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REQUEST FOR MODIFICATION OF FIRE CODE ORDINANCE UNDER AUTHORITY OF L.A.M.C. SECTION 57.104.8

PERMIT APP. #:

DATE:

JOB ADDRESS: Tract:

Block: Lot:

Owner: Address: City

Petitioner: Address: City

State

Zip

Phone

REQUEST (SUBMIT PLANS OR ADDITIONAL SHEETS AS NECESSARY)

State

Zip

Phone

CODE SECTIONS:

JUSTIFICATION (SUBMIT PLANS OR ADDITIONAL SHEETS AS NECESSARY)

Owner/Petitioner Name (Print)

(Signature)

Position

FOR CITY DEPARTMENT’S USE ONLY BELOW THIS LINE Concurrences required from the following Department(s) Los Angeles Building Department

Approved

Print Name

Sign

Public Works Bureau of Engineering Print Name

Sign

Department of City Planning

Print Name

Sign

Department of County Health

Print Name

Sign

Other ________________________ Print Name

Sign

DEPARTMENT ACTION GRANTED

Denied

Reviewed by: (Staff) (print)

Sign

Date

Action taken by: (Staff/Supervisor) (print)

Sign

Date

DENIED

CONDITIONS OF APPROVAL (Continued on Page 2):

FEES

Review Fee.....................(No. of Items) =

1

x $216

=

For Cashiers Use Only

(PROCESS ONLY WHEN FEES ARE VERIFIED)

$________

Fees verified by: Print and Sign _________________________________________________________

Rev. 9/12/2017

Page 1 of 2

www.lafd.org


Permit App #:

Job Address: CONDITIONS OF APPROVAL (Continued from Page 1)

Rev. 9/12/2017

Page 2 of 2

www.lafd.org

Request for Modification of Fire Code Ordinance Form  
Request for Modification of Fire Code Ordinance Form