HomeMy Public PortalAbout5925 AGNES AVE_Building__ APPLICATION f OR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRE,ta
hereby affirm that I have a certificate of consent to self insure, BUILDING ADDRESS SILL)
or a certificate of Workers' Compensation Insurance, or a certified C � ��"S. 14 1/1'
copy thereof (Sec.3800,Lab.C.) CITY ^ ZIP
I�,�N �'L� L?i 6 ��/'T '�' /59 Jl—1 141 LOCALITY �le
Policy No. Company SIZE OF CT NO.OF BLDGS.NOW ON LOT
❑ Certified Copy is hereby furnished. C! X Ir f F/� NEAREST CROSS ST.
ElCertified copy is filed with the County building inspection TRACT BLOCK LOT NO.
• USE ZONE MAP NO.
department.
ASSESSOR MAP BOOK PAGE PARCEL ,'�
Date Applicant -L� ") �% 0 S SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER a� TEL NO. YES NO
COMPENSATION INSURANCE CNZ'W7�' ��s'4 �' r ,14.,V Fy t --2Yl•-%,641LZ WITHIN 1000 FT.OF SCHOOL?
ADDRESS
(This section need not be completed if the permit is for one hundred �-- r�f-- A f ` AZ DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY
dollars ($100) or less.)
CITY ZIP
I certify that in the performance of the work for which this permit ('4
is issued, I shall not employ any person in any manner SO as to. ARCHITE T 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' CONTRAC R TEL NO. SET BACK YARD HWY PROP LINE WIDTH
Compensation provisions of the Labor Code, you must forthwith FRONT
comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC.NO. P L
SIDE
LICENSED CONTRACTORS DECLARATION CITY LIC.CLASS P L
}
1 hereby affirm that I am licensed underprovisions of Chapter 9 SEWER MAP tL
(commencing with Section 7000)of Division 3 of the Business and SQ.FT.SIZE NO.OF STORIES NO.OF FAMILIES O
Professions Code,and my license is in full force and effect. Cj/Vr " ,nlC' NEW ❑ BK PG ' U
License Number Lic.Class D SC
RI ION O 41 i WORK
Ci ADD VALUATION
Contractor Date � 1 � � S'� •ALTER ❑
' REPAIR ❑ ~
❑ I am exempt under Sec. $ (J
W
BAP.C. for this reason DEMOL ❑ LDMA P/C# N
Date: USE OF EXISTING BLDG. URM - ❑ f- T_ Z
Signature APPLICANT(PRINT) TEL NO. LDMA Perm#
f.�'-.f'•1 C' +`� i Ea! %�.'. l-' 'C¢i�- 2 '7-'.l �G -_ t._,; Z,
` I, as owner of the property, or my employees with wages as - O
this, Sole compensation, will do the work and the structure is . ADDRESS_
not `ntended or offered for sale (Section 7044, Business and .S � s .�/Z--� t�cL. c C-17 (/� FINAL DATE � -
Prof essions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL
'� I, S owner Of the property, am exclusive) contracting Wlth OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE �•.•.
i+. _ p p Y. Y g AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY .'` s e-ri 1 n T _.-
I' ensed contractors to construct the project (Section 7044, YES 1:1 Noy r/, Jw�'
Business and Professions Code.) _
WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING `,., .,.5_ '•
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. .. 1 5 �+ �F
1 hereby affirm that there is a construction lending agency for YES ElNOD
i tf
N the performance of the work for which this permit is issued(SecaHAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING _ ._,TM •s, ,
3097, CIV.C.) CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE,
N TITLE 2,CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING HAZARDOUS �•) !i F o rl=`
Lender's Name_ MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD. 'ti'°•� 3`"
o Lender's Address
OWNER OR AGENT
o I certify that I have read this application and state under penalty
PERMIT FEE
o of perjury that the above information is correct. I agree to comply P.C.FEE ,*'"
with all county ordinances and State laws relating to building
construction, and hereby authorize representatives of this County ISSUANCE FEE
CD
2 to enter upon the above-mentiQQd property for inspection purgoses. � v
INVESTIGATION FEE TOTAL FEE �[
ignalure I Appland or Agen( Date
SEE REVERSE FOR EXPLANATORY LANGUAGE