HomeMy Public PortalAbout5113 AGNES AVE_Building_0 APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUI DING AND SAFETY
WORKER S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUIL �D
I hereby affirm that I have a certificate of consent to self Insure BUILDING ADDRESS ,(l��S
or a certificate of Wore s Compensation Insurancergr a eyy�+�dd J
o Sgwx
13
380 ab C) �� J/W/ , /!` ZI�/ �®
�� !!�� (� [ LO ALITY I
1 Company SIZE OF LOT 1 NO OF BLDGS NOW ON LOT❑ Ce is hereby fur ish d NE EST CROSS ST
❑ Certified copy Is filed with the unty bull I nspectlo TRACT BLOCK LOT NO /
depart nt � ,.
USE ZONE MAP O
Date��L��SAppllcant ��/` ASSESSOR MAP BOOK PAGE PARCEL (SPECIAL CONDITIONS _
CERTIFICATE/F EXEMPTION FROM WORKERS
COMPENSATION INSURANCE OWNE �� � PL�J=�2 WITHIN 1000 FT OF SCHOOLS YES NO '
This section need not be completed 1 rmlt Is for one hundred ADDRESS / �! v
( p V DISTRICT GROUP TYPE CONST FIRE ZONE PROCESSED BY
dollars ($100)or less)
CITY ZIP
I certify that In the performance oft work for whlc this permit �
is issued I shall not employ any p s n In any m er so as o
be S Workers nsatlon ARCHITECT OR ENGINEER TEL NO
STATISTICAL CLASSIFICATION APT CONDO
D Appel n ADDRESS - CLASS NO � DWELL UNITS
I
NOTICE TO APPLICAN If ter Ing this Certificate of REQUIRED TOTAL SETBACK FROM EXIST
Exemption you sh0 d ecome subject to the Workers CO CTOR a C�FtCAO SET BACK YARD HWY PROP LINE WIDTH
Compensation prove ns of the Labor Code you must forthwith % o FRONT
comply with such p visions or this permit shall be deemed revoked ADQRE�S C P L
LICENSED CONTRACTORS DECLARATION c�/VS p /� LIC s�j� SIDE #
I hereby affirm that I am licensed underprovlslons of Chapter 9 "0 � `� `� SEWER MAP
(commencing with Section 7000)of Division of the Burnes SQ FT SIZE NO OF STORIES NO OF FAMILIES
��-e-' NEW BK PG a
Profession a nj f ce and G
License Nu er Lit c C ass EDE-9(55;IPTnI � /f ADD ❑ VALUATION Q
o G7 1:1 $ �'��� cc
C trac A� Date ALTER C
am exempt under Sec
^�r 7REPAIR ❑ $ 0
1 1 9
B8PC for this reason V, DEMOL ❑
LDMA P/C# 1 W
Date USE OF E WING BLD 1 URM 1:11 �
Signature APPLICANT(PRINT) `7� TEL NO LDMA Perm# Z
ElI as owner of the property or my employees with wages as I Z AGCTeB
their sole compensation will do the work and the structure Is ADDRESS 3303 1993.85
not Intended or offered for sale (Section 7044 Business and FINAL DATE r Q
Professions Code) _ 1 ITEMS
* WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL � J
❑ I as Owner of the property am exclusively contracting with OR A MIXTURE AMOUNTS SPECIFINTAINING A ED ON THE HAZARDOUS AZARDOSM MATERIAL
EQUAL
TOONRGU DETGREATER THAN THE FINAL BY > T�iTAL 1'� ® �
Lensed contractors to construct the project (Section 7044 YES❑ NO❑
x
Business and Professions Code) , CHECK Ica �c
WILL THE INTENDED USE OF THE BUIDUNG BY THE APPLICANT OR FUTURE BUILDING (�
COAST AIR QUI OCCUPANT OAUIRE A PERMIT FTY MANAGEMENOTRDIISTR CT USCAOMDR EEEDPEIRMITTINGRCO ECKLIISTOFOR r o 00
CONSTRUCTION LENDING AGENCY GUIDEUNES CHANGE
i
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 ��(y(� (�� I (�
3097 Civ C) CHECKLIST I UNDERSTANDVE READ THE US MATERIALS MY REQUIREMENTS UNDERTION GUIDE
THE LOSAND
ANGE ES COUNMD TY CODNG
E (,j1 J1JV-0001 12!2.0,71
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 ;OL L 1 AM 9'07
o Lender s A ress 70Y s
p OWNER OR AGENT I
p S I ce t I have read this application and state under penalty
o peri that the above information is correct I agree to comply PC FEE PERMIT FEE
II County oremaAes and Stat laws relating to buildingc str Ctlon and hauthor) esentatives of this County ISSUANCE FEEt upon the aentio perty for In ectlort primp �c
al a� INVESTIGATION FEE TOTAL FEE
Sc . I rod D1
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SEE REVERSE FOR EXPLANATORY LANGUAGE