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Home My Public Portal About4904AGNES AVE_Building (10) APPLICATION FOR BUILDING PERMIT COUNTY OF LOS ANGELES ' BUILDING AND SAFETY WORKERS COMPENSATION DECLARATION FOR APPLICANT TO FILL IN - BUILDING ADDRESS I hereby affirm that I have a certificate of consent to self Insure BUILDING ADD ESQ A�� 99 or a certificate of Workers Compensation Insurance or a certified A copy thereof(Sec 3800 Lab C) I CITY ZIP Policy No !o!s yq a i — Company �� '�� PIE- SIZE IS L(fl q 17f3(� LOCALITY SIZE OF LOT NO OF SLOGS NOW ON LOT Certified copy is hereby furnished I NEARIM CROSSAT ❑ Certified copy is filed with the county building Inspection TRACT BLOCK LOT NO ` department ], USE ZONE MAP NO Date —15-VL Applicant I � /N ASSESSOR MAP BOOK PAGE PARCEL USE CONDITIONS CERTIFICATE CO COMPENSATION INSURANCE VIIORKERS ADDREOWNESS �NA 700k,ki TEL r'NC) 3 6//S YES NO i7(� WITHIN 1000 FT OF SCHOOL (This section need not be completed If the permit Is for one hundred ADDRESS O N A � i p A l DISTRICT GROUP TYPE CONST FIRE ZONE PROCESSED BY dollars($100)or less) I certify that In the performance of the work for which this permit CITY,' F GZIP / 9i1 c�SU V,rD� ✓ a IS issued I Shall not employ any person In any manner so as t0 ARCHITECT OR ENGINEE TEL NO '� :yr become subject to the Workers Compensation Laws STATISTICAL CLA SIFICATION APT CONDO Date Applicant ADDRESS - CLASS NO DWELL UNITS NOTICE TO APPLIC4NT If after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST Exemption you Should become Subject t0 the Workers CONTRACTS i ww A y Q SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code you must forthwith f/iT/u A/.7*5 comply with such provisions or this permit shall be deemed revoked ADDRESS 2 y� LIC N011// FRONT 1�-/7S �17�?7 PL i LICENSED CONTRACTORS DECLARATION SIDE CITY L LIC CL S _PL I hereby affirm that I am licensed underprovisions of Chapter 9 C�v C,T !7ola ^'2 S NO OF FAMILIES SEWER MAP (commencing with Section 7000)of Division FT SIZE NO OF STORIE lsion 3 of the Business and NEW ❑ BK PG — O Professions Code sal limnse Is In full force and effec License Nu- ei yEj7 / LIc Class C_ D CR TON 0 WORK ADD ❑ VALUATION Contractor n�HgSo�v Date 3—/ s— �/ ¢��/�'' C!�/ A, 3'�i1 ck $ ( — CD ALTER ❑ c) 150`E 1001F Lim; IVIF ?U [3REPAIR oL !'1 am exempt under Sec rn BBPC for this reason Cr1f`7'r�(,vAf'� ��V DEMOL ❑ Z 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 Z their sole compensation will do the work and the structure is ADDRESS ' C rt T a not Intended or offered for sale (Section 7044 Business and _ FINAL DATE Professions Code) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL ❑ I as owner of the property am exclusively contracting with �/ OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE �! ' 4 AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDES FINAL Y licensed contractors to construct the project (Section 7044 ES 1:1No 11 `" Business and Professions Code) YTi EIL 3 .,.. to 0 WALL THE INTENDED USE OF THE BUIDLING 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 I hereby affirm that there is a construction lending agency for YES 11 NO❑ N the performance of the work for which this permit is Issued(Sec CD 3097 Civ C) IHAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING ICHECKLIST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE — - Lenders Name TITLE 2 CHAPTER 2 20 SECTIONS 2 20 100 THROUGH 2 20 140 CONCERNING HAZARDOUS MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD 1 s o Lender s Address ° �Yn H'i L a s I- DWNER OR AGENT - o I certify that I have read this application and state under penalty r of perjury that the above Information i3 correct I agree to comply PC FEE PERMIT FEE N with all county ordinances and State laws relating to building construction and hereby authorize representatives of this County ISSUANCE FEE ro to eo upon the b mentioned property for inspection purposes G O fes;t :J INVESTIGATION FEE TOTAL FEE ? D � gV la I 1 D t 7- J SEE REVERSE FOR EXPLANATORY LANGUAGE