The URL can be used to link to this page

Home My Public Portal About5014 AGNES AVE_Building_0 APPLICATION FOR BUILDING PERMIT t � a COUNTY OF LOS ANGELES BUILDING AND SAFETY t WORKER S COMPENSATION DECLARATION BFOR APPLICANT TO FILL IN BuILDI ��RESS> UILDJDIDRES$a_ Lj 1V�s Avg'- C! I I hereby affirm that I have a certificate of consent to self Insure ,/ VV or a certificate of Workers Compensation Insurance or a certified OA - copy thereof (Sec 3800 Lab C) CITY ,t // �/ ZIP ��/� L G (/I T) f, LOCALITY Policy No Company SIZE OF LOT NO 01 BLDGS NOW ON LOT ❑ Certified copy Is hereby furnished NEAREST CROSS SVF ❑ 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 CERTIFICATE CO PENSAT ONI INSURANCE ORKERS °W OS �� SaN VS'07-97-,00V WITHIN 1000 FT OF SCHOOLS Yes No v (This section need not be completed If the permit Is for one hundred ADD SS'/ /� /� - dollars ($100) Or less) ��7 Ve (�'�/V� /�1 V ff DISTRICT GROUP TYP CONST FIRE ZONE PROCESSED BY r I certify that In the performance of the work for which this permit t CIT ff� L r n j�� ZIP �/7 is issued I Shall not employ any person in any manner so as t0 ARCHITECT OR ENGINEER TEL NO become subject to the Workers Compensation Laws STATISTICAL CLASSIFICATION - APT CONDO Date Applicant ADDRESS CLASS NO --V/ 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 FRONT comply with such provisions or this permit shall be deemed revoked ADDRESS LIC NO P L LICENSED CONTRACTORS DECLARATION SIDE CITY LIC CLASS P 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 SQ FT SIZE NO OF STORIES NO OF FAMILIES Professions Code and my license Is In iull force and effect NEW 1:1 BK PG d License Number LIC Class DES TION Oif- ALTER ❑OFF WORK _ ADD C] VALUATIO b Poo. 0 Contractor Date $ � O cc El I am exempt under Sec sPT �11A, hI ae REPAIR 11 $ 0 SL B&PC for this reason LFC-'"No DEMOL ❑ 0 LDMA P/C# Date USE OF EXISTING BLDG URM ❑ a Signature APPLICANT(PRINT) TEL NO LDMA Perm# r Z ❑ 1 as owner of the property or my employees with wages as ZO }*lC 1 a their sole compensation will do the work and the structure Is ADDRESS c C-- not Intended or offered for sale (Section 7044 Business and FINAL DATE a jam _ �� i I Professions Code) VALL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL '('Sc y OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE J l I C `�3-} �_� ❑ I as owner Of the property am exclusively contracting^with AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL B TI IT''L 1-25 " "s licensed contractors to construct the project (Section 7044 YES❑ NO❑ Business and Professions Code) WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING t��1 'jC CC OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH - CONSTRUCTION LENDING AGENCY COAST AIR QUAUTY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKUST FOR �"f GUIDELINES t Al1.3C I hereby affirm that there Is a construction lending agency for YES❑ No❑ a the performance of the work for which this permit Is Issued(Sec rn IHAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING N 3097 Civ C) CHECKLIST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE 1 I, TITLE 2 CHAPTER 2 20 SECTIONS 2 20 100 THROUGH 2 20 140 CONCERNING HAZARDOUS Lenders Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD o Lenders Address 1 l4� 'r O OWNER OR AGENT o I certify that I have read this application and state under penalty of perjury at the above Information is correct I agree to comply PC FEE PERMIT FEE 57 - N with all ty or nances and State laws relating to building < constru Zove amb Eedproperty presentatives of this County ISSUANCE FEE O to ente t for Inspect n rpose INVESTIGATION FEE TOTAL FEE/ ^ sg i i Apel SEE REVERSE FOR EXPLANATORY LANGUAGE