HomeMy Public PortalAbout5702 AGNES AVE_Building_7/1/1993_reroof . APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES
BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION BUILDIADDRESS FOR APPLICANT TO FILL IN BUILDING ADDRESS �`•n' ps
Al I hereby affirm that I have a certificate of consent to self insure, 02,. vg�s
or a certificate of Workers' Compensation Insurance, or a certified
copy thereof (Sec.3800,Lab.C.) �j.�`- CITY i ZIP 8
0 I
Policy Noes'�� �4_(Company �"r`� LOCALITY
SIZE OF LOT NO.OF BLDGS.NOW ON LOT
❑ Certified copy is hereby furnished. NEAREST CROSS ST.
[eZ Cdepartment.ertified copy is filed with the County building inspection TRACT BLOCK LOT NO.
USE ZONE MAP NO.
Date I ' C1Applicant C-4117 h c��- ASSESSOR MAP BOOK PAGE PARCEL ,n
04N((�� 11 SPECIAL CONDITIONS
RTI�J �T OF EXEMPTION FROM WORKERS' OWNER TEL NO.
COMPENSATION INSURANCE WITHIN 1000 FT.OF SCHOOL? YES NO
(This section need not be completed if the permit is for one hundred ADDRESS
DISTRICT ✓GROUP TYPE CONST. FIRE ZONE PROCESSED
dollars ($100)or less.) CITY ZIP
3 �1V,///,
I certify that in the performance of the work for which this permitJT 12
is issued, I shall not employ any person in any manner so as to ARCHITECT OR ENGINEER TEL NO.
become subject to the Workers'Compensation Laws. STATISTICAL CLASSIFICATION APT CONDO
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 to the Workers' CONTRACTOR TEL NO. SET BACK YARD HWY PROP LINE WIDTH
Compensation provisions of the Labor Code, you must forthwith C 3,:�iV,-3 O 1-- FRONT
comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC.NO. P L
LICENSED CONTRACTORS DECLARATION L&�� 519
SIDE
CIT LIC.CLASS P L
I hereby affirm that I am licensed underprovisions of Chapter 9 4-,t C_—
(commencing with Section 7000)of Division 3 of the Business and SQ.FT.SIZE NO.OF STORIES NO.OF FAMILIES SEWER MAP
Professions Code,and my license is in full force and effect. NEW ❑ BK PG �-
0..
License Number Si 3L7 Lic.Class c- j DESCRIPTION OF WORK ADD ❑ VALUATION ,
Contractor - n e� O
�1)�kPA�-�51r Date —at.3 C' `�' ALTER ❑ � `t b0C _ U
❑ I am exempt under Sec. �') 0
REPAIR ❑ _ O
$ iEr
BAP.C.for this reasonY� DEMOL ❑ LDMA P/C# -� W
� 1Zra
Date: USE OF EXISTING BLDG. URM ❑ ''I~'(�� 02 30 a
Signature ( 'I';,-0
APPLIC T PRINT) NO. LDMA Perm# CHECK, �'�'- `'�' Z
❑ I, as owner of the property, or my employees with wages as ADDRESS ��`��L O °''t"
their sole compensation, will do the work and the structure is (`'HANGS
not intended or offered for sale (Section 7044, Business and lG ZT FINAL DATE a
Professions Code.) 0 _
WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL 1-1//7
❑ I, as owner of the property, am exclusively contracting With OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EOUAL TO OR GREATER THAN THE FINAL BY itir;I r 113 f f yj
AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE1
licensed contractors to construct the project (Section 7044,
YES El No El Ii`f-{ �, j^)E t.iti°°I f'�
Business and Professions Code.) --- -
WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH
CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FOR
GUIDELINES.
I hereby affirm that there is a construction lending agency for YES❑ NO❑
N the performance of the work for which this permit is issued(Sec.
� I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING ,
3097,CIV.C.) CHECKLIST,I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE,
TITLE 2,CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING HAZARDOUS
3 Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD.
CL Lender's Address
p OWNER OR 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 P.C.FEE PERMIT FEE S
with all county ordinances and State laws relating to building
)construction, and representatives of this County ISSUANCE FEE T
co
+ to enter mentioned property for inspect'pp urp S. J
INVESTIGATION FEE TOTAL FEE
�` gnalure of Applicant or Agent Date J
SEE REVERSE FOR EXPLANATORY LANGUAGE r