HomeMy Public PortalAbout4937 AGNES AVE_Building__ I F
APPLICATION FOR BUILDING PERMIT i
4 tl COUNTY OF LOS (ANGELES t BUILDING AND SAFETY
WORKER S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS
4 lig �� ~; B ILDI G ADDRESS Allt
I hereby affirm that I have a certificate of consent to self Insure < S
or a certificate of Workers Compensation Insurance or a certified
copy thereof(Sec 3800 Lab C) r TY ' ZIP
P0114zn��/� �� /;r Ci+ � LOCALITY
O O� Z ompany SIZE OF LCT NO of BLDGS NOW ON LOT
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❑ Certified copy is herebyfurmshed 1 ` ` ' ' ' NEAREST CROSS ST
Ier Ified copy Is filed with the county budding Inspection TRACT BLOCK LOT NO
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J, department v USE ZONE MAP NO j
Datel/` 6f �Appllcartl� 5 ASSESSOR MAP BOOK PAGE '`" PARCEL 4 '
+ SPECIAL CONDITIONS )
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CERTIFICATE OF EXEMPTION FROM WORKERSOWNER r TEL NO / '�-
COMPENSATION INSURANCE — .� & V � ^t j[ .7 WITHIN 1000 FT OF SCHOOLS YES NO
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(This section need not be completed If the permit Is for one hundred v ADDRESS
dollars ($100) or less)° 3' DISTRICT GROUP CO ST FIRE ZONE PROCESSED BY
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n'r C ' I ZIP
I certify that In the performance of the work,for which this
�permlt , r G )
Is Issued I shall not employ any person In any manner so as to { ARCHI CT OR ENGIN R TEL NO
become subject to the Workers Compensation Laws
t , : F ` r STATISTICALCLA SIFICATION APT CONDO
„ f Date Applicant a ,ADDRESS `" CLASS— l DWELL UNITS I _
NOTICE ,TO APPLICANT If after making thlsr,Certificate Of REQUIRED TOTAL SETBACK FROM EXIST
Exemption you should become subject t0 the Workers CONTRACTOR- TEL NO SET BACK YARD HWYRONT
PROP LINE WIDTH
Compensation provisions of the Labor Code you must forthwith r 57 t
comply with such$rovlslons or this permit shall be deemed revoked A ESs s t LIC No FRONT
L
dam- / D l SIDE
LICENSED CONTRACTORS DECLARATION LIC CLASS IPL
I hereby affirm that I am hcen`sed underprovlslons of Chapter, 9 �'�•�
(commencing with Section 7000)of Division 3 of the Business and SQ FT SIZE NO OF STORIES( NO OF FAMILIES _ SEWER MAP + _ + d
Professions Code and my licenseIs In full force and effec NEW 1:1 BK PG O
' e W
�3 DE RIPTION OF O ,
License Number Cp 7�6 7 LIC Class Y ADD ❑ VALUATION U
Contractor Date o $ BDOr
tr F � �_ ^ ALTER 1:1f
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❑ I am,exempt under Sec REPAIR ❑ $ �--
' - V
B&PC for this reason DEMOL ❑ LDMA P/C# /E NJ
`Date h USE OF EXISTING BLDG CL
URM ❑ ti
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Signature �G1�wwi I -
a• APPLICANT(PRINT) TEL NO r LDMA Perm# Z
❑ 1 as owner of the property-or my Temployees'with wages as Z - _ s
their sole compensation will do the work and the structure Is ADDRESS O
not Intended or offered for sale (Section 7044 Business and FINAL DATE
Professions Code) ' [ K WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL 4 r 3rJ3� OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE -J
❑ I as Owner of the property am exclusively contracting with + AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE'SQ
FINAL BY
licensed contractors to construct the project (Section 7044
a Business and Professions Code)' YES❑ NO
WILL THE INTENDED USE OF THE BUIDUNG BY THE APPLICANT OR FUTURE BUILDING
c OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH
CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRI MD)SEE PERMITTING CHECKUST FOR
GUIDELINES y Ott
t I hereby affirm that there Is a construction lending'agency fore '
` a< the performance of the work for which this permit Is Issued(Sec ves❑ No -
p> I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING ?.
N 3097 CIV C) CHECKLIST I UNDERSTAND MY REQUIREMENTS UNDER THE ANGELES COUNTY CODE
i TITLE 2 CHAPTER 20 SECTIONS 2 20 100 THROU 2 CONCERNING HAZARDOUS
3 Lenders Name MAT RIN.
AND FOR OBT HE SCAOMD
4o IA Lenders Address "E1]r!r'�'�
O OWNER CP XG T
o I certlfy,that I have read this application and state under penalty
O of perjury that the above Information Is correct agree to comply 1 PC FEE PERMIT FEE 1 ,�
b,N 'with all county ordinances and State laws relating to budding j '
OD construction and hereby authorize representatives of this County ISSUANCE FEE `� t
a �p er�l >n th�b`IyE�+eySlfll�d property for inspection p rpos�s, a
�r(��/-�.�"�� INVESTIGATION FEE TOTAL FEE /g/
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I SEE REVERSE FOR EXPLANATORY LANGUAGE