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HomeMy Public PortalAbout6361 SULTANA AVE_Building__ 1 APPLICATION FOR' BUILDING PERMIT ti ! COUNTY OF LOS ANGELES BUILDING AND SAFETY 'WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING DR BUIL.I G ADDRESS Q 1 fitreby affirm that I have a Certificate of consent to self insure, l L u or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec.3800,Lab. C Y `. ZIP LOCALITY Policy No,A& /_.(111 ��Company S���G SIZ 0 LO G " NO.OF BLDGS.NOW ON LOT e ` ❑ Certified copy is hereby furnished. NEAREST CROSS ST. f3elbertified Copy is filed With the county building Inspect! TRACT BLOCK LOT NO. USE ZONE MAP NO. department. I Date Applicant a ASSESSOR MA BOOK PAGES / PA�R}C� SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' N o77 d !J dL TEL NO. �C- YES NO COMPENSATION INSURANCE 41THIN 1000 FT.OF SCHOOL? ADESS (This section need not be completed if the permit is for one hundred DISTRICT GROUP TYPE CONST.' FIRE ZONE PROCESSED BY � dollars($100)or less.) 1 I certify that in the performance of the work for which this permit S ead '72,2 �'•3 l� is Issued. I shall not employ any person in any manner so as to AR HITECT OR ENGINEER TEL NO. become subject to the Workers'Compensation Laws. STATISTICAL CLASSIFICATION APT CONDO Date Applicant ADDRESS CLASS NO. �3 DWELL UNITS NOTICE TO APPLICANT. If, after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST Exemption, you should become subject to the Workers' CO OR r TEL.NO. _� SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith C- ' 'Re '���v FRONT comply with such provisions or this permit shall be deemed revoked. ADDR LIC.NO. PL LICENSED CONTRACTORS DECLARATION CITY( LIC.CLASS FIDE o I hereby affirm that I am licensed under provisions of Chapter 9 m ' ® SEWER MAP v (commencing with Section 7000)of Division 3 of the Business and SQ.FT.SIZE NO.OF STORES NO.OF FAMILIES NEW El BK PG Professions Code,and my license is in full force and effect. DESCRIPTION OF WORK ADD ❑ VALUATION / W License Number ic.Class a Contractor Date 2077esU r ALTER ❑ $ ❑ I am exempt under Sec. REPAIR El $ B.&RC.for this reason DEMOL 800 LDMA PIC# Date. USE OF EXISTIN DG. URM ❑ Signature APPLICANT(PRINT) TEL.NO. � LDMA Perm# Z ❑ I, as owner of theroe g F'`•� p p rty, or my employees with wages as O ��.ti• o r their sole compensation,will do the work and the structure is ADDRESS _� not intended or offered for sale (Section 7044, Business and FINAL DA v�r .13.8'.0 Professions Code.) MRLLTHEAPPL16AWORFUTURE BUILDING OCCUPANT HANDLEAHAZARDOUS MATERIAL ❑ I, as owner of the property, em exclusively COmtrectin With OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN 9 THE AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY licensed contractors to construct the project.(Section 7044, YEs❑ No❑ Y'4, , I €Cal A. '38_C. Business and Professions Code.) WILL:THE INTENDED USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING ����� ��n Ill OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THESOUTH CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FOR GUIDELINES. !i-l�tNGE `�• n Oct 1 hereby affirm that there is a construction lending agency for vEs❑ NO❑ the performance of the Work for which this permit is Issued(Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD . 3097,Civ.C.). PERMITTING CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE,TITLE2,CHAPTER 220 SECTIONS 220.100 THROUGH 220.140 CONCERNING 00001-0010 1 10/15/90 Lender's Name HAZARDOUS MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD. an IL; 2' L Lenders Address =�: 1 fil`I 3 tL OWNER OR AGENT o I certify that I have read this application and state that the above RC.FEE PERMIT FEE information is correct. I agree to comply with all county . ordinances and State laws relating to building construction,and hereby authorize representatives of this County to enter upon ISSUANCE FEE ? th bove-mentio ed property for Inspection purposes. m ` �� 'y f i ) 1b 1 �b/ INVESTIGATION FEE TOTAL FEE ��s L -- ^v �Bq,rWreol Mp=taAYm1 � oft , SEE REVERSE FOR EXPLANATORY LANGUAGE APPLICATION FOR BUILDING PERMIT � COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS �03 �;tp LTr4N�4- 1 hereby affirm that I have a certificate of consent to self Insure, BUILDING ADDRESS ( /t�L—C1a�,,, j or a certificate of Workers'Compensation Insurance,or a certified CITY ' i Jr Zip copy thereof Se . 800,Lab.C. ^r Po y No. ( D f3 Company E CA LOCALITY T,� p � 0 SIZE OF LOT NO.OF BLDGS.NOW ON LOT `� l� Certified copy is hereby furnished. gyp— NEAREST CROSS ST. ❑ Certified co is filed with the county building inspection TRACT BLOCK LOT NO. Py tY 9 USE ZONE MAP NO. �v ASSESSOR MAP BOOK PAGE PARCEL n J ��epp a APPlicant "®_/��B7�[/.jAj��yy�,p r �e K.-.� SPECIAL CONDITIONS �r ����L!�t_'�ic�l IMC, OWNE TEL NO. CERTIFICATE OF EXEMPTION FR WORKERS' WITHIN 1000 FT OF SCHOOL? YES NO COMPENSATION INSURANCE ADDRESS (This section need not be completed if the permit is for one hundred DISTRICT r/ ROUP TYPE CONST.' FIRE ZONE FWdolls $hat orlesspe p CITY .zIP �5 Vo� J, 3I certi that in the rformance of the work for which this ermit Vh Is Issued, I shall not employ any person in any manner so as to MCHITECT OR ENGINEER NO. become subject to the Workers'Compensation Laws. ASACOW I8 STATISTICAL CLASSIFICATION APT CONDO Date Applicant ADE� CLASS NO. DWELL UNITS NOTICE TO APPLICANT: If, after making this Certificate Of CONTRACTOR TEL NO. REQUIRED TOTAL SETBACK FROM EXIST Exemption, you should become subject to the Workers' SETBACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code,you must forthwith FRONT comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC.NO. PL SIDE LICENSED CONTRACTORS DECLARATION CITY LIC.CLASS PL o I hereby affirm that I am licensed under provisions of Chapter 9 SEWER MAP ° v SQ.FT SI NO.OF STORES NO.OF MILIES 2 r (commencing with Section 7000)of Division S of the Business and NEIN � �1�7 r +� � Professions Code,and y I nso is In full force and effect. BK PG ��•_°•: License Number J Lic.ClassION qF RK ADD ❑ VALUATIONITEMS Conf7[��-•orf icy /j Date,/ 4 ALTER ❑ $ TOTAL 825 5a �K bCi Nii I��/P�Ji 1YTj ��Ytr 7-40 1--Y\ AleJ- ©� 3 I a �- �i� i ❑ I am exempt under Sec. REPAIR ❑ $ 8,J r/7_ CHECK va�.�°�}t ,E_ DEMOL ❑ ' CHANGE 00 B.&P.C.for this reason LDMA P/C M • ° Date: USE OF EXISTING BLDG. URM ❑ n SignatureNARDM', T(PRINT) TEL NO. LDMA —p Z 00010-0-00 1 S/15/90 ❑ I, as owner of the property, or my employees with wages as O 1*707 1 AMits C�1 their sole compensation,will do the work and the structure IsF not Intended or offered for sale (Section 7044, Business and FINAL DATE QQ C Professions Code.) WILLTHEAPPLICANTORFUTUR BUILDING OCCUPANTHANDLEAHAZARDOUS MATERIAL 4+Z� -1 ❑ I, as owner of theproperty, 9 OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN am exclusively contracting with THE AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY licensed contractors to construct the project.(Section 7044, YES❑ NO❑ Business and Professions Code.) , WILL THE INTENDED USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING OCCUPANT REQUIREA PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THESOUTH CONSTRUCTION LENDING AGENCY COAST DIEL NES TY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST I hereby affirm that there is a construction lending agency for YES❑ NO❑ the performance of the work for which this permit is issued(Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD lot, Q 3097,Civ.C.). PERMITTING CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES g. COUNTY CODE,TITLEZ CHAPTER ZW SECTIONS220.100THROUGH 220.140 CONCERNING ] r--' = r^. x, td Lender's Name HAZARDOUS MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD. I I ,;- r— p..+• Lender's Address ovunenonAooar _o I certify that I have read this application and state that the above F M information is correct. I agree to comply with all county RC.FEE �j /�5 ' (_ PERMIT FEE 9 j (�Q h.� 19 ordinances and State laws relating to building construction,and D a Y�IJ t hereby auttprizeloprosentatives of this County to enter upon ISSUANCE FEE the ab or inspection purpo �7 - r �, C 1 �v INVESTIGATION FEE TOTAL FEE /S � � - •Cj CO CQ c) LG SEE REVERSE FOR EXPLANATO 9=4 -� CQ CO n_