HomeMy Public PortalAbout6006 AGNES AVE_Building__ °y APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION ac_ k,FOR;APPLICANT TO,F.ILL,;IN,
BUIL
WORKER'S ADD ESS '
1 hereby affirm that I have a certificate of consent to self insure, BUILDING ADDRESS //{����j ' loOD�i
or a certificate of Workers' Compensation Insurance,or a certified ��� '�S j %! C.
copy thereof (Sec.3800,Lab.C.) CITY�j� �1 ZIP
l";.L' �N•d' P� y �! ,> LOCALITY
Policy No, Company SIZE OF LCT - NO OF BLDGS.NOW ON'LOT
❑ Certified copy is hereby furnished. SC2. ;.,�3 �, . r.. NEAREST CROSS ST
lk/evO,e�.t t�6
❑ Certified copy is filed with the county building inspection TRACT i BLOCK LOT NQ„^ ;p
department. 11 i{l�l, USE ZONE MAP NO.
ASSESSO A BOOK. PAG PARCEL -
Date Applicant S ®N SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER ` � A TEL No.
COMPENSATION INSURANCE �/M /`�+� / � 3SS-�S6 WITHIN 1000 FT.OF SCHOOL? YES No
(This section need not be completed if the permit is for one hundred ADDRESS
dollars ($100)or less.) DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY
S Oq 'a�ftJ I��
CITY
I certify that in the performance of the work for which this permit /fid d /�
is issued, I shall not employ y person in any manner so as to J•pop .! j
become subject to the Workers Com
e do Law§. ARCHITECT OR ENGINEER TEL NO. `
I' '1 l L� p STATISTICAL CL SIFICATION APT CONDO
Date/ -K?'/` Applic ADDRESS CLASS NO. DWELL UNITS
NOTICE :TO APPLICANT, fter making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST
Exemption, you should become subject t0 the Workers' CONTRACT B TEL NO, SET BACK YARD HWY PROP LINE WIDTH
Compensation provisions of the Labor Code, you must forthwith j/v1 /✓� ��A-i�L �SS-�SG g FRONT
comply with such provisions or this,permit shall be deemed revoked. ADDRESS LIC.NO. - P L - �•-
LICENSED CONTRACTORS DECLARATION CITY O �,CW�� LIC.CLASS PIDE O
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.S ENO.OF STORIES NO.OF FAMILIES
Professions Code,and'�msy license is in full force and 112effect. (bl( r NEW BKPG 0
License NUm4@r�7-/•J 741 Lic. Class ,J DESCRIPTION OF WORK .ADD VALUATION , V
J ��2�S ALTER ❑ CL
w
Contractor-JM +���5/dl��Date "�- "�l $ �✓ rL" N
❑ I am exempt under Sec. CA, REPAIR O Z
BAP.C. for this reason CA,,nr.r.43Gt/S DEMOL ❑
LDMA P/C#
Date'. USE OF EXISTING BLDG. URM ❑
Signature APPLICANT(PRINT) TEL NO. LDMA Perm# "-
❑.1, as owner of the property, or my,employees with wages as Z1 w•z•"? n
their sole compensation, will do the work and the structure is ADDRESS O
not intended or offered for sale (Section 7044, Business and FINAL DATE Q � I t�-rjJ
Professions Code.) t
WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL
OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE "� _ J [ ''
❑ 1, as owner of the property, am exclusively contracting with AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL B4 0A•'• T' .9
licensed contractors to construct the project (Section 7044, t tt�•
•�•I n a
Business and Professions Code.) YEs.❑ No❑.
_•r a
WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING � .;°�I Itie � 711.n i
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH
CONSTRUCTION LENDING AGENCY COAST AIR OUAUTY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FOR 2 N•S
GUIDELINES. s:. .1.T1+ •
I hereby affirm that there is a construction lending agency for YES❑ No❑ j"1 a
the performance Of the Work for which this permit IS Issued(Sec. 67
IHAVEREAD THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING ,
3097,CIV.C.) CHECKLIST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, ' 1,. 1= 7_!,(,n i 4/_
TITLE 2.CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING HAZARDOUS
m Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD.
CHANGE ='00 C5
Lender's Address
OWNER OR AGENT
3 I certify that I have read this application and state under penalty
a P.C.FEE PERMIT FEE -y0•,• 2 /Q�
0 of perjury that the above information is correct.I agree to comply sD / Q }i (j y�l F;3 iJ 1. . t
1n with all county ordinances and State laws relating to building • (G' +Q
M const cti In' and reby authorize representatives of this County ISSUANCE FEE ® Lt.A�j 7 1 1 AM 10 e E
to ent upon the v mentioned roper inspection purposes.
- INVESTIGATION FEE TOTAL FEE +7/
N -
alure of ,,can,or A-n, Date / /I /
SEE REVERSE FOR EXPLANATORY LANGUAGE