REQUEST FOR MODIFICATION OF FIRE CODEORDINANCE
UNDER AUTHORITY OF L.A.M.C. SECTION 57.104.8
REQUEST (SUBMIT PLANS OR ADDITIONAL SHEETS ASNECESSARY)
JUSTIFICATION (SUBMIT PLANS OR ADDITIONAL SHEETS ASNECESSARY)
CONDITIONS OF APPROVAL (Continued on Page2): For Cashiers Use Only
APP.
DATE:
ADDRESS: Tract: Block: Lot: Owner: Address: Petitioner: Address: City State Zip Phone City State Zip Phone
PERMIT
#:
JOB
CODESECTIONS:
Owner/Petitioner Name (Print) (Signature) Position FOR CITY DEPARTMENT’S USE ONLY BELOW THISLINE Concurrences required from the following Department(s) Approved Denied Los Angeles Building Department Public Works Bureau of Engineering Department of City Planning Department of County Health Other Print Name Sign Print Name Sign Print Name Sign Print Name Sign Print Name Sign DEPARTMENT ACTION GRANTED DENIED Reviewed by: (Staff) (print) Sign Date Action taken by: (Staff/Supervisor) (print) Sign Date
(PROCESS ONLY WHEN FEES ARE VERIFIED) FEES Review Fee.....................(No. of Items)= 1 x $361 = $ Fees
Print and
Rev. 10/10/23 Page 1 of 2 www.lafd.org
verified by:
Sign
Rev. 10/10/23 Page 2 of 2 www.lafd.org Permit App #: Job Address:
CONDITIONS OF APPROVAL (Continued from Page1)