HomeMy Public PortalAbout5655 SULTANA AVE_Building__ APPLICATION FOR BUILDING PERMIT
,IJt0U'1 Y OF LOS ANGELES BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR--APPLICANT TO FILL IN BUILDING ADDRESS
�5� RJ
I hereby affirm that I have a certificate of consent to self iBUILDING ADD
'insure �SS J� �, .�
or a certificate of Workers'Compensation Insurance,or a certified r
copy thereof(Se 3800,Wb.C.) t�' l� CITY ',yl 0
Policy No. %C 1S Company AlA �,I V SU - LOCALITY /
SIZE OF LOT NO.OF BLDGS.NOW ON LOT
Certified copy is hereby furnished. NEAREST CROSS ST.
❑ Certified copy is filed with the county building inspection TRACT BLOCK LOT NO.
department. �e�uL,��` � USE ZONE MAP NO. frr
Date t�SApplicant�J P4�0r n v ASSESSOR MAP BOOK PAGE PARCEL
SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER , ,4 EL O.
COMPENSATION INSURANCE C.Ci iv �� I. d`� WITHIN 1000 FT.OF SCHOOL? YES NO
(This section need not be completed if the permit is for one hundred A DRESS p
dollars($100)or less.) C V`� V E k--V DISTRICT GROUP TYPE CONST FIRE ZONE PROCESSED BY
I certify that in person
performance of the work f which this permit CITY U i�� `® ZIP 5�6L5 b2 x�! 2 p�
is issued, I shall not employ any peon in an manner so as to T`
become subject to the Workers'Compensation Laws. ARCHITECT OR ENGINEER TEL NO.
STATISTICAL CLASSIFICATION JV APT CONDO
Date Applicant ADDRESS CLASS NO. e?-Z DWELL UNrrs
AR)TICE 70
G4NT. If,
making
te
REQUIRED
Exemption, you s should become subject this
thertifiWorke Workers' (�;p�NTT9�AqCTOR TEL NO. SETT BACK YARD HWY SAL SETBACK ROP LINE FROM WIDTH
Compensation provisions of the Labor Code, you must forthwith yz6`!0�, Torr- GQ PitO`'"S' ; FRONT
comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC.NO. PL
LICENSED CONTRACTORS DECLARATION Wq�° E ��'C� ST• 'i I � SIDE
CI P UC.C P L
I hereby affirm that I am licensed underprovislons of Chapter 8 dON A �� C
(commencing with Section 7000)of Division 3 of the Business and
SQ.FT.SIZE NO.OF STORIES NO.OF FAMILIES SEWER MAP
Professions Code,and my license is in full force and effect. I I INEW BK PG M
License Number I AIZ(01 Lic.Class L 3q ADD VALUATION
DESCRIPTION OF WORK C
❑
Contractor `CO JIDL QRSXII . Date W%Z' S ��" t� ALTER 11 � 140 a
141 % �2�CAN& REPAIR ❑ $ C
[I I am exempt under Sec. �-
BAP.C.for this reason DEMOL ❑ IU
LDMA P/C#
Date: U EOF EXIST GBL�.
+.T . — "mr-7- URM ❑ Can
Signature APPLI NT PfU ) NO. LDMA Perm# JL
❑ I, as owner of the property, or my employees with wages as
�.�, W6 io �o 4�1� Z ACCTo4
their sole compensation, will do the work and the structure is ADD �j� o 3303 175.55
not intended or offered for sale (Section 7044, Business and v `>CS C. �' �O.ACS FINAL DATE (-
Professions Code.) cy-I Z _9� c_ 1 ITEMS
WILL THE APPUCANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL G
OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE
licensed contractor to construct the project (Section 70444, J
❑ I, as owner of the property, am exclusively contracting 4AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY n y TOTAL 125.55
,
Business and Professions Code.) YES❑ No❑ j''HE('�' 125.55+1 P CLC.I
WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING CHECK 12 o55
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM HE SOUTH V
CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR
GUIDELINES
I hereby affirm that there is a construction lending agency for VES❑ No❑
N the performance of the work for which this permit is issued(Sec. I HAVE READ THE UIDE AND THE_ (� (�� ��ry/p
MD PERMITTING
W 3097.CTI%.C.) CHECKLIST I UNDERSTANDUMV REQUIREMENTS UNIDERON GTHE OS ANGELESQCOUNTY CODE, 0000-0001 1p1/30/75
N Lender's Name MATETITLERIALS REPORTING AND FOR OBTAINNG A PERMIT FROM 2.CHAPTER 2.20 SECTIONS 2 20.100 THROUGH 2.20 THE HE SCAOMD.CONCERNING HAZARDOUS 3508 1 r M 12:24
00 Lender's Address
0 ONNER OR AGENT
o I certify that I have read this application and state under penalty
of perjury that the above information is correct.I agree to comply P.C.FEE PERMIT FEE
N with all county ordinances and State laws relating to building
construction, and hereby authorize representatives of this County ISSUANCE FEE
to enter pe ve mentioned property for inspection purposes.
CD INVESTIGATION FEE TOTAL FEE / J
\ atom APP'C•:MaAgent Dd. e
SEE REVERSE FOR EXPLANATORY LANGUAGE
r - COUN* OF LOS ANGELES TEMPLE CITY # 0508 "BUI•LDING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS _DEMOL_I.1I"ON" 1
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 BL`050.8.9910200030
PHONE: (626) 285-0488 EXT: r` -
GAL D: NO. OF CONST BUILDING DRESS:
ON FILE SQ. FT STORIES TYPE 5655 SULTANA AV
STRUCTURE: 6534 TEMP CA 917802328
ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET:
5387-028-003 THOMAS PAGE: 596 GRID: H3 LOCALITY: TEMPLE CITY
TEN
ANT: EXIS B G USE: R SI USE ZONE: ISSUED-ON: PROCESSED B EXPIRES 0 :
EXIST OCC GRP: 10/20/99 UT 04/17/00
OWNER: TEL. N0: BLDGS. NOW ON LOT: VALUATION: FINAL DATE FINAL BY: E:
'CONOVER JOHN M;DONA C TRS - 2 0
TEMP 917807588 FEES PAID DESCR T 0 OF WORK
DEMOLISH 6 UNIT APARTMENT BUILDIN
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT:
APPLICANT: EL. N0:
HARTFIELD CONST. (626) 401-3062- AA BLDG PERMIT ISSUANCE 27.75
10128 1/2 RUSH 02 DEMOLITION INSPECTN 163.50 SPECIAL CONDITIONS:
S. EL MONTE, CAUTA FEES 191.25
�N�E LE S C
CONTRACTOR: TEL. NO: o�� APPROVALS DATE INSPECTOR SIGNATURE
Cj
HARTFIELD CONSTRUCTION (626) 401-3062-
10128 1/2 RUSH STREET LIC. NO PEDESTRIAN 0 C 0
SO. EL MONTE, CA 478529/A
SEWER DISCONNECTION
ARCHITECT OR-ENGINEER: TEL. NO: AWNDOWTHUrE S OUT
LIC. NO: 1111111 UNDERGRND STRUCT REMOVAL
AND SOIL RECOMPACTION
1MAP NO:47H265 SEWER MAP BOOK: PAGE: FIRE ZONE: C�OO;� UFO-)
L
[+ ,�Or �/J 3
0. 0 I S: D EL G S: APT CO D: S C ASS:- \1v//� IU�I{11LJKC�
NO 23 4 0
O ❑
HOOL WI HIN HAZARDOUS
AIR QUALITY: 1000 FEET MATERIALS Q ❑
NO NO NO A ❑
R`
service That VV
REPORT ID: DPR261 ROUTE TO: BS0508
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