HomeMy Public PortalAbout5921 AGNES AVE_Building__ t „ WORJCERS COMPENSATION DECLARATION
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insure boraafcertif cafirm tharte ofaWorke srtCompensation Insuran elf APPLICATION FOR BUILDING PERMIT
or a certified copy thereof (Sec 3800�Lob C )'
o cy No Company__Fal RM DOT- COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished FOR APP ANT TO FILL IN BUILDING _
ADDRESS
Certified copy s filed with t county ildi g inspec BUILDING (,..' ` G
tion department 7 t ADDRESS S 9 7— lA Q eS V`
I
Date �+V Applicant CITY ZIP LOCALITY
CERTIFICATE OF EXEMPTION ROM KERS NO OF BLDGS NEAREST
COMPENSATION INSURANCE SIZE OF LOT g 6 t 515NOW ON LOT CROSS ST `
(This section need not be completed if the permit is for one ASSESSOR
hundred dollars ($100)or less ) TRACT BLOCK. ) LOT NO MAP BOOK PAGE PARCEL
OWNER 1�I.�4�f,dS NO TEL USE ONE MAP
I certify that in the performance of the work for which this NO _
permit is issued I shall not employ any person in any manner t SPECIAL ]
so as to become subject to the Workers Compensation Laws ADDRESS CONDITIONS
CITYOSI V
Date Applicant I pS ZIP `
ARCHITECT OR 11TEL
NOTICE TO APPLICANT If after making this Certificate of � DISTRICT GROUP TYPE FIRE PROCESSED BY O
Exemption you should become subject to the Workers ENGINEER NO ss1 / CONST ZONE U
Compensation provisions of the Labor Code you must forth ADDRESS ✓t VU A3 LtJ
with comply with such provisions or this permit shall be w TEL G G. D'1
deemed revoked CONTRACTOR MDf,1-J0e7TF� NO p t �j b(� STATISTICAL CIASSIFICA710N — APT DO N
LICENSED CONTRACTORS DECLARATION Q LICCLASS NO DWELL UNITS � Z
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS G X 4 04 NO 7--101,53
(commencing with Section 7000)of Division 3 of the Business and LIC SEWER MAP
Professions Code and my license is in full force and effect CITY AMO RPAVWJ15- dt CLA55 'a BK VALIDATION
C {^1„z SQ FT NO OF O OF CHECK
License Number O 153 Lc Class f ` / SIZE tib STORIES FAMILIES ONE
/ VALUATION
Contractorl�a"&-Kb&-*7 Date DESCRIPTION OF WORK �YhO ILSQS NEW a $
ADD
__ ,
I am exempt under Sec �e�� �'o� �❑
ALTER
B &P C for this ason REPAIR $
J,-
USE OF DEMOL ❑ �03a3A
EXISTING BLDG t a SSignatureAPPLICANT , TEL 4 b 6 FINAL J�� #{° o ° ° ° 1
1 O E I R L PRINT �� NO DATE —Z
I hereby affirm th t m exem t f t r ctor s License 6 0�U O G
Law for the following reason (S io 7031 5 Business and ADDRESS v ` / �V1O FINA A ) °I' 6 iQ J� 0
Professions Code) I
BUILDING By l/ /yl a 0 0 bfQ 5 0
o
I as owner of the property or my employees with ADDRESS
wages as their sole compensation will do the work and ® 08,08t88
the structure is not intended or offered for sale(Section LOCALITY ati
7044 Business and Professions Code) MOVING TEL
❑ I as owner of the property am exclusively contracting CONTRACTOR NO F
with licensed contractors to construct the project (Sec ADDRESS
tion 7044 Business and Professions Code)
CONSTRUCTION LENDING AGENCY REQUIRED TOTAL SETBACK FROM
SET BACK YARD HWY PROP LINE WIDTH
I hereby affirm that there is a construction lending agency for FRONT
the performance of the work for which this permit is issued �- P L
(Sec 3097 Civ C ) SIDE
rPP
Lender s Name Fee$ Permit Fee �� �� Ref #
Lender s Address ,
I certify that I have read this application and state that the Issuance Fee LDMA P/C#
oabove information is correct I agree to comply with all County Investigation Fee
0 ordinances and State I relating to building construction
$ and her ) o.thonze rep sentatives of this County to enter Total Fee t LDMA Perm
A upon a bov en n d propert for inspection purposes/
t w �� r SEE REVE E FOR E PLA ATORY lA GE os-.8-0
ignature o Applicant or Agent Date
73 -/:i* S,64 ��� nllt>�
7GA630A CE#808.9-60 APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING
ADDRESS_
DEPARTMENT OF COUNTY ENGINEER 7\
BUILDING AND SAFETY DIVISION LOCALITY
JOHN A. LAMBIE, COUNTY ENGINEER NEAREST
WILLIAM A. JENSEN SUPT OF BUILDING CROSS ST.
DISTRICT N9 GROUP TYPE
O PgO��SL
FOR APPLICANT TO FILL IN ' I CONST._
STATISTICAL CrSEWER"MAP
BUILDING �/ BK PG
ADDRESS s % N �� ze 5 � I �
CLASS. NO. DWELL.UNITS
LOT NO. BLOCK MAP NUMBER C?C=j HWYE YES NO
TRACT , fi USE ZONE SPECT L
NO.OF BLOGS. J CONDITIONS
SIZE OF LOT Cyd y e I NOW ON LOTUSE 1
EX STOING BLDG. J,� _ j !� / �G BUILDING YARD STREET NAME EXIST.
TEL. SETBACK WIDTH
OWNER &6 4 U AS NO. FRROL T >,i I 661
ADDRESS sr y-2 f A/ A 1p j_ SIDE
ARCHITECT OR TEL. P.L.
ENGINEER Aolp NO' INSPECTION RECORD
ADDRESS 'D"
CONTRACTOR L t"r li r A)# 13f13 '///7ykA5f `
ADDRESS AV GA I,YJfn'o /f 9AL -' .:'_..•tIL
O
DESCRIPTION OF WORK Yv
W
NEW ADD ALTER REPAIR DEMOLISH Z
SO.FT. NO.OF NO.OF
SIZE STORIES FAMILIES
USE OF
STRUCTURE S i C+�'
SIGNATURE OF
APPLICANT
VALUATION$ ®�P-ed'I -
APPROVALS DATE INSPECTOR'S SIGNATURE
J FOUNDATION: LOCATION -✓ x
P.C.
PMT.
FEE "$' FEE FORMS, MATERIALS
$
FRAME: FIRE STOPS, fi r
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION BRACING, BOLTS ]
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY FURNACE: LOCATION,
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING - GAS VENT DUCTS t�
BUILDING CONSTRUCT I ON. I CERTIFY THAT IN THE PERFORMANCE .�r rr /1
L
RK FOR WHICH THIS PERMIT IS ISSUED I SHALL NOT LATH, INT. - f �� •lg" ,.: ..��'-'""I
Y PERSON IN ANY MANNER SO AS TO BECOME SU BU ECT
RKMEN'S COMPENSATION LAWS OF CALIFORNIA.
LATH,EXT.
E OF HOUSE NUMBER COR-
RECT AND POSTEDFINAL {F -
CLYDE N. DIRLAM, PRINCIPAL'STR T4RAL ENGINEER
PLAN CHECK VALIDATION CK. M.O. CASH PERMIT VALIDATION CK.!' M.D. CA$H
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