HomeMy Public PortalAbout4942 AGNES AVE_Building_6/5/1968 s
APPLICATION FOR BUILDING PERMIT
_ COUNTYjOF LOS ANGELES ' BUILDING AND SAFETY
WORKER S COMPENSATION DECLARATION * K FOR APPLICANT TO FILL IN
I DIN ADDRESS �
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hereby affirm that I have a certificate of consent to self Insure
or a certificate of Workers Compensation Insurance ora certified
copy thereof JSer„3890 Lab C) C1 �( Z �9 rLOCALITY
Policy No G' Company SIZE OF LOT - NO OF BLDGS/NOW ON LOT
S
-O'C76rtlfled copy Is hereby furnished NEAREST CROSS ST
ElCertified copy Is filed with the county building Ins ectTRACT BLOCK LOT NO ion , ”
USE ZONE MAP NO 1
department a r
Date grz.Z �`Appllcant ASSESSOR MAP BOOK PAGE PARCEL
SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTIO - WORKERS ! o R TEL NO ^
COMPENSATION SURANCE F WITHIN 1000 FT OF SCHOOLS YES I No
This section need not be completed If the permit is for one hundred AD RE
( P P { n�/f i DISTRICT GROUP TYPE CONST FIRE ZONE PROCESSED BY
dollars ($100)or less)
CITY ZIP— �
I certify that in the performance of the work for which this permit C/�'
is Issued I shall not employ any person In any manner so as to
x ARCHITECT OR ENGINEER TEL NO
becomei subject to the Workers+ Compensation Laws STATISTICAL CLASSIFICATION APT CONDO
Date Applicant ;° ADDRESS - A CLASS NO �` DWELL UNITS
t
NOTICE TO APPLICANT If after making this Certificate Of REQUIRED .. TOTAL SETBACK FROM EXIST
Exemption you Should become Subject t0 the Workers C NTRACTOR T L NO /� SET BACK YARD HWY PROP LINE WIDTH
Compensation provisions of the Labor Code you must fort[ h v FRONT {
" comply with such provisions or this permit shall be deemed revoked ADDIRjfSS % LI T P L
LICENSED CONTRACTORS DECLARATION / CNO / SIDE
CITY r a LI LASS P L x
1 thereby affirm that I am licensed underprovisions of Chapter�9 0 7� - Com' SEWER MAP
(commencing with Section 7000)of Division 3 of the Business and SQ FT SIZEC,7 NO OF STORIES NO OF FAMILIES
NEW ❑ BK PG ® r- >'
Professions Code and my license is In will force and effect R + a
License Number LIC Class RIPTION OF WORK - ADD ❑ LU�ONn r Q
Contractor ��/�C� L Date �L— A le- r TER ❑ Cvv/-111/�/J
❑ I am exempt under Sec �� l REPAIR $
B&PC for this reason DEMOL ❑ LDMA P/C# 4 W
' Date T USE OF EXISTING BLDG - URM 11 IL
l 1 W
Signature APPLICANT(PRINT) ',f TEL NO LDMA Perm# _ _tri t.T
Z
El as owner of the erty or my employees with wages as Z FFFFffiRlll i
their sole compe on wi11 do tthe work and the structure is ADDRESS Cl
not intended or offered for sale (Section 7044 Business and r I FINAL DATE Q 3303 125.55
Professions Code) Gt
I WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL `tel� J
❑ I as owner Of the OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE -�A1 ITE
►,I.Z
property am exclusively contracting with AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDES FINAL BY C 381..- 5 -55
^ licensed contractors to construct the project (Section 7044 , +
.e..._ m -.-8
YES 11 No
Business and Professions Code) ❑WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING , �LJcj'��//
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH CHR K 125.59
CONSTRUCTION LENDING AGENCY COGUIDEAST AIR NES QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR
LI (HANGE� �� - .00
I hereby affirm that there Is a construction lending agency for VES El No El _
N the performance of the work for which this permit Is Issued(Sec I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING } Q ♦/) Q
° �3097 CIV C) CHECKLIST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE 0000-0001 i
TITLE 2 CHAPTER 2 20 SECTIONS 2 20 100 THROUGH 2 20 140 CONCERNING HAZARDOUS 0/JlJ/7
Lenders Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD u'
3
o Lenders Address - 7111 1 AM 10°33
O OWNER OR AGENT
o I certify that I have read this application and state under penalty
oPC FEE PERMIT FEE
of perjury that the above information is correct I agree to comply
o with all county ordinances and State laws relating to building
construct n and hereby thorize representatives of this County ISSUANCE FEE ^
to en u on the above n e Honed prope y for Inspection purposes v
� INVESTIGATION FEE TOTAL FEE r ^� _
S , i nod � � J .,
SEE REVERSE FOR EXPLANATORY LANGUAGE