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HomeMy Public PortalAbout6009 AGNES AVE_Building__ r 9 WORKERS COMPENSATION DECLARATION ' r , I I' I,.hereby affirmthat I have a certificate of consent to self insure or a certificate of Workers Compenstion InsUraNice ar APPLICATI®N � F®R ILDING �PERIVIIT 4 a 1ertified copy thereof (Sec 3800 Lab C ) I t COUNTY OF LOS ANGELE� BUILDING AND SAFETY �^ Policy No Company 1 ' El, Certified copy is hereby furnishedFOR APPLICANT TO FILL; IN ADDRESS Certified copy is filed with the county building inspec BUILDING - / hon department r ADDRESS /,�fS A)S ` LOCALITY (% NEAREST Date Applicant - CITY r' C,7v ZIP CROSS ST CERTIFICATE OF EXEMPTION FROM WORKERS If INO OF BLDGS ASSESSOR 'COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK r PAGE IWPARCEL (This section need not be completed if the permit is for one USE ZONE FSP P , hundred'`dollors ($100)or less ) TRACT BLOCK LOT NO © /'� �eTEL1 � CIAL aI certify that in the'performance of the work for which this OWNER NO $ �� a NDITIONS } O DISTRICT GROUP TYPE FIRE P CES BY ,permit is issued I shall not employ any person in any manner a y U so as to become subject to the Workers Compensation Laws ADDRESS ��,�/ s �r e CONST Z Date } 1 Applicant--I CITY ZIP STATISTICAL CLASSIJF Cq�ION APT CONDO s ARCHITECT OR TEL V NOTICE TO APPLICANT If after makings this Certificate of ENGINEER NO Lu Exemption 'you should become subject to the Workers CLASS NO DWELL UNITS Compensation provisions of the Labor Code you must forth y with comply with tsuch provisions or this permit shall be ADDRESS SEWER MAP Z_ F deemed revoked _ _ TEL CONTRACTORNO ( BK PG VALIDATION LICENSED CONTRACTORS DECLARATION UC I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO Y VALUATION (commencing with Section 7000)of Division 3 of the Business and t LIC Professions Code and my license is in full force and effect { CITY CLASS $ i SQ FT NO OF NO OF CHECK t License Number Lic Class SIZE STORIES FAMILIES / ONE t DESCRIPTION OF WORK ( 1 A NEW Contractor Date ❑ 0 1 am exempt from the licensing requirements as I am a ADD licensed architect or a registered professional engineer ALTER FINAL ` acting in my professional capacity, (Section 7051 REPAIR DATE 2— Business and Professions Code)' USE OF FINAL EXISTING BLDG s DEMOL Lic or^Reg No / Date APPLICANT / TEL 8y v OWNER BUILDER DECLARATIONI (PRINT) /�! NO�$S I hereby affirm that I am exempt from the Contractor s License /� Y Law for the following reason (Section 7031 5 Business and ADDRESS,,(009 'N/e' !V` Ire_ I17,50 Professions Code) _ PR SE T ® ' BUILDING / ^ ,Q , � I as owner of the property or my employees with ADDRESS 4-© /4';,!1 ` ' "v'7 7�/78d M wages as their sole compensation will do the work and 4/78J the structure is not intended or offered for sale (Section LOCALITY /C r1 L.: Cil 7044 Business and Professions Code) Lt MOVING TEL 7 p ❑ CONTRACTOR NO� J / I as owner of the property am exclusively contracting with licensed contractors to construct the project (Sec [ADDRESS t $� • e • o • tion 7044 Business and Professions Code) r QUIRED TOTAL SETBACK FROM EXIST 7 9 0 CONSTRUCTION LENDING AGENCY BACK YARD HWY PROP LINE WIDTH r2 • o' I hereby affirm that there is a construction lending agency for ONT J - the performance of the work for which this permit is issued L i o 0 01'7 9 O 0 m (Sec 3097 Civ C ) t DE f q Lender s Name 20 '7-87 Fee$ Permit FeeLender s Address W I certify that I have read this application and state that the Issuance Feeabove information is correct I agree to comply with all County stigation Fee ordinances and State laws relatmg to building construction Total Fee u and hereby authorize representatives of this County to enter upon the abo✓e mention d pr petty for inspection purposes Q -7 SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant oror Agent— r Date C�' ��3 25M BE _ l 'L_�� ��_���� t v DEPARTMENT SOF BurLbMG7 AND SAFETY `�� Ai TION FOR PERMIT COUNTY OF LOS ANGELES WM J FOX CHIEF ENGINEER B U ' L D I N G lamauffelammFOR APPLICANT TO FILL IN FOR OFFICE USE ONLY DISTRICT NO PLAN CK NO PERMIT NO BUILDING r _ ADDRESS S -5 3��O / LOCALITY / RECEIIVVED,,BY�� DATE OF APPLL DATEISSUED CROSSBST A����, r���� f&W ��/'��r6 (V /��!�� `r��'C./�� �� ABUILDING r OWNER TV!// /!l7 Ll! ��t��. /0 / La k, ADD ESS r! G S // G,:'ycMAIL , ��j ���� /j /ip �� LOCALITY ADDRESS NEAREST ��T / / /�� TEL ,/ CROSS ST ��Cl Q n CITY /A h, !l/ia ( J t/ No ARCHITECT Q' TEL ZONE I PLANE +-��'-��f SPE FIRE NO OF . ! ( GROUP ��. ENGINEER NO V I J- BLDG ORD NO ADDRESS SETBACK LINE TEL APPROVED CONTRACTOR - NO BY DATE USEAPPROVED ADDRESS ZONE BY Y�� + DATE LEGAL / u."4 CORRECTIONS DESCRIPTION LOT NO Q BLOCK ��'4/fc 1 00 TRACT (p ��i / Y /,F Q-VCXCAS ��'9 A'2L -POP ?Y/ .��A NO OF BLDGS P SIZE OF LOT a' ��nZ S�� I NOW ON LOT USE OF I NO OR I NO OF s EXISTING BLDG FAM, L16ROOMS DESCRIPTION OF WORK V' NEW ALTERATION ADDITION f O REPAIR y MOVING` DEMOLISH 61 Bq FT NO OF F = SIZE ROOMS STORIESWALL COVERING / 5-206 e t- I COVOERINO p USE OF NEW (V BUILDING p? f'C7 G LAJ.0 C5 p lqU F=Pr - r APPROVALS I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE I9 CORRECT FOUNDATION LOCATION, INSPECTOR DATE AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES FORMS, MATERIALS ,�� f'�� .���� AND STATE LAWS REGULATING BUILDING CONSTRUCTION FRAME FIRE BTOP8, SIGNATURE OF BRACING BOLTS q OWNCR �� �� LATH INT 5 1 AUTHORIZED AOT ��-/ t �� LATH, EXT 1 P O V PLASTER INT FEE .Y PLASTER, EXT VALUATION `��J ��D FEE fU FINAL ��- PPIM-PARTA-, BUILDIPTG SAND- APPLICA CO ' OF LOS ANGELES f ® I WM J FOX, CHIEF ENGINEER BU I L I FOR APPLICANT TO FILL IN FOR OFFICE USE ONLY BUILDING �" DISTRICT NO PLAN CK NO PERMIT NO ADDRESS 3a S �1.un�j (241�n� �,� Q 1, n LOCALITY Q�NEARESTqq EQ j/ {JJ� R�/CJEIIN E�D BY DATE OF APPL DATE)ISSUED CROSS ST .��[%.IVl�'f-V'� C /�" 47, �� OWNER ` n\/z t 1fA1�_w �1 Ft F1�l �Htk ADDRESS 3 0 S ! V i l e A r- \ 4y/: MAIL ? mac" 1l -'ry(' (^y (r\J LOCALITY / c / ADDRESS ) O S {I{ 1x 1 {`p l�6 JA \_�( -9. NEAREST �A Y Q l M1 ,NO CROSS ST vV G Q,0 R CITY O/1... FIRE NO OF TYPEGROUP? ARCHITECT OR S TEL. ZONE ..rte- PLANS ENGINEER NO _v --� BLDG / � / ORD NO ADDRESS SETBACK LINE , F-• �'g APPROVED TEL BY DATE CONTRACTOR NO USE APPROVED ADDRESS ZONE I BY DATE LEGAL CORRECTIONS DESCRIPTION LOT NO A 0 BLOCK ¢Yi'T./ i NO TRACT ! cS SIZE OF LOT '°� / NOW ON LOT USE OF N13 NO OF EX ST NG BLDG I-'9'�iw.� I FAM E /I ROOMS DESCRIPTION OF WORK NEW i ALTERATION ADDITION Q yu e REPAIR MOVING DEMOLISH � � _. Sq FT NO OF .- -�. Z SIZE ROOMS STORIES D WALL ROOF f' COVERING I COVERING USE OF NEW BUILDING O-e ti QL I -AII_ 1 D A 1 h06A.,0,1- j S A 11 V A 1N ft.I n .nn A.A 1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPROVALS APPLICATION AND STATE THAT THE ABOVE 15 CORRECT FOUNDATION LOCATION INSPECTOR DATE AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES FORMS MATERIALS AND STATE LAWS REGULATING BUILDING CONSTRUCTION 0& ar' v wr' , FRAME FI S, SIGNATURE OF BRACING BOLTS PERMITTEE kltLl LATH,INT - AUTHORIZED AGT. LATH EXT DBS 3 50M SETS 7 47 $ P C III ' PLASTER,INT I a �ion ..► FEE PLASTER,EXT VALUATION FEE aJ FINAL ( Z • APPLICATION FOR BUILDING PERMIT COUNTY OF LOS ANGELES`- �'y BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN " BUILDING ADDRESS I hereby affirm that I have a certificate of consent to self insure, BUILDING ADDRESS O D -P�✓ L%��e ell or a certificate of Workers' Compensation Insurance,or a certified 6200 ;�I copy thereof(Sec.3800,Lab.C.) CITY ZIP 1 LOCALITY Policy No. Company SIZE OF LOT` NO.OF BLDGS.NOW ON LOT 1:1Certified copy is hereby furnished. Vv NEAREST CROSS S . ❑ Certified copy is filed with the county building inspection TRACT BLOCK LOT NO. USE ZONE MAP NO. department. .SD Date Applicant ASSESSOR MAP BOOK /� /1r PAGE �.f PARCEL 1Z_ SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER (TEL ('7 COMPENSATION INSURANCE VtkiA(A / /1 WITHIN 1000 FT.OF SCHOOL? Yes No (This section need not be completed if the permit is for one hundred ADDRESS p dollars($100)or less.) ZIP DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY I certify that in the performance of the work for which this permit CITY is issued, I shall not employ any person in any manner so as t0 ARCHITECT OR ENGINEER TEL NO. o L1lliL�C/ become subject to the Workers'Compensation Laws. STATISTICAL CLASSIFICATION APT CONDO Date Applicant ADDRESS CLASS NO.-iR' 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 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 ' 111C.NO. PL SIDE 1 LICENSED CONTRACTORS DECLARATION CITY n LIC.CLASS P L ?h=-' °•!' I hereby affirm that I am licensed underprovisions of Chapter 9 v SEWER MAP ~'p� SQ.FT SIZE NO.OF ST RIES NO.OF FAMILIES - " '0 °�'' (commencing with Section 7000)of Division 3 of the Business and r136 O Professions Code,and my license is in full force and effect. �J�� NEW ❑ BK ,G PG �� } .DESCRIPTIO F,. RK VALU s 1 License Number Lic.Class ADS ---p; -- O Contractor DateALTER W ElI am exempt under Sec. REPAIR ❑ $ Z BAP.C. for this reason DEMOL ❑ LDMA P/C# Date: USE OF EXISTING DG. URM ❑ — Signature APPLICANT(PRINT)----% TEL NO. -/� 10 LDMA Perm# I,as owner of the property, or my employees with wages as their sole compensation, will do the work and the structure is ADDRES O not intended or offered for sale (Section 7044, Business and , FINAL DATE -.- '.; Professions Code.) WILL THE APPLIC NT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE ❑ I, as Owner of the property, am exclusively contracting Wlth AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY - Y' licensed contractors to construct the project (Section 7044, YES❑ No❑ -- Business and Professions Code.) C 111 ` WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING J t'-'r•ie - - OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH t-. ,` (•.v�.� CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FOR - a GUIDELINES. - I hereby affirm that there is a construction lending agency for YES❑ NO❑ `.jA).UE a the performance of the work for which this permit is issued(Sec. IHAVE MD PERMITTING 3097,Civ.C.) CHECKLISTD.1 UNDERSTAND THE UMV REQUIREMENS MATERIALS TS UNDER ON GT EE OS ANGELEAND THE S COUNTY CODE, TITLE 2,CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING HAZARDOUS �= r- 3 Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD. o Lender's Addressjib is^;;y O OWNER OR AGENT Z•TL+.: s .- 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 �, / �O CN with all county ordinances and State laws relating to building /� construction, and hereby authorize representatives of this County ISSUANCE FEE to a pon the above-menti eEl p o rty for inspection purp es. , f„ INVESTIGATION FEE TOTAL FEE Z9 4/J / ;Z� Sgnatu :OI pLcanl or gganl Dat � ✓� SEE REVERSE FOR EXPLANATORY LANGUAGE ,i'