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►.A.ea,cehas.t APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING
DEPARTMENT OF COUNTY ENGINMR ADDRESS
BUILDING AND SAFETY DIVISION LOCALITY
JOHN A. LAMBIE. COUNTY ENC;INEER NEAREST
WILLIAM A.JENSEN SUPT OF BUILDING. CROSS ST.
DISTRICT N O.UP TYPE P Y
FOR APPLICANT TO FILL IN
� CONST.
BUILDINGp7 A STATISTICAL C FICATION S ER MAP
ADDRESS f/C..,.,IBK
4p—CLASS.NO. DWELL.UNIT
LOT NO, p BLOCK WATER f.NOT REQUIRED RECEIVED
TRACT MAP -/o - HGHWAY
APHGHWAY STATE MAJO SECOND LOCAL
NO.OF BLDGS. NO. (CIRCLE)
SIZE OF LOT. NOW ON LOT USE ZONE SPECIAL
USE OFn CONDITIONS
EXISTING BLDG. U
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OWNER O/�'1 - -cAmtrz> NO. BUILDING YARD HWY STREET NAME EXIST.
b�4 �`O- df,eLhos� A4� SETBACK WIDTH
ADDR S FRONT
ARCHITECT OR TEL. P.L.
ENGINEER NO. SIDE
P.L.
ADDRESS TEL. pp INSPECTION RECORD O
CONTRACTOR
ADDRESS C9 y
O
DESCB PTI N OF WOAK
W
CL
NEW 4ADD ALTER REPAIR DEMOLISH N
Z
SQ.F NO.OF NO.OF
IZE STORIES FAMILIES
USE UJC � li-
STRTURE�-- SL1�ib�7upL'p /JA'iT
V-5 13 T V•
SIGNATURE OF ,p
APPLICANT
VALUATION$ 0 I
APPROVALS DATE INSPECTOR'S SIGNATURE
FOUNDATION:LOCATION
FEE $ FEE $ O V FORMS,MATERIALS
FRAME:FIRE STOPS,
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION BRACING,BOLTS
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY FURNACE:LOCATION,
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING GAS VENT DUCTS
BUILDING CONSTRUCTION. 1 CERTIFY THAT IN DOING THE WORK
AUTHORIZED HEREBY 1 WILL NOT EMPLOY ANY PERSON IN VIOLA- LATH.INT.
TION OF THE LABOR CODE OF THE STATE OF-CALIFORNIA RELAT-
ING TO WORKMEN'S COMPENSATION INSURANCE.
LATH,EXT. '
SIGNATURE O HOUSE NUMBER /1
COR-
PERMITTEE- RECT AND POSTED � J
ADDRESS E I FINAL ! ' -6 441
CLYDE N. DIRLAM, PRINCIPAL ST RAL ENGINEER
PLAN CH= VALIDATION CK. m.c. CASH PERMIT VALIDATION CK. M.O. CASH
Ao 3 4 7 1 APR 1 7 1 D L ,Q QN