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Home My Public Portal About6019 AGNES AVE_Building__ 6/78) , t APPLICATION FOR BUILDING PERMIT COUNTYrOF LOS ANGELES BUILDING AND SAFETY BUILDING FBu'LD R APPLICANT TO FILL IN ADDRESS D/ `cf A E LOCALITY / N EAREST` ZIP CROSS ST GZ_ _^� c NO OF BLDGS ASSESSOR 3 J NOW ON LOT MAP BOOK PAGE_ PARCEL 4 DISTRICT GROUP I TYPE FIRE PROLE S D BY TRACT , & BLOCK LOT O L NO J p�CONSj I E I (J V OWNER r / NO 9 ADDRESS T7 S n STATISTICAL CLASSIFICATION EWER MAP CLASS NO DWELL UNITS SK PG 1 CITY ZIP r ARCHITECT O �. TEL VALUATION ENGINEER NO �Z ADDRESS BLDG SETBACK FROM FRONT PROP LINE OF (STREET) CONTRACTOR Q HIGHWAY + YARD _ TOTAL SETBACK FROM TYPE OF EXISTING LIC FRONT PROP LINE HIGHWAY WIDTH ADDRESS NO LIC + CITY CLASS BLDG SETBACK FROM CONSTRUCTION LENDER NAME AND BRANCH NDN E SIDE PROP LINE OF (STREET) o TOTAL SETBACK FROM TYPE OF EXISTING HIGHWAY + YARD = SIDE PROP LINE HIGHWAY WIDTH ADDRESS CITY y _ O SO FT/ NO OF / NO OF 6 CHECK + = V SIZE / -00 STORIES ( FAMILIES I ONE DESCRIPTION OF WORK do L NEW ❑ PC Fee$ 3 Permit Fee f{ 19 b ADD ❑ Issuance Fee / Q ALTER Y / REPAIR ❑ Total FeeUS (O EXISTI NG BLDG L M DEMOL ❑ 3�r �md 1 2 APPLICANT TEL 0 IPRINT) NO Q D � � r BY(SIGNATURE) Q IHEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE Y THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL ORDINANCES uU AND LAWS REGULATING BUILDING CONSTRUCTION I CERTIFY THAT IN DOING THE +§ S i WORK AUTHORIZED HEREBY I WILL NOT EMPLOY ANY PERSON IN VIOLATION OF V THE LABOR CODE OF THE STATE OF CALIFORNIA IN RELATING TO WORKMEN S COM Z PENSATION INSURANCE th ;27058A r 1 SIGNATURE OF PERMITTEE ADDRESS Z 2 ° - 6 1 0 0 TEL 0 CITY NO Q - 610030 ;E 0��111E MAP _G NO J 11 004-79 ��/ O Q ` � a j ECIAL NDITIONS 71 FINAL BY DATE / r S WO%KERS' COMPENSATION DECLARAT40N s e'h i,j bpo affirm that I have certificate of consent to self APPLICATION FOR BMJ I LD I N G PERMIT ' insu: r a c�rfificate of Worr kers' Compensation Insurance, ' or a crtified copy thereof (Sec: 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No.' Company ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING ADDRESS ❑ Certified copy is filed with the county building inspec- BUILDING tion department. ADDRESS (0 C. ,o Date Applicant CITY Z C ZIP 80 LOCALITY .NO. OF BLDGS. ^ _ NEAREST CERTIFICATE OF-EXEMPTION FROM WORKERS' SIZE OF LOT NOW ON LOT d CROSS ST. COMPENSATION INSURANCE ; ASSESSOR h 7 (This section need not be completed'if the permit is for one TRACT BLOCK LOT NO. MAP BOOK PAGE 4 T PARCEL C910 hundred dollars ($100) or less.) TEL' USE ZONE MAP OWNER Tt G VAP_ NO. Zgr�o`U 3L I certify that, in the performance of the work for which this NO. permit.is issued, I shall not employ any person in any mannerADDRESS 0. A], 2 c� �-, SPECIAL so as to become subject.to the Workers'Compensatiqr�La y CONDITIONS O CITY ZIP 80 U Date Applicant %( �.�-+ [//� Mil ARCHITECT OR' TEL. W NOTICE TO APPLICAN : If, after. making thiss Certi ENGINEER ff DISTRICT' WGROUP TYPE FIRE PROCESSED BY O g S. 1 Nq A� ND- Z�O CONST. ZONE' Exemption, ;you ,should become subject to the, Workers' L aU Compensation provisions of the Labor Code, you must forth- ! . ADDRESS •�i ] y — a to with comply with such ,provisions or This permit shall be `14 !1 TEL. STATISTICAL CLASSIFICATION APT. CONDO. Z 19i� deemed revoked. CONTRACTOR p( LL F N T . — ?S _ LICENSED CONTRACTORS DECLARATION LIC ao CLASS NO. / DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS 0,q O. 56 q 3 Cl''/ LIC. SEWER MAP (commencing with Section 7000)of Division 3 of The Business CITY S'�� /�}} R CLASS and Professions Code,and my license is in full force and effect. ...,VALIDATION p SQ. FT NO. OF /► NO. OF CHECK BK. PG. License Number -G 3 c� / Lic. Class I' SIZE STORIES FAMILIES ONE eZ VALUATION Contractor i1�n Q L C E_9=- TtV-t. G -�5 -9 DESCRIPTION F�3 WORKgZaa I'(y NEW S �, `�0 i , . ADD �,( ❑I am exempt under Sec. X i4 a V E N P� � cL Ctou;�$Aa.� E N1 PLO 7 EFS ti E /�,^ ALTER ► .i i.� i� F�t B.&P.C. for this reason �. ►r36n14 A�.��• r� Sir Oct a. $ r; ; fesUSE OF PAIR ❑ : ,: Date:' (o�-�S'c/� ,, � `•e : • _..,.-'T., .;. EXISTING BLDG. DEMOL.❑ t ' Signature APPLICANT _ TEL.', - q (PRINT) NO.r ' ' FINAL OWNER-BUILDER DECLARATION DATE r�r..y." .. .` I hereby affirm That I am exempt from the Contractor's License - t; t ••, Law for the following reason (Section 7031.5, Business and ADDRESS FINAL Professions Code): PRESENT ByBUILDING ❑ I, as owner of the property, or my employees with ADDRESS '° t 3r wages as their sole compensation,will do the work and �. • ��"'� ,.,�)�, ` •' `` -"'""" ' „ The structure is not intended or offered for sale(Section LOCALITY i ► t a ; 7044, Business and Professions Code.) MOVING TEL. t ❑ CONTRACTOR NO. I, as owner of the property, am.exclusively contractingb . f`' with licensed contractors to construct the project (Sec- - ADDRESS t tion 7044, Business and Professions Code.) z REQUIRED TOTAL SETBACK FROM'" dD"TTH CONSTRUCTION LENDING AGENCY SET BACK YARD ` HWY. PROP. LINE I hereby affirm that there is a construction lending agency for FRONT The erformance of the work forwhich this permit is issued P.L. P P (Sec. 3097, Civ. C.). SIDE Lender's Name p f Lender's Address P:C. Fee$ Permit FeeLDMA Ref. #1 certify that I have read this application and state that the �CG2 ' Issuance FeeLDMA P/C#above information is correct: I agree to complywith all County Investigation Fee6 ordinances and State laws relating to building construction, Total Fee f) aLDMA Perm. # and hereby authorize representatives of This County to enter upon the above-mentioned property•for inspection purposes. a SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent _ - Date WORKERS' COMPENSATION DECLARATION hereby affirm cI have a'certificate of consent to self APPLICATION FOR BUILDING PERMIT insur�,'or a certificate of Workers' Compensation Insurance, or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company BUILDING 1:1Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS BUILDING //�� ❑ Certified copy is filed with the county building inspec- ADDRESS J'i�/li tion department. Date Applicant CITY —, ` `` L ZIP C1 1-7 J'6_0 LOCALITY ppcaN F BLDGS. NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT X (�(�N ON LOT CROSS ST. COMPENSATION INSURANCE ASSESSOR (This section need not be completed if the permit is for one TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL hundred dollars ($100)or.less.) TEL. OWNER TEL , RAq,e NO.Z�(o-0 7 USE ZONE MAP NO. I certify that in the performance.of the work'for which this SPECIAL a permit is issued, I shall not employ any person in any manner ADDRESS ca ✓\e Yi CONDITIONS so as to become subject to.the Workers'Compensation,Laws. r 1 0 CITY t o 1 1 ZIP 1 / U Date Applicant ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY Q NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. CONST. ZONE F- Exemption, you .should become subject to the Workers' 0�/ a Compensation provisions of the Labor Code, you must forth- ADDRESS N with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION APT. CONDO. Z deemed revoked. CONTRACTOR NO. LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. DWELL. UNITS ADDRESS NO. I hereby affirm that I am licensed under provisions of Chapter 9 SEWER MAP (commencing with Section 7000)of Division 3 of the Business LIC. and Professions Code,and my license is in full force and effect. CITY CLASS BK PG VALIDATION SQ. FT. NO. OF NO. OF CHECK License Number Lic. Class SIZE - L STORIES FAMILIES ONE VALUATION Contractor Date DESCRIPTION OF WORK NEW ❑ �yy ADD $ '^�-yo - T LSI lJJ VV V V , ❑I am exempt under Sec. _ - ALTER ❑ B.BP.C. for this reason REPAIR ❑ $ Date: USE OF EXISTING BLDG. Qf� DEMM�01 ❑ Signature APPLICANT � `vt FINAL (PRINT)�jr NO.G c�7D OWNER-BUILDER DECLARATION 6_ DATE 1 hereby affirm that I am exempt from the Contractor's License ADDRESS d 1 I�-l ' FINAL Law for the following reason (Section 7031.5, Business and Professions Code): PRESENT BY - ❑ I, as owner of theproperty, or m em to employees with BUILDING' Y P Y ADDRESS wages as their sole compensation,will do the work and the structure is not intended or offered for sale(Section LOCALITY a 7044, Business and Professions Code.) MOVING TEL. I I, as owner of the property, am exclusive) contracting CONTRACTOR NO. _ P P Y, Y 9 3 � 4S 3 with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code.) REQUIRED TOTAL SETBACK FROM EXIST. -••-=• -_`-'= CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH I hereby affirm that there is a construction lending agency for FRONT GI)1*1uL a ''•I_t the performance of the work for which this permit is issued P.L. (Sec. 3097, Civ. C.). SIDE P.L. Lender's Name ;s / I }.I. j7 LDMA Ref. # i , P.C. Fee$ Permit Fee Lender's Address { 0 1 certify that I have read this application and state that the Issuance Fee ,57— LDMA P/C# , above information is correct. I agree to comply with al I County Investigation"Fee 19 / 0 ordinances and State laws relating to building construction, Total Fee �.7� LDMA Perm. # a and hereby outhorize representatives of this County to enter up n the above-mentio d property for inspection purposes. " r( SEE REVERSE FOR EXPLANATORY LANGUAGE ` Signature of Applicant or Ag Date 1� ® : , APPLICATION"FOR. BUILDING PERMIT COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS F;14, ESS I hereby affirm that I have a certificate of consent to self insure, � �S .Q or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec.3800,Lab.C.) CIF Z141-73-0 P 1� O � C",�1 LOCALITY Policy No. Company SIZE OF LOT NO.OF BLDGS.NOW ON LOT ❑ Certified copy is hereby furnished. S-D X 140 NEAREST CROSS ST. ❑ Certified copy is filed with the county building inspection TRACT BLOCK LOT NO. department. USE ZONE MAP NO. Date Applicant ASSESSOR MAP BOOK PAG PARCEL SPECIAL CONDITIONS CCss ��-=j OW41E TEL.NO. CERTIFICATE OF EXEMPTION FROM WORKERS' m �${q �j WITHIN 1000 FT.OF SCHOOL? YES NO COMPENSATION INSURANCE ADDRESS L^1 (This section need not be completed if the permit is for one hundred l�.1 DISTRICT GROUP TYPE CONST.' FIRE ZONE PROCESSED BY dollars($100)or less.) 1 certify that in the performance of the work for which this permit ( 110, (!�4i is issued, I shall not employ any person in any manner so as to ARCHITECT OR ENGINEER TEL.NO. V become subject to the Workers'Compensation Laws. STATISTICAL CLASSIFICATION PT CONDO Date Applicant ADDRESS CLASS NO —DS . WELL UNIT NOTICE TO APPLICANT. If, after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST Exemption, you should become subject to the Workers' CONTRACTORTEL.NO. SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith A1111 FRONT comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC.NO. PL SIDE a LICENSED CONTRACTORS DECLARATION CITY LIC.CLASS PL � I hereby affirm that I am licensed under provisions of Chapter 9 SEWER MAP SQ.FT SIZE NO.OF STORES NO. FAMILIES (commencing with Section 7000)of Division 3 of the Business and �. Professions Code,and my license is in full force and effect. NEW ❑ BK PG , v, CRIPTION OF W,OR ADD E]aDVALUATION License Number Lic.Class Contractor Date ALTER ❑ $ z r III ❑ I am exempt under Sec. t REPAIR $ ❑ h p t`v�S B.BP.C.for this reason 1 DEMOL ❑ LDMA P/C# Date: USE OF EXISTINP BLDG. URM ❑ Signature AP LICA RI T) TEL.NO. LDMA Perm# ❑ I, as owner of the property, or my employees with wages as v e Z?-(—ou z O their sole compensation,will do the work and the structure is A DRESS not intended or offered for sale (Section 7044, Business and C. a FINAL DATE Professions Code) WILL THE APPLICANT OR FUTUREeU INGOCCUPANTHANDLEAHAZARDOUSMATERIAL 7�f �L- J „ I, as owner of theproperty, am exclusive) contracting with OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN Y g THE AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY � _ N licensed contractors to construct the project (Section 7044, ❑ ' YES NO❑ p�(Q{/r/'C_f -.. Business and Professions Code.) WILL THE INTENDED USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING 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. ••p ",,__, • •t^ I hereby affirm that there is a construction lending agency for YES❑ NO❑ the performance of the work for which this permit is issued(Sec. = 4 t 3097,CIV.C. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD p� ). PERMITTING 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 Lender's Name HAZARDOUS MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD. a Lender's Address 0 t>NmEA OR ACsEP11' . o 1 certify that I have read this application and state that the above P.C. EE PERMIT FEE information is correct. I agree to comply with all county . Ordinances and State laws relating to building construction,and C hereby authorize representatives of this County to enter upon ISSUANCE FEE the e-mentio ed prope for inspection purpos s. c;:_, �j7 `t ��j � INVESTIGATION FEE TOTAL FEE Signature of Applka t or Agent lAto SEE REVERSE FOR EXPLANATORY LANGUAGE ►j