HomeMy Public PortalAbout6121 SULTANA AVE_Building__ APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILPING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS
I hereby affirm that I have a certificate of consent to self insure, BUILDING ADDRESS
or a certificate of Workers'Compensation Insurance,or a certified CITY /.2/ ZIP
copy thereof(Sec.3800,Lab.C.) S' � '9l],y LOCALITY
Policy No. Company — SIZE OF LOT NO.OF BLDGS.NOW ON LOT G
❑ Certified copy is hereby furnished. b x M NEAREST CROSS ST.
346'ertified copy is filed with the county build' inspect' TRACT BLOCK LOT NO.
departm nt. USE ZONE MAP NO.
Date Applicant ASSESSOR MAP BOOK PAGE PARCEL
SPECIAL CONDITIONS y D/
CERTIFICATE OF EX PTION FROM WORKERS' OWNER TEL NO. YES NO
COMP 9A ION INSURANCE /`} S�st/ WITHIN 1000 FT.OF SCHOOL?
(This section need not a Completed if the permit is for one hundred ADDRESS
dollars($100)or less.)
SL/L L
GROUP TYPE CONST. FIRE ZONE PROCESSED BY
CITY ZIP
I certify that in the performance of the work for which this permit _
is issued, I shall not employ any person in any manner so as to ARCHITECT OR ENGINEER TEL NO. � ""
become subject to the Workers'Compensation Laws. STATISTICAL CLASSIFICATION APT CONDO
Date Applicant ADDRESS CLASS NO. DWELL UNITS
NOTICE TO APPLICANT.• If, after making this Certificate of REQUIREDTOTAL SETBACK FROM EXIST
Exemption, you should become subject to the Workers' CONTRAPTOR ��77 TEL NO. SET BACK YARD HWY PROP LINE WIDTH
Compensation provisions of the Labor Code, you must forthwith tv/ FRONT
comply with such provisions or this permit shall be deemed revoked. ADDREpp LIC.NO. �/ 7 P L }
L TOS` ikdo tr/ W/ 7�/ SIDE IL
LICENSED CONTRACTORS DECLARATION CITY LIC.Co L �
I hereby affirm that I am licensed underprovisions of Chapter 9 �� SEWER MAP
(commencing with Section 7000)of Division 3 of the Business and SO.FT.SIZE No.OF STORIES NO.OF FAMIUES
Professions Code,and my license is in full force and effect. / NEW BK PG C
License Number �/y� 1 DESCRIPTION OF WORK VALUATION �, U
LID.Class ADD ❑
W
Contractor�J�ni�l,A/ 1-21 COE Data Tr`�4 1Y � ��� ALTER ❑ $ ����' IL
❑ 1 am exempt under Sec. REPAIR ❑ $ Z
B.BP.C.for this reason DEMOL ❑ LDMA P/C#
Dat ' USE OF EXISTING BLDG. URM 13Signature APPLICANT(PRINT) TEL NO. LDMA Perm
13I, as ow r the property, or my employees with wages as ADDRESS ZO ACCTe a
their s compensation, will do the work and the structure is .,.,
not int nded or offered for sale (Section 7044, Business and FINAL DATE �� 0.
Q .}505 110.70
Professions Code.) G
HALL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL J 1 ITEMS
OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE
❑ I, as owner of the property, am exclusively contracting with Q
AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY �j
licensed contractors to construct the project (Section 7044, TOTAL 10o 7101
Business and Professions Code.) .YES 11No
WILL THE IN NDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING CHECK 110.70
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH _
CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR (41J#)1IrC v fel
GUIDELINES V.H 4GE V
I hereby affirm that there is a construction lending agency for YES❑ Noe
the performance Of the work for Which this permit IS Issued(SBC. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING 7/18/96
7/ /n/
3097,CIV.C.) A CHECKLIST I UNDERSTAND MY REQUIREM TS UNDER THE LOS ANGELES COUNTY CODE, 13000'-13001 f! 1 176
,n �� �r ` �, TRLE 2. PTER SECTION THROUGH 2.20.140 CONCERNING HAZARDOUS
Lender's Name MATE REP D O G A PERMIT FROM THE SCAQMD.
Lender's Address 75222, 1 HM 9:04
OYVNER T
; I certify that I have read this application and state under penalty
0 of perjury that the above information is correct.I agree to comply P.• EE PERMIT FEE
W with all county ordinances and State laws relating to building
m construction, and hereby authorize re resentatives of this County ISSUANCE FEE
C to erp on th ove-m ,
S [,, ) erty for inspect' n urp as.c ' INVESTIGATION FEE TOTAL FEE Q
a cy,w a iv
SEE REVERSE FOR EXPLANATORY LANGUAGE