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<br /> NAME(please print): ek, T ),r
<br /> i 1,1 rS c-4,f,,,0 Telephone# 3-1/3 - 570- 192, 6
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<br /> Applicant's Signature: ---A .40,-- --AP' -e.,/ Date: '7 - /5-- -Lozo
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<br /> Applicant's Mailing Address: po g 0)( —7,5-3 City414)LAZ01 At ) Zip: 91 ,
<br /> FOR OFFICE USE ONLY
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<br /> PLANNING: Date: •
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<br /> PUBLIC WORKS: .. L 15 2020
<br /> BUILDING INSPECTION (Acceptab1e for Planning requirements. only) Date:
<br /> Ti ' . • COUNTY
<br /> ., BUILDING INSPECTION
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