONE MAP NO.
de artment. ''�►�
Data
Applicant- __ ASSESSO MAP BOOK PAGE PARCEL a
5 Zc� Q l SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' OWN TEL NO. YES NO
COMPENSATION INSURANCE u I WITHIN 1000 FT OF SCHOOL?
ADDR
(This section need not be completed if the permit Is for one hundred erW '� DISTRICT ' GROUP TYPE CONST.' FIRE ZONE PROCESSED BY
dollars($100)or less.)
I certify that in the performance of the work for which this permit CITY - ZIP
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. STATISTICAL CLASSIFICATION APT CONDO
Date Applicant ADDRESS CLASS NO. 54-1 DWELL UNITS
NOTICE TO APPLICANT.' If, after making this Certificate of REQUIRED TOTAL SETBACK FROM 'EXIST
Exemption, CONTRACTOR TEL NO.
p you ShOUId become subject t0 the Workers' SETBACK YARD HWY PROP LINE WIDTH
Compensation provisions of the Labor Code,you must forthwith FRONT
comply with such provisions or this permit shall be deemed revoked. ArJLIC. O. PL
�' SIDE a
LICENSED CONTRACTORS DECLARATION CIT LIC.c P L CD
1 hereby affirm that I am licensed under provisions of Chapter 9 /' C. ✓Y SEWER MAP �
(Commencing with Section 7000)of Division 3 of the Business and SO.FT.SIZE NO.OF STORES NO.OF FAMILIES
NEW ❑ BK PG
Professions Code,and my license I in full force and effect.
D CRIPTION OF WORLU
License Number 6 Lic.Class ' C. ADD ❑ vALUARat?,
IN_
Contractor Data q/-C Lg1K ALTER G 0
❑ I am exempt under Sec.
REPAI ❑
B.B,P.C.for this reason DEMOL ❑ LDMA PIC#
Date. USE OF EXISTING BLDG. URM ❑
.
Signature APPLI (PRI T) . / N9 LDMA Perm N Z
❑ I, as owner of the property, or my employees with wages as C
their sole compensation,will do the work and the structure is ADDR
not intended or offered for sale (Section 7044, Business and "� = . FINAL DATE vJ 7
Professions Code.) WILLTHEAPPLICANT OR FUTURE BUILDING O PANT HANDLE A HAZARDOUS MATERIAL JCo. I
❑ I, as owner Of theproperty, am exclusively contracting with OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN Q
Y 9 ?HE AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY
licensed contractors to construct the project.(Section 7044, YES❑ NO❑ _ _
Business and Professions Code.)
IVALL THE INTENDED USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING _..
OCCUPANT REQUIRE PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH
CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST
FOR GUIDELINES. - y3;,,• - _
I hereby affirm that there IS a construction lending agency for YES❑ NO❑the performance Of the work for which this permit IS Issued(Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD
3097,CIV.C.). PERMITTING CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES
ib' COUNTY CODE,TITLE 2,CHAPTER 220SECTIONS 220.100THROUGH 220.140 CONCERNING
Lender's Name HAZARDOUS MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD. `II'
Lender's Address
ORAGENr „
0
o I certify that I have read this application and state that the above
information is correct. I agree to comply with all county P.C.FEE PERMIT FEE ��� ���i'
ordinances and State laws relating to building construction,and _7 O •;„:, r,.:
hereby authorize representatives of this County to enter upon I ISSUANCE FEE yt`
E the above- Rtioned pro or inspection purposes.r� CX 7'
INVESTIGATION FEE TOTAL FEE
SymmnxApwnbmI G�
SEE REVERSE FOR EXPLANATORY LANGUAGE
I
APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS AtAGELE9 •• BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION I BUILDING ADDRESS a FOR APPLICANT TO FILL IN BUILDING ADDRESS
I hereby affirm that I have a certificate of consent to self insure, � p L
or a certificate of Workers'Compensation Insurance,or a Certified ME ZIP
copy thereof(Sec.3800,Lab.C.) CITY e t r ' o O /
STi�LE Fuc��o 9 LOCALITY
Policy No. Company SIZE OF LOT NO.OF BLDGS.NOW ON LOT
❑ Certified copy is hereby furnished. NEAREST CROSS ST.
;Certified copy is filed with the county building inspection TRAECT BLOCK LOT NO.
department.p USE ZONE MAP NO.
Date �'-Z�' / Applicant ASSESSOR MAP BOOK PAGE PARCEL
S3;MAP ` SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER . TEL NO.
COMPENSATION INSURANCE Af thM / AL-/t't' vi&. s7 C) 7 WITHIN 1000 FT.OF SCHOOL? YES No
(This section need not be completed if the permit is for one hundred ADDRESS
S m E DISTRICT GROUP TY CONST. FIRE ZONE PROCESSED BY
dollars($100)or less.) R
CITYzIP �O� _3
I certify that in the performance of the work for which this permit I
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. STATISTICAL CIL SI/FICATION APT CONDO
Date ApplicantADDRESS CLASS NO. DWELL UNITS
NOTICE TO APPLICANT. If, after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST
Exemption, you should become subject to the Workers' CONTRACTOR TEL NC SET BACK YARD HWY PROP LINE WIDTH
Compensation provisions of the Labor Code, you must forthwith GLIgSS(C f00 -3 - a I FRONT
comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC.NO. P L
LICENSED CONTRACTORS DECLARATION
lob O3 Fle�C S 3$29 -3,? SIDE
CIT ` CUC�LASSP L
I hereby affirm that I am licensed underprovisions of Chapter 9 { 9 SEWER MAP
(commencing with Section 7000)of Division 3 of the Business and SO.FT.SIZE NO.OFSTORIESTORIES NO.F FAMILIES
Professions Code,and my license is in full force and effect. 3�pQ
/ NEW BK PG , a
License Number ^3gZR3a[? Lic.Class C 39 DESCRIPTION OF WORK ADD ❑ VALUAnON C
+
Contractor C'LASSIC Ilk Data 7":•G"�3 �' OO�F �O/r1 .$ CLf4ss � ALTER El $ /00 d , Ix
I'
Sl l fa WALS ,r IOLYuWdOD REPAIR ❑ C
❑ I am exempt under Sec.
BAP.C.for this reason DEMOL ❑ TDMA P/C#
LL
Date: USE OF EXISTING BLDG. URM ❑ a
Signature VA2, APPLICANT(PRINT) TEL NO. LDMA Perm# 1 Z
❑ I, as owner of t e property, or my employees with wages as p h4{T■a
their sole compensation, will do the work and the structure is ADDRESS
not intended or offered for sale (Section 7044, Business and FINAL DATE rely G �.I�LITtir `lo-tirl
Professions Code.) HALL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL .. ""' . 9 Z -'/3 j 1ITEMS
OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE J
El I, as owner of the property, am exclusively contracting Wlth -AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? Q
licensed contractors to construct the project (Section 7044, YES❑ NO❑ FINAL BY ' TOTAL 181. 35
Business and Professions Code.)
WILL THE INTENDED USE MI THE BUIDUNG BY THE APPLICANT OR FUTURE BUILDING �. 181.35 n
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH Y
4r�E��► 1CONSTRUCTION LENDING AGENCY COAST AIR QUAUTY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKUST FOR /�L�qq{
GUIDELINES /// 4f11'ti'FGE .00
I hereby affirm that there is a construction lending agency for YES❑ NO❑ ///�/J�/
C11 the performance of the work for which this permit is issued(Sec. IHAVEREAD THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING r/'
3097,CIV.C.) CHECKLIST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, 01300-11013
'y'+ �} /-y /
cli TITLE 2,CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING HAZARDOUS 01300—!10131 !l LL�f J+
Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD.
0 Lender's Address OWNER OR AGENT 0?24 1 AM 8:5210
0I certify that I have read this application and state under penalty
0 of perjury that the above information is correct.I agree to comply P.C.FEE PERMIT FEE
0
cv with all county ordinances and State laws relating to building
construction, and hereby authorize representatives of this County ISSUANCE FEE _lb
to enter on the above-mentioned property for inspection purposes. �G
COa D � �p
CO � y��. rl 7_7-&-.13 INVESTIGATION FEE TOTAL FEE O' /
n
ftw. PI-1 m Awt Gm9 Q
SEE REVERSE FOR EXPLANATORY LANGUAGE