HomeMy Public PortalAbout5803 AGNES AVE_Building__ APPLICATION FQR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS /J
I hereby affirm that I have a certificate of consent to self insure, BUILD 1 S T >7 G�
or a certificate of Workers' Compensation Insurance,or a certified
copy thereof(Sec. 3800,Lab. C.) /„� I P r , �� i ZIP
„_. 1 LOCALITY
Policy No. Company- 1"1��t1 SI E OF LOT NO.OF BLDGJ NOW ON LOT
❑ Certifi d-copy is hereby furnished. NEAREST CROSS ST
OF L7
Certified copy is filed with the co u building inspection TRACT BLOCK LOT NO.
USE ZONE MAP NO.
department.
Date ApplicantASSESSOR MAP BOOK PAGE PARCEL
' SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FR ORKERS' ER TEL O YES No
COMPENSATION INSURANCE L I— �S 2 WITHIN 1000 FT OF SCHOOL?
(This section need not be completed if the permit is for one hundred ADDRE ®� r�
S DISTRICT GROUP ECO T. FI PROCESSED BY
dollars($100)or less.)
dICIT �- nTE
certify that in the performance of the work for which this permit � b �_ �1is issued, I shall not employ any person in any manner so as to Jbecome subject to the Workers'Compensation Laws. ARC ITECT OR ENGINEER O. STATISTICAL CLASSIFICATION APT CONDO
Date Applicant ADDRESS CLASS NO. ;!r'21 DWELL UNITS
NOTICE TO APPLICANT.' If, after making this. Certificate Of REQUIRED TOTAL SETBACK FROM EXIST
Exemption, you should become subject to the Workers' CO ACTOR, TEL NO. SET BACK YARD HWY PROP LINE WIDTH
Compensation provisions of the Labor Code, you must forthwith \ Q FRONT
comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC.NO. P L
LICENSED CONTRACTORS DECLARATION PILE
CIT � \ � LIC_GLAS P L
I hereby affirm that I 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 NO.OF FAMILIES
Professions Code, Ii en/S 1s In full force/a�,of'p5t.G, NEW BK PG }
1 �- J C D �ON OF WORK ADD ❑ VALUATION , O
License Num r Lic.Class
/ �J �'O U
Contractor Dates S ALTER ❑ $ C.�.l ;;7,;).
El am exempt under Sec. L cc
REPAIR El $ 0
BAP.C.for this reason DEMOL ❑ LDMA P/C# W
Date: USE OF EXISTING BLDG. V
URM ❑ 3 �-
Signature APPLICANT(PRINT) TEL NO. LDMA Perm# "�•�'T ' Z
❑ I, as owner of the property, or my employees with wages as Z - j�•7 lz`
their sole compensation, will do the work and the structure is ADDRESS O '30 r z a_•..'•
not intended or offered for sale (Section 7044, Business and FINAL DAT C z EMS
Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL Y I..
OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE J ` 172 o �!a
❑ 1, as owner of the property, am exclusively contracting with AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY �3 ;C
licensed contractors to construct the project (Section 7044, YEs 1:1 No❑ r L'•r •. 17 r
i i.z
Business and Professions Code.) -••--•• ''"
WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING ��•• (n'10
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH ) f ;.H�1�'�4iS,=, .00
CONSTRUCTION LENDING AGENCY COAST AIR QUAUTV MANAGEMENT DISTRICT(SGAQMD)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. Lee!1` 1 /41b 00010-000 q 5
3097,CIV.C. [HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING � 4f ''
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 S g�lJ;e .ti AN 3:OV
Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD.CL '
o Lender's Address
0 OWNER OR AGENT
o I certify that I have read this application and state under penalty
of perjury that the above information is correct.I agree to comply P.C.FEE PERMIT FEE �O
"N with all county ordinances and State laws relating to building
construct , and here authorize representatives of this Count ISSUANCE FEE
a p y
ro /
to enter p thea ve-m nti ned property for inspection pur se [�
a s INVESTIGATION FEE TOTAL FEE
Sg a of A Dant o,Ag enl Dale
SEE REVERSE FOR EXPLANATORY LANGUAGE