HomeMy Public PortalAbout6258 SULTANA AVE_Building__ APPLICATION FOR BUILDING PERMIT
Y
COUNTY OF LOS ANGELES BUILDING 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 �d
or a certificate of Workers'Compensation Insurance,or a certified G2-'S SSI.-rNjA
copy thereof(Sec.3800,Lab.C.) CITY ZIP
4b 0 Policy No. Company I '�-M PL E 0— LOCALITY
SIZE OF LOT NO.OF BLDG&NOW ON LOT
❑ Certified copy is hereby furnished. LEO' X I t 0/ NEAREST CROSS ST
❑ Certified copy is filed with the county building inspection TRACT BLOCK LOT NO.
department.
USE ZONE MAP NO.
Date Applicant ASSESSOR MAP BOOK PAGE PARCEL
SPECIAL CONDITIONS r O/
TEL NO.
CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER t
COMPENSATION INSURANCE C—Ik{-LDS S ICK try UA.LL ���_ - n� WITHIN 1000 FT.OF SCHOOL? YES NO
(This section need not be completed if the permit is for one hundred ADDRESS
Ce ZS S' S ca L A W ADISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY
dollars($100)or less.)
I certify that in the performance of the work for which this permit CITYTEAM ZIP I'E 1T GI I S
ARCHITECT OR ENGINEER TEL NO.
is issued, I shall not employ any person in any manner so as to EE
become subject to the Workers'Compensation Laws.
• Olti:FSE STATISTICAL CrIFICATION APT CONDO
Date Applicant ADDRESS CLASS NO. DWELL UNITS
NOTICE TO APPLICANT.• If, after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST
Exemption, you should become subject to the Workers' CONTRACTOR TEL NO. SET BACK YARD HWY PROP LINE WIDTH
Compensation provisions of the Labor Code, you must forthwith 0,,m SR— FRONT
comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC.NO. PL
LICENSED CONTRACTORS DECLARATION SIDE
CfFY LIC.CLASS PL
I hereby affirm that I am licensed underprovislons of Chapter 9
SEWER MAP
(commencing with Section 7000)of Division 3 of the Business and SQ.FT.SIZE NO.OF STORIES NO.OF FAMILIES
Professions Code,and my license is in full force and effect. NEW BK PG a
License Number Lic.Class DES IPTION OF WORK ADD ❑ VALUATION pop- 0
Contractor Date r/Q ( to ALTER t L��C$ V
ALTER ❑ IY
❑ I am exempt under Sec. REPAIR ❑ $
B.BP.C.for this reason DEMOL ❑ LDMA P/C# W
Date: USE OF EXISTING BLDG. URM ❑ IL
Signature APPLI NT dA'2cU/A �C- Z 7 -3 a7z
(PRINT TE'fiL O. LDMA Perm# iw z
.F�? I_ �I, as owner of the property, or my employees with wages as A!--r—� a.
X
their sole compensation, will do the work and the structure is ADDRESS r O ';:•.: o
not intended or offered for sale (Section 7044, Business and g .Su L,—t14AIA /e-/Id A-Ir G 17-11 FINAL DATE Q - --
Professions Code.) / a� "31-G ="�•_1_
WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL � �I"LS
❑ 1, as owner of the property, am exclusively contracting with ORA MIXTURE
SPECIFIEDCONING A HAZARDOUS MATERIAL THE HAZARDOUS MATERIALS QUAL ToONRGUREEA7 ER THAN THE FINAL BY
licensed contractors to construct the project (Section 7044,
Business and Professions Code.) YES❑ No❑ €1(sC 4 s
WILL THE INTENDED USE OF THE BUIDUNG BY THE APPLICANT OR FUTURE BUILDING
OCCUPANT REQUIRE A COAST NR QUALITY MANAGEMENT DISTRICT SCAOMD)EEDPERMITTING OCHE KUST OR .MIT FOR CONSTRUCTION OR MOIFICATION FROM THE SOUTH3 I3 j_I a `i
CONSTRUCTION LENDING AGENCY GUIDELINES
I hereby affirm that there is a construction lending agency for I YES 11 NO❑ fITEMS
W
the performance of the Work for which this permit Is Issued(Sec. 1 HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMDCzJ PERMITTING
TOTAL ��_ s �5
� 3097,CIV.C.) CHECKLIST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, -�•• P' �'—
TIRE 2,CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING HAZARDOUS _ d '-
Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD. t_
io Lender's Address `{(- ; i i i-;
c i OWNER OR AGENT CHAN'SE A i ILI
o I certify that I have read this application and state under penalty I
0 of perjury that the above information is correct.I agree to comply P.C.FEE M' �-r PERMIT FEE
a with all county ordinances and State laws relating to building �U (1 _
m construction, and hereby authoriz representatives of this County ISSUANCE FEE 1€! !(G-1 11 11* �:; 1 .� s
m to ent n t bove-men' property for inspection purposes.
mS -",75 INVESTIGATION FEE TOTAL FEE 944 1 AKI 9-42
Afttgo p AW1 Date
SEE REVERSE FOR EXPLANATORY LANGUAGE