HomeMy Public PortalAbout4940 AGNES AVE_Building_8/30/1995_reroof house garage APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
WORKER S COMPENSATION DECLARATION FO P IC ILL IN WIN
DRESS
I hereby affirm that I have a certificate of consent to self Insure B ILDI ADDRESS y/, '-f 7
or a certificate of Workers Compensation Insurance or a certified CIT ZIP
copy thereof Se 3 0 L C) ^�
�"` T � L'C LOCALITY
POIICy No � Compan;,����_�__^./� SIZE OF LOT V NO OF 8LDGS NOW ON LOT
❑ eopy Is hereby furnished NEAREST CROSS ST
❑ Certified copy Is filed with jbuiIdin specti0 TRACT BLOCK LOT NO -department USE ZONE MAP NOASSESSOR MAP BOOK PAGE PARCEL
Date.(/���1/� ppllcant1 SPECIAL CONDITIONSCERTIFICATE OF EXEFROM WORKERSo "ERwL � � YEs No
COMPENSAURANCE '7/ WITHIN 1000 FT OF SCHOOLS
(This section need not be completed If the permit is for one hundred AD RE ,y `� DISTRICT GROUP P NE PROCESSED BY
dollars ($100)or less) CITY /4 rt/� ZIP
I certify that in the performance of the work for which this permit
is Issued I shall not employ any person In any manner s0 as t0 A CHITECT OR ENGINEER TEL NO - Q
become subject to the Workers Compensation Laws STATISTICAL CLASSIFICATION APT CONDO
Date Applicant ADDRESS CLASS NO r-Q_ DWELL UNITS
NOTICE-TO APPLICANT If after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST
Exemption you should become Subject t0 the Workers CONTRACTOR TEL SET BACK - YARD HWY PROP LINE WIDTH
Compensation provisions of the Labor Code you must forthwith 4 2� av W. a64� FRONT
comply with such provisions or this permit shall be deemed revoked ADD ESS LIC NO P LI
� /'~ 7o ,
LICENSED CONTRACTORS DECLARATION cl F SIDE
PL
I hereby affirm that 1 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 I NO OF FAMILIES
Professions Code Vd my license Is In lull force and effect ' NEW ❑ BK PG ® d
License Number LIC Class DE PTION OF WORK ADD ❑ VALUATION 0
Contractor Date LTER ❑ �O Q
f 6216 "\l"_OeIAIZ REPAIR 0
❑ I am exempt under Sec 7 $ U
B&PC for this reason C7 47Z
we_ /co C/ DEMOL ❑ LDMA P/C# W
Date I ISEf OF EXISTING BLDG URM ❑ 1 N
SignatureAPPLICANT(PRINT) TEL NO LDMA Perm# ACUT a Z
❑ 1 as owner of the pr rtj or my employees with wages as ZO 3-603 v 125.55
their sole comper n well do the work and the structure is ADDRESS
not intended or offered for sale (Section 7044 Business and FINAL DATE Q00.
Professions Code) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL 1 ITEMS
❑ I as owner Of the property am exclusive) contracting with OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE Q I ��
P P Y Y g AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY > TOTAL 12 5 e 5
licensed contractors to construct the project (Section 7044
Business and Professions Code) YES❑ NO❑ NE( i 7r a rC
WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING NE(K 1
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH JYJAI,1!'C a Oft
CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FOR CHANGE C1
GUIDELINES t
I hereby affirm that there is a construction lending agency for YES El NO 11 - - f�(���-(�(�{ OO fftt
the performance of the work for which this permit is issued(Sec HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMDPERMITTING OQ00-0001 Gl3Vl9C
3097 Civ C) CHECKLIST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE
r^,7 TITLE 2 CHAPTER 2 20 SECTIONS 2 20 100 THROUGH 2 20 140 CONCERNING HAZARDOUS f� AM
�
3 Lenders Name ", J MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD 7110 1 A p�110 o 32
o Lenders Address
OWNER OR AGENT
O
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
N with all county ordinances and State laws relating to building
construction and hereby au Onze representatives of this County ISSUANCE FEE so
to ente po the above�ned property f nspec urposes
,L 3Q INVESTIGATION FEE TOTAL FEE
� sre � i Anoi � o o< <7
SEE REVERSE FOR EXPLANATORY LANGUAGE
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