HomeMy Public PortalAbout4904AGNES AVE_Building (9) r r
APPLICATION FOIR BUILDING�PERJMIT
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_ ^ ' COUNTY OF LOS ANGELES _ �i BUILDING AND SAFETY t
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n WORKER SeCOMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDIN ADORES
I hereby affirm that I have arcertificate of consent self Insure BUILD NG ADDRESS ���5 "'¢ + / y i
or a certificate of Workers Compensation jInsurance or a certified
copy„thereof(Sec 3800 Lab C) ' CITY C�n ZIP 1
r �rj` kK L 4 r LOCALITY tr t
Policy;No` ' Company , SIZE OF LOT It NO OF BLDGS NOW ON LOT
❑ Certified copy s hereby furnished / ' + r NEAREST CROSS ST
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the
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ertif ed copy,is filed with the county building Inspection TRACT j BLOCK LOT NO
department , USE ZONE MAP NO ,
`^ 1 ASSESSOR MAP BOOK PAGE PARCEL ; e
Date Applicant
SPECIAL CONDITIONS /J _ O/
t `CERTIFICATE OF"EXEMPTION FROM WORKERS OWNER TEL NO ,s S (fir ,
COMPENSATION INSURANCE + � A �U if
�g WITHIN 1000 FT OF SCHOOLS YES # NO a
(This section need not be completed If the permit Is for one'hundred ADDRESS �� G5 -
dollars($100)`or less) �i DISTRICT GROUP TY E CONST FIRE ZONE PROCESSED(3Y
tP-Ir- + I D!/ -31
I certify that In the performance of the work for which this permit CITY ZIP
e �� C
Is Issued I"shall not employ any person In any manner so asltoe
r ARCHITECT OR ENGINEER �TEILN-01
become subject to the Workers CoSTATISTICAL CLASSIFICATION y APT 1 CONDO
Corn anon L � ,
Date 34Applicant ADDRESS , CLASS NO, A DWELL ITS �
Js NOTICE i TO APPLICANT If after making,thl Certificate of e 'REQUIRED + TOTAL SETBACK FROM n EXIST
t Exemption you should 'become subject to the Workers NTRACTORn 1 TEL NO SET BACK YARD HWY t PROP LINE WIDTH r
L Compensation pToviswns of�the Labor"Code you must forthwith �� C CJS t NC ft -74-q-Z&O5, FRONT
comply,with'such provisions or this permit shall be deemed revoked ADDRESSLIC NO PL
a . } LICENSED4�CONTRACTORS DECLARATION, Z$ W o � 'j B(.u0, 3 Zt SIDE -
CITY "FfSpq 0 LIC CIS PL V
I hereby affirm that I am licensed underprovlsions of Chapter 9 /��IF'f"� SEWER MAP,
(commencing withlSection 7000)of Division 3 of the Business and SO FT SIZE NO OF STORIES NO OF FAMILIES-
Professions ❑ " + r
Professions Code and my license Is in full force*and BK PG ieeffect 0O
License Number 312-144 LIC Class I7 t DESCRIPTION OF WORK r „ ADD ❑ VALUATION I ' #U
Contractor fL� (EiZe�Gala e` f(���a g. 6 g5 (� � ALTER 'K $ 3 a.
_ P y (n
❑ 1 am exempt under Sec ; #s 1 REPAIR ❑ $@ i Z
� � W
B&PC forAthis reason r - DEMOLI ❑ +
> x LDMA P/C•
Date USE OF EXISTING BLDG + URM ❑
Signature t �*
Ir SAPPLICANT(PRINT) TEL NO LDMA Perm r
❑ I'-as owner of the property,or my employees with wages as If f „ Z ` �tyC T.S ,L1 a r
their sole compensation will do the work and the structure is ADDRESS , I O
"riot Intended or offered for sale (Section 7044 Business and FINAL DATE � t a _ LTJ
Professions Code) r +
44 WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL Z'� f ? N I FEN:- -
El I as owner of the y y g OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE
a property am exclusive) contracting with AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE1 FINAL BY
Ilcensed contractors,to construct the project /Section 7044 , x TI 17A!-A!- r -a' ® '0
VES❑ NO❑
Business and Professions Code)F {�( 'jl
J + WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING {LlEO T * 1-,2 :31
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH
CONSTRUCTION LENDING AGENCY COAST AIR DUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST AORti t HN�� ro
GUIDELINES i' G 4.1
n
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 c I? + i a
I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING -f
3097 CIV C) , r 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 HAZARDOUS
Lenders Name w MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THEISCAOMD J +
it Lenders AddressJ a P i 1 L c t
M µr OWNER OR AGENT
I certify that I have read this application and state under penalty ` _s
p of perjury that the above Information Is correct I agree to comply PC FEE .. r `PERMIT FEE 1 O r, "1� ! k
rn with all county ordinances and State laws relating to building
m r cons Wiopand hereby a raze (@presentatives of this County ISSUANCE FEEo
to eb pro rt for inspectlopur oses lJ i +- ` • . 1 t
g ��
1 Ag.-2r INVESTIGATION FEE + s "TOTAL FEE
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