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HomeMy Public PortalAbout5021 AGNES AVE_Building_0 APPLICATIO F�013 BUILDING PtRMIT COUNTY OF LOS ANGELES - BUILDING AND SAFETY y �r WORKER S COMPENSATION DECLARATION FOR APPLICANT TO FILL 10 BUILDIN�"DDFjE$s j \ I hereby affirm that I have a certificate of consent to self Insure BUILDI © ESS �� ' �(/�/ or a certificate of Workers Compensation Insurance ora certified copy thereof JSec 3800 Lab C) CITY ZIP LOCALITY { Poh CL mal Company �9/ �T �!� ' � ^T SIZE OF LOT r NO OF BLDGS N WON LOT Certified copy Is hereby furnished ' NEAREST CROSS ST t Eldereritmenopy Is filed with the county budding TRACT BLOCK LOTiNO pection s r USE ZONE MAP NO I _ ted Date Applicant ASSESSOR MAP BOOK PAGE PARCEL } SPECIAL CONDITIONS CERTIFICATE OF EXEMPTI FROM WORKERS PADDR�ZES pTEL tiq COMPENSATION INSURANCE V � r' �/z IV7 � ..3 a6 WITHIN 1000 FT OF SCHOOLS vEs No This section need not be completed If the permit is for one hundred r( P P DISTRICT GROUP PE E ZONE PROCESSED BY dollars ($100) or less) J � ,x" ZIP / ?B'0 ��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 toT OR ENGINEER TEL NO ly become subject to the Workers Compensation Laws STATISTICAL CLASSIFICATION APT CONDO I 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 t0 the Workers ZNTRACTQFL/_f/7�� L O �� I SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code you must forthwith (w /t_�/!�9 �( le FRONT comply with such provisions or this permit shall be deemed revoked AD4 S LIC NO P L1_4 1 LICENSED CONTRACTORS DECLARATION / Zo LIC CUSS Ces /7 SIDE C Y l P L I hereby affirm that I am licensed u`nderprovislons of Chapter 9 / SEWER MAP " (commencing with Section 7000)of Division 34 of the Business and STZ NO OF STORIES I NO OF FAMILIES 1 Professions Code and m license Is In full force and effect NEW ❑ BK PG , x � r � f D_ -- �Z D CRIPTION OF WORK ADD T ❑ VALUATI N License Number Llc Class n 0 Contractor L��/r,r, 1 ate �� !L /ALTER ❑ (� U 4 L'P 5PL de REPAIR $ O El "A' O I am exempt under Sec A �c y DEMOL ❑ U B&P C for this reason ` -ti�/ e - v f LDMA P/C r Ill Date USE F XISTING BLDG In;460 URM ❑ 0- U) Signature - AOPLICANT(PRINT) TEL NO LDMA Perm a Z El as owner of tl} erty or my employees with wages as z their sole comp ation will do the work and the structure Is ADDRESS not intended or offered for sale (Section 7044 Business and FINAL DATE Professions Code) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL ���/ a ❑ I as owner of the property am exclusive) contracting with OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE / Y Y AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY licensed contractors to construct the project (Section 7044 VES❑ NO❑ T T Ct i_ IN Business and Professions Code) z s WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING _ OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH i t AL 2 12 CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKDST FOR GUIDELINES i HD 1 i i 1 = y C I hereby affirm that there Is a construction lending agency for VES 1:1 No Elf�G i N the performance of the work for which this permit is Issued(Sec IHAVEREADTHE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING t t I'►1N T •�I 3097 CIV C) CHECKLIST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE t 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 SCAQMD o Lenders Address I---U O O NER O AGENT ' o 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 PC FEE PERMIT FEE a with all county ordinances and State laws relating to building L�' - constr on and hereby �thor¢e representatives of this County ISSUANCE FEE toe on the above boned property r Inspection purposes INVESTIGATION FEE TOTAL FEE 4-;2 SEE REVERSE FOR EXPLANATORY LANGUAGE t