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HomeMy Public PortalAbout6042 AGNES AVE_Building__ 2-3 APPLICATION FO' IEI�.LDING PERMIT � �.. COUNTY OF LOS ANGE39 .. ,,•�:.1BUILDING AND SAFETY FOR APPLICANT TO FILL IN "' BUILDING ADDRESSI WORKER'S COMPENSATION DECLARATION � � BUILDING ADDRESS r� a I hereby affirm that I have a certificate of consent to self insure, . V or a Certificate of Workers' Compensation Insurance, or a certified copy thereof(Sec.38 0,Lab C.) CITY ZIP �h LOCALITY C �, Policy No. Company SIZE OF L T NO.OF BLDGS.NOW ON LOT El Certified copy is hereby furnished. I 0 fJ� NEAREST CROSS ST. r ❑ Certified copy is filed with the county building inspection TRACT BLOCK LOT NO. department. 014> ^ J I� ®(, USE ZONE, MAP NO. �O �9 / Date ��APPlicant T. V b°'�J� / INr� ASSESSOR MAP BOOK sly PAGd� PARCEL � � / To SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER TEL NO. COMPENSATION INSURANCE j WITHIN 1000 FT.OF SCHOOL? YES No (This section need not be completed if the permit is for one hundred ADDRESJ DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY dollars ($100) or less.) I Y I certify that in the performance of the work for which this permit ZIP Hrs� is issued, I Shall not employ any person in any manner So as t0 CH. TOR NGIN NO. ' ©f become subject to the Workers'Compensation Laws. �) i STATISTICAL CLASSIFICATION AC TTS CONDO Date Applicant ADDR SS l CLASS NO. d DWELL UNITS / NOTICE TO APPLICANT.' If, after making this Certificate Of REQUIRED TOTAL SETBACK FROM EXIST °+ Exemption, you should become Subject t0 the Workers' CONTRA TOR TEL NO. SET BACK YARD HWY PROP LINE j — WIDTH Compensation provisions of the Labor Code, you must forthwith � FRONT comply with such provisions or this permit shall be deemed revoked. ADDRESS L C.N0. �P P L f iiL e GI SIDE r+ LICENSED CONTRACTORS DECLARATION L^ '_FES T =t�•`. 1'_j CITY LIC.CLASS P L I hereby affirm that I am licensed underprovisions of Chapter 9 SEWER MAP :,,tt_�., L,• °3S! (commencing with Section 7000)of Division 3 of the Business and SQ.FT.SI E NO.OF STORIES NO.OF FAMILIES /� / Professions Code,and my license is in full force and of t NEW BK PG !1i , ;_.�..�t;;��•�i�E °C1;; a License Number Lic.Class SCRIP OF WOf ADD ❑ VALUATION l� . . Q p� /� U Contractor�� d+41,iT N/ ate : ALTER El $ � `��• i l 13 01-I 4F i i 1 r �:',''= O REPAIR ❑ 8 y: ❑ I am exempt under Sec. � 0"1,, r - f'!. V B.BP.C.for this reason DEM( ❑ LDMA P/C# W Date: USE OF EXISTING BLDG. URM ❑ CO Signature APPLICANT(PRINT) TEL NO. LDMA Perm# 23, z i�.f '' ❑ I, as owner of the property, or my employees with wages as Z g their sole compensation, will do the work and the structure is ADDRESS O tiC �T■a not intended or offered for sale (Section 7044, Business and ^^1, FINAL DATE. Q ?� tr; Professions Code.) `\ �'=� U347; AL 2255°6'� M WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL ❑ 1, as owner of the property, am exclusively contracting with i OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE _— J r ,y j ITEMS AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? '"•'" ` Q' !' 1 1 i S licensed contractors to construct the project (Section 7044, i. FINAL BY ,.,,,,�'•q; > _0Q+� Business and Professions Code.) VES❑ NO❑ VITAL r+�i cr 4 WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING i ° OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH _ X [{ [J— rSriCC CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR -, CHEQK GUIDELINES. I hereby affirm that there is a construction lending agency for YEs❑ No❑ CHANGE a the performance of the work for which this permit is issued(Sec. - p� I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING 3097,CIV.C.) CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, TITLE 2,CHAPTER 2.20 N Lender's Name MATERIALS REPORTING AND FORSOBTAINING2.20.100 TA PERMIT T FROM THE HROUGH 2.20,140 CONCERNING G HAZARDOUS 00013-011301 •y01-1 —1 !i 2 `/±�/ 1 J 1 T 6 /� °: I o Lender's Address t OWNER OR AGENT J�}`}y 1 A °��, o I certify that I have read this application and state under penalty of perjury that the above information is correct.I agree to comply P.C.FEE ^ G,57- PERMIT FEE with all county ordinances and State laws relating to building G 00 construction, and hereby authorize representatives of this County ISSUANCE FEE �. to enter upon t above- ntioned property for inspection purposes. • � s m INVESTIGATION FEE TOTAL F Sgal-,¢oAp A9enl / Q c SEE REVERSE FOR EXPLANATORY LANGUAGE /