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Home My Public Portal About5211 SERENO DR_Building__ WORKERS COMPENSATION DECLARATION hereby affirm that I have certificate of consent to self -APPLICATION FOR BUILDING PERMIT insure, or a certificate of Workers Compensation Insurance, - or a certified copy thereof (Sec 3800, Lob C) - COUNTY OF LOS ANGELES BUILDING AND SAFETY ' a ' Policy No Company ❑ Certified copy is hereby furnished -FOR APPLICANT TO FILL IN ADDR� ❑ Certified copy is filed with the county building inspec- %RESTS 11 c tion department rrII Date Applicant j CITYam p _r zip E� LOCALiry, _ NO OF&DGS NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' " SIZE OF LOT 11. OSa - NOW ON LOT CROSS ST COMPENSATION INSURANCE ASSESSOR (Thu section need not be completed if the permit is for one - TRACT BLOCK LOT NO - -' ' - MAP BOOK PAGE PARCEL hundred dollars ($I00) or less ) 6 USE ZONE MAP OWNED I certify that In the performance of the work far which this permit is issued, I shall not employ any person in any manner ADDRESS p_ CONDITC d so as to become subject to the Workers Compensation laws /'� O ' CITY G ZIP _ j_ _ Date Applicant ARCHITECT OR TEL ac NOTICE TO APPLICANT If, after making this.Cemflmte of I ENGINEER NO D'$TRICT_ GROUP _ E PROCESSED By O Exemption, you should become subject to the Workers' �-- f 2 Compensation provisions of the Labor Code, you must forth- I ADDRESS i . ;J �4 with comply with such provisions or this permit shall be TEL STATISTICAL CLASSIFICATION APT CONDO N deemed revoked i CONTRACTOR NO - - _ Z LICENSED CONTRACTORS DECLARATION UC CLASS NO DWELL UNtrS_ I hereby affirm that I am licensed under provisions of Chapter 9 l ADDRESS NO SEWER MAP (commencing with Section 7000)of Division 3 of the BusinessLIC and Profess ons Code and my license is in full force and effect _ CITY CLASS BK PG VALIDATION - SO FT �/I1_� NO OF NO OF CHECK License Number Lic Class SIZE /{) STORIES FAMIUES ONE ./ VALUATION Contractor Data DESCRIPTION OF WORK r NEW ❑ $ E] _ ADD ❑ IJV ► I am exempt under Sec � I �Z'' � ALTER 1:1 - B SP C for this reason I W REPAIR ❑ $ USE OF Dater EXISTING BLDG OEIAOL ❑ Signature APPLICANT _ TEL FINAL ' OWNER-BUILDER DECLARATION (PRINT) NO DAA I hereby affirmthat I am exempt from the Contractors License _ _ Low for the following reason (Section 7031 5, Business and ADDRESS FINAL anions Code) NT _ _ __ _ _ B KR-ZI r s I, as owner of the ro BUILDING T P POLY, or my employees with ADDRESS F�l`LT' wages ct then sole compensation,well f o the work and Pj e� ,>o �7 9° 63 the structure Is not intended or offered for sale(Section LOCALITY Pilo v• ❑ 7044, Busmen and Professions Code ) MOVING TEL �Iy _ I, as owner of the property,am exclusively contracting CONTRACTOR NO r/L 1 110115 with licensed contractors to construct the project (Sec- ADDRESS - - - TOTAL 98.63 tion 7044, Business and Professions Code ) TOTACHES S CONSTRUCTION LENDING AGENCY" U8.63 vARD FNV1' TOTAL IX FROM IST _- E WIDTH I hereby affirm that there is a construction lending agency for FRONT el the performance of the work for which this permit Is Issued _ P L (Sec 3097 Civ C ) SIDE ' PL Lenders Name �I]Q-�Qi 1171Q�9'.1 g _ I579 14F �LDMA Rel N Lenders Address P C Fee Permit Fee �T'/ ► vLL� �J 1 AM 9:2y i I certify that I have read this application and stofa that the Iawance �`7 7� LDMA Pic It above Information Is correct I agree to comply with all County InveYigailon Fee or races and State Iowa relating to budding construction, Total Fee /,q , �O J LDMA Perm N ` an h eby aurhonze reprsaentatrves of this County to enter IY¢ u th a ve- phoned projxrry for inspOdiic, U,rp�pQsea� t FILL!E-r r� M RKVERSE FOR IX/MNATORY LANGUAGE Signature of Applicant or Agent to , APPLICATION FOR BUILDING PERMIT_ ^ • COUNTY OF LOS ANGELES 1} 1� t. BUILDING AND SAFETY WORKER S COMPENSATION DECLARATION 1 FOR APPLICANT TO FILL IN A T- BUILDIN ADonE/ss I hereby affirm that I have a certificatenaent of ooto self macre B11R01N0-ADDRESS` \ ^^' •- � { �/ or a certificate of Workers Compensation Insurance or a cerbfed copy thereof(Sec 3800 Lab C) QTY" , `. LE J ZIP policy No SIZE OF LOTt� NO OF BLOG,S NOW ON LOT UqCAW ' 13 Certified Copy a hereby furtyushed /�./60 f NEAREST GROSS ST _ ❑ Certified Copy a filed with the County building inspection TRACT BLOCK LOT NO17 .fin - ^ department - - - - / USE ZONE MAP NO _ Date Applicant ASSESSOR MAP BOOK RAGE oo PARCEL r 018 - C SPECIAL CONDITIONS I CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER N[/AIEr �.jolj <-�u TE L ND vas fa COMPENSATION INSURANCE 0 6/ q WTTHN ICAO FT OF SCHOOL, ADDRESS _ (The section need not be completed d the permit a for one hundred I� �C/ a: � DISTRICT GROUP TVPE CONST FIRE ZONE PFiCCESSED BY dollars 1$100)a lase) ! T I certify that In the performance of the work for which this permit CITY PGlE TC Zip G AO I/ �- O - .? M issued I Shall not employ any person in arty mariner iso as-to O 1 become subject to the Workers Compensation Laws ARCHITECT OR ENGINEER TEL NO _ STATISTICAL CL ASS TION APT CONp0 Dare AppllCani ADDRESS CLASS NO DWELL UMTS NOTICE TO APPLICANT If after making this Csrofcate of REQUIREDTOTAL SETBACK FROM EXIST ExerpEpn you should become subject to the Workers CONTRACTOR TEL NO SET BACK YARD HWV PROP UNE WIDTH Compensation provisions of the Labor Code you must forthwith Comply with SUCK provisions or this permit shall be deemed revoked ADDRESS LIC NO pP LL NT LICENSED CONTRACTORS DECLARATIONSIDE CITY LIC CLASS - PL 1 hereby affirm that I am licensed underproIslam of Chapter 9 SEWER p O ors (commencing with Section 7DOO)of Division 3 of the Business and SO T NO OF STOREMI S NO OF FALIES NEW ❑ SE PQ ► C! ProfessCode and my license Is m full force ce aeffect License Number Lc Class DESCRIPTION OF WORK ADD ❑ VALU/IfION - Contractor Data ALTER ❑ $ w ❑ I am exempt under Sec REPAIR ❑ V H 2 BBPC for this reason04I&A DEMOL gr N CDMA P/C Date SE O EXISTING URM ❑ _ i ,/Sgnature APPLICANT(PRINT) TEL NO CDMA Perm ® I as owner d the property or my employees with wages as z liCCT.i their sole compenaatcn will do the work and the structure a ADDRESS O _`Q` not Intended or offered for sale (Section 7044 Busness and FINAL iF¢ N 17 not Professions Code) µl1 THE IPFLIGWT oR RUTJM BUCOINp OCCeMNr VWpLE A iNUf S MATEr i I EI I� ❑ 1 es owner of the property am exclusively cantrach wdh oR A AoxTLPE carrwraxn A HA2Afe0u9 IMTFRAL EauAL ro oR GREATER*INN THE n9 MIOLNTS SPECIFIED ON THE H [)CUS MATERIALS WOl noN 0U 1 r _FINAL By C Businlicensess Aon Profs to ,Code) the project (seaman 7oaa rEs❑ No El I yj j(tJITA1L 1a3 3. 6:• &naire69 afd I'rofessorus Code) µILL THE NIERpED ASE OF THE BUIDUNG aV THE APPUCNR OR FUTURE BllOfe _ CHECK 1311.!-', CCCURWT 1EOUNE A PERM*FOR CDNemaCllaN CR IAODIFICATION FFpM THE SOUTH CONSTRUCTION LENDING AGENCY Cors*AR Coos p MINT asrruT(ecA )SEE PE TING CIECXUST Foe I u .,-I- I s I hereby affirm that there e a construotnon lending agency for YES❑ No❑ N the performance of the work for which this permit is Issued(Sec o )NAY£REAa TIE NAZAPIXXe WTERVLSIIFORMATIONGTHE MID TIE SG S CCPER,WTTee H 3097 CATV C) UELKIL4T UnIDEP3TMD W REUAREAEHm U111ER THE LOS ux£1E9 COUNTV CODE �1 fl_f If '71 V Lenders Name UERALS� ANDFORPORTM 2PERvJT� SCAQ�t S �{_U_ �C�1 _ �/ 4 Lender Address 421]1 1 A1111:1p I cartdy that I have read the application and seta order penalty g of pawry that the above Information Is CorreCl I spree to Comply PC FEE PERMIT FEE �. µll all county ordinances, and State laws relsng to bulkbng �26' oonstruMon and hereby aut Dnn representatives,of the County \ _ IA4SUANCE FEE tpenter upon the above-me m rN w far epecbon purposes oY/ 1/ INVESTIGATION FEE ` TOTAL FEE - r • !o - (/�((/v/) �� SEE REVERSE FOR EXPLANATORY LANGUAGE 05 r APPLICATION FOR BUILDING PERMIT _ COUNTY OF LOS ANGELES a BUILDING AND SAFETY WORKER S COMPENSATION DECLARATION FOR APPLICANT Tq-ILL Il BUILDWO ADORES$ �jJ I hereby affirm that I have a certificate of consent to self insureeu G/yo0 SS z a` or a certificate of Vbrkem Compensation Insurance or a certified ` -2 ' v - C R`/ copy thereof (Sec 3800 Lab C) . 1 17 t LOCALITY Policy No el Company SIZET�� 1 NO OFB1L�S NOW ON LOT El Certified copy Is hereby furnishedhed ' NEAREST CROSS ST 97 ❑ Certified copy Is filed with the county building InspectKm TRACT BLOCK LOT NO department � USE ZONE NO Date Applicant ASSESSOR _ - _ 'I �R � Ila _a SPECIAL C- N,v ONS _ CERTIFICATE OF EXEMPTION FROM WORKERS C YES NO COMPENSATION INSURANCE 9E f 'l w� WRRIN 1000 FT OF SGHOOL� (This section need not be completed if the permit Is forgone hundred L L DISTRICT GROUP TYPE CONST FIRE ZONE PROCESSED BY dollars ($100)or less) Y M �� IssA Id I-certue that h the t performance arr of the work for which thus permit Is issued I shall not employ arty person In any manner so as to - become subject to the Workers Compensation Laws TECT OR OINEER TEL NO STATISTICAL C ASSIFICAg TN PPT CONDO Date Applicant ADDRESS CLASS NO DWELL UNITS NOTICE TO APPLtC4NT If after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST Exemption you should become subject to the Workem CONTRACTOR TEL NO SET BACK yPAO FNNV PROP LINE WIDTH Compensation provisions of the Labor Code you must forthvnth FRONT n comply with such provisions or this permit shall be daemed revoked ADDRESS LIC NO P L - 1 LICENSED CONTRACTORS DECLARATION cv - LIC CLASS p DE CITY ACCT.`. I hereby affirm that I am licensed underprov6gns of Chapter 9 SEWER MAP - c co mmenang with Section 7000)of DMslon 3 of the Business and SO FT SIZE NO OF STORIES NO OF,FAMILIES NEW ❑ ex pG 3307 156.4) Professions Code and my license is in full face and effect , 1 IT 5 a > License Number L. Class DE RIPTION WORK D ❑ VALU/A�7� , �(8 Contractor Date TER ❑ $ ' 1 TOTAL ESA - 4-5 ❑ I am ex 8y" REPAIR ❑ $ CHECY. 66.45 Q exempt under Sec ,�"" /�"" �i BBPC for this reason ,� �osci tip DEMOL ❑ LDMA P/C r LHf 'TGE .00 LU Date E OF EXISTING BLDG URM ❑ Q- Signature _FRNJAJ ODOR-phi 3/16/93 �I as owner of the property or rtry employees with wages as nntheir sde compensation will do the work and the structure isOu6gO 1 9•L6 rot intended or offered fa sale (Section 7044 Busness and E Q Profe6snns Code) WILL THE MPUGANT OF FUTURE RIILWA OCMPANT HANDLE A INZARD S IMTERI1 ❑ I as owner Of the property am exclusively contracting with OF A MIXTURE COhnNNNG A HAZIPDIXR MA7FFiEWIL TO C project (Section 7044 R GREATER THIN THE Q licensed contractors to construct the AMMINTs ePEORED ON THE HAZAADCUS MATELAU6 HFOR"TON WIDEI FINAL BY > YEs El No ElBusiness and Professions Code) OCCUPANT CC THE INTENDED USE OF THE e6Y THE MPJCAM OR FROM T SLI OGCUM R QE y A FERMn FOR CONSTRUCTION TRICSCACOR ME PEF TpN FROM THE SCFOR CONSTRUCTION LENDING AGENCY W,UST NH ouurry MANAGEMENT DISTRICT Isc,,aMm ME PERMnnN3 crEcrcusT FOR WDELIea£s I hereby affirm that there Is a construction lending agency for YEs❑ No❑ H the performance of the work for which this permit Is Issued(Sec m 3087 CN, C HnvEREapT�HAZAHmus raTEaAis eEaaanTnNOLmE,wCTHE suoMn RERMmuD n, ) CIECKLISr I UNDERSAND Mr HEW WEUENTS UNDER THE l MMI-ES COUNTY COM Lender a Name MATES RER�oH2 20 R NG um FOOR MCiAS`rAJWNQ ATnRCUGH PERMIT AF 110 E ECAWD G Hn�Anook>s _ Lender Address I certify that I have read this application and state under penalty 0 of perjury that the allose mformaton Is correct I agree to comply PC FEE PERMIT FEE O - $ :h county ordinances and Stale laws relating to budding S n91 a hereby authorize representatives of this Pounty ISSUANCE FEE ,A� to ant the -meMoned property for Inspect I es - AG J m INVESTKIATION FEE TOTAL FEE SEE REVERSE FOR EXPLANATORY LANGUAGE - APPLICATIFFOR BUILDING PERMIT COUNTY OF LOS ANGELES BUILDING AND SAFETY A .1 WORKER S COMPENSATION DECLARATION FOR APPLJCANT TO FILL IN ILDe1G ADORE I haktay affirm that 1 have a certificate of consent to self Insure BUI ��ertZVvG I o2 o a certificate of Workers Compensation Insurance or a certified copy thereof(Sec 3800 Lab C) ! 'C zIR R Qom, 1 Policy No 42-IZfiA"3 —9z ComPary 1 SIZE OF L NO °F BLDGS NOW ON LOT 0 Certified copy m hereby furnished 17 1 1 Z NEAREST CROSS ST _ ( 4Cilied copy s filed with the county building inspection -1 OF BLOCK LOT NO3, department USE ZONE MAP NO ASSESSOR MAP BOOK PAGE PARCEL Data / !y3 Applicant 7iez� _ O O 1 SPECIAL CONDfg iNS CERTIFICATE OF EXEMPTION FROM WORKERS ER TEL NO !/ YES NO COMPENSATION INSURANCE WITHIN! 1000 FT of SCHOOL? YES (This section need not be completed d the permit IS for orie hundred ADDPESS 14511 lq�5 fir-J, DISTRICT GROUP TYPE CONST mFIRE ZONE PROCESSED BY Collars ($100) a less) I cerhh' that m the performance of the work for which this permit cflY rc-rzUQ- tt CLr z 9 r p Is Issued I shall not empty army person In amy manner so as to �QO _ `' I hecoe subject to the Workers Compensation OR ENGINEER TEL NO STATISTICALCLASSIFICATION APT CONDO Date Applicant ADDRESS CUSS NO L��LJ /L DWELL UNITS NOTICE TO APPLICANT It after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST Exemption ypu should become subject 10 the Workers CONTRACTOR TEL NO SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code you must forthwith15 d . Z 2. 3 i FROM comply with such prpamsxus or this permit shall be deemed revolved ADDRESS uC NO P L LICENSED CONTRACTORS DECLARATION /0 SIDE �. - DC _ PL I hereby affirm that I am licensed underprovlspns of Chapter 9 SEWER MAP (commencing with Section 7000)of Division 3 of the Business and so FT 517 NO F S NO OF FAJnWES NEW SK IV PO 7�� a Professions Code and my licx 'e s In full force and effect 5 License Number Uy7/dy L. class DESCRIPTION OF WORK ADD ❑ VALUATION O Contracto (i71tA.wA�� DateZAIALTER ❑ $ bd/ cc ❑ 1 am exempt undo Sec REPAIR ❑ $ BdPC for this reason .A.� DEMOL ❑ LDAs PIC I W �� Die q us oP EXISTING Bim URM ❑ A2f3 U) Signature I�_ t/ �5 APpJCANT(P94NT) - TEL NO I.DMA Porm a t'ItCT.T ? ❑ 1 as mmer�of the Property o my employees with wages as O 33CI7 4E.75 their sale compensation will do the work and the structure is ADDRESS F not Intended or offered for sale (Section 7044 Business and FML DATE G 1 Professions Code) wqL iryE AGftIVJfI pR FUTIME BIRONO OCCIIMNi IWCLE A HAURa^l19 MmEnMl ,�Yx.�'� ❑ 1 as Owner of the property am exclusive Contracting with OR A MIXTURE CONTNNNG A NAZNIDWS MATERW-EQUAL TO OR GREATER TH,W RE Q lyy,(T.T N AMpIiNTS SPECIFED ON THE HAZARDOUS MATEI NFOR4 TION Gl➢DE] FINAL > licensed contractors to construct the project (Section 7044 YEs❑ No❑ S37 M7.5+ Buwness and Professions Code) VAL THE REM USE IA THE ZONEm TI THE AFFVCANT OR FUTURE Bl.IDf.0 _ _ I�tf OC(:I.fMNT REWIRE A PERMIT FOR CONSTRIx:TIW OR M^gFIGAi1N1 FROM i1E SOUTH � ITEM llvv CONSTRUCTION LENDING AGENCY COAST w+QU UTY MAHAOEMENT DtSTiiCT(sc,eMD)SEE PERMITTING a CKusr FOR _ 1 n I hereby affirm that there s a construction lending agency for Yzs El No❑ TOTAL 436. 29 the performance of the wok for which this permit is ssued(Sec IIAYEPEApTEiI,wlpousMArERALswawATxn+cugENOTHEsueMOFEPYRIWO CHECYn 536.29 m 3097 Civ C) CHECKLIST I UNafR MV R£WFEMENTS UNDER THE UOS ANp S CW MV CODE TITLE 2 CHAPTER 220SECTIONS 2 20 100 THROWN RI 220140 CONCERNG HAZARDOUS f HArH111NGS •UU Lenders Name MATEPoAL9 KPOMING AND FOR OBTNNNG A PERM7 FROM THE SCAQMD J 1e Lenders Address O avow IT Kc.VT �nnn�nnn g I Certify that I have read this appli:ation and state under penalty PC FEE /J PERMIT FEE /�• 13000- � l 1/29/93 of perjury that the above Infomaton s correct I agree to comply / (O7 41 $ with all county ordinances and State laws relating to builrnng 7� 1 AM 9:14 g construction and hereby aultlonze representatives of this CWnty ISSUANCE FEE to enter Iqm the above-mentioretl property far inspection purposes m INVESTIGATION FEE TOTAL FEE 17 / / J SEE REVERSE FOR EXPLANATORY LANGUAGE APPLICATION FOR BUILDING PERMIT a� ] COUNTY OF LOS ANGELES BUILPING AND SAFETY WORKER S COMPENSATION DECLARATION FORA CANT TO FILL IN BUILDNG ADDRESS I hereby affirm that I have a certificate of consent to self insure BUILDING ADDRESS or a certificate of Nbrkers Compensation Insurance or a certified copy thereof(Sec 3800 Lab C) CITYZIP 7,&0 Policy NO Comparry SIZE OF LOT OF BLOCS NOW ON LOT ❑ Certified copy is hereby furnished NEAREST CROXS ST ❑ Certified copy m filed with the county building inspection TRACT BLOCK LOT NO - v L..7-;19N* O _ daparimgnt USE ZONEMAP NO • Date Applicant ASSEgSYp PPGE PARCEL Hats ..J.JX Q/ Q - �L SPECIAL CONDITIONS tI CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER N� 6 "7J k T Lf'1O fIN I000 Fr of seFaa.7 �S I'fO COMPENSATION INSURANCE lam/ (The section need not be Completed d the permit m for oris hundred ADDRESS dollars ($100)or lose) T"� DiSTRICT GROUP TYPE CONST FIRE ZONE PROCESSED BY .1 �D L / 1 certify that In the performance of the work for which this permit CRY !•l�lG ZIP G�W141 p s awed I shall not employ any person in any manner eo as to /-C m - becoe subject to the Workers Conpansation Laws AACRn`ECT OR ENGINEER TEL NO sTATISTICA CLASSFICATIDN APT CONDO Date Applicant ADDRESS CLASS NO =;:2 Z DWELL UNITS NOTICE TO APPUp1NT N after making the Certificate of Exemption you should becorlle subtect to the Workers CONTRACTORR TEL NO REQUIRED TOTAL SETBACK FROM EXIST Compensation provmlons of the Labor Code you ritual forthwith SET BhCK YARD HNV PROP LM WIDTH FRONT comply with such provisions or the Parma shall be deemed revoked ADDRESS LIC NO PL LICENSED CONTRACTORS DECLARATIONSIDE CITY LIC CLASS PL I hereby affirm that I an, licensed underprovsiors of Chapter 9 (commencing with Section 7000)of Dumps 3 of the Suamee4 and SD NO OF STORIES NO OF FAMIUES SEWER MPP � Professions Code and my license m In full force and effect NEW ❑ SK PG , O IPTION OF WORK U License Number Uc Claw J' ADD WLUA710N('� C/ Oo Contractor DateCD u Y ALTER W w ❑ I am exempt under Sec / IR ❑ $ y Z BBPC for the reason DEMOL ❑ LOMA P/C I — - Date USE OF EXISTING BLVf URM ❑ Y a Signature APPLICANT(PFPiT) TEL NO LD1W Perm "♦ j \-NS T,T I as owner of the proper or / I It• S-,�I:i property my employees with wages as Z I- J Meir skis tArrlpersetlan will do the work and the structures ADDRESS � --" /� O v� not Intended or offered for sale (Sect Dn 7044 Buainees and FlNAL/(p�pTE Profesepns Gods) WILL TE IPRILMT OR FUNRE BU40Nn OCGLMNT IWIDLf A IMZAROnll41MTERYy �[/ {/ � AC ❑ 1 a3 owner Of the property am exclusively contract) with OR A WnIXiE a NM A RALPOOUS ANTERIAL EQUAL TO OR GREATEfl TIWI TIE ng ANOlMT9 sPHC D ON nE RAIARWDS MATERNLS aFpTAu GIADE+ FlNAL (� licensed COntradOrS to CMWLpt the project (Section 7044 Busl189a and Professions Code) r s vo❑ wLL TIE NTETDED UsE aF TIE eDDfNG erTIE AFPLIGVIL OR FURIPE 9ULDIIKt c i ITEM:-,C CONSTRUCTION LENDING AGENCY REOIRE A TERWT FOR 004,1 ucnoN ooftVloD CATpN FnOAI TIE aouni M4r NR OUNfTY AWNC£AEKT DsMCT ISCAp sEE PER 140 CIECKLIST FOR I hereby affirm that dere is a construction larding agency for YES❑ sro❑ TriTAL 993 v 78 ,v the performaroe of the work for which the permit is issued(Sec ' f,ry UMREAn CHECK 3097 Cry C) CKL4coo . IIT3 993,7� H4WjE •I!I 1 Lender s Nam IMTEPIM.9 REPURnND ND FOR aeUlYA A r£RMT FROM TRE SGA01A A Lender Address �('i(� p 1 certify that I have read the application and state under penally 090L)-No A 3/ y Of penury that the above Information rs correct I agree to comply PC FEE D• PBLNIT FEE nlbuilding R with all county onancea and State laws retailing to builds g (P O 42,32 Ja 1 =1AM11:11T construction and hersbY eu)honze representatives of the County TSUANCE `f E A ZL m enter upon the above n(prop"for inspection ion L. T 0 m NVESTIOAPON FEE TOTAL FEE g .7 SEE REVERSE FOR EXPLANATORY LANGUAGE