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HomeMy Public PortalAbout5015AGNES AVE_Building (2) J- APPLICATION FOR BUILDING PERMIT COUNTY OF LOS-ANGELES BUILDING AND SAFETY WORKER S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUIL IN�Dp Ss I hereby affirm that I have a certificate of consent to self Insure BUILD]��D SS/v d 4N t�S or a certificate of Workers Compensation Insurance or a certified copy thereof (Sec 3800 Lab C) CITl�Y e ZIP7 f� n' LO ALIT Policy NO Company SIZE OF LOT NO OF B`LDGS NOW ON LOT ❑ Certified copy Is hereby furnished / NEAREST CROSS S ❑ Certified copy IS filed with the county building Inspection TRACT BLOCK LOT NO department USE ZONE MAP NO Date Applicant ASSESSOR MAP BOOK PAGE PARCEL c SPECIAL CONDITIONS &� — ` CERTIFICATE OF EXEMPTION FROM WORKERS QWNTNoH�s©N TEL NO �J COMPENSATION INSURANCE Ap1� WITHIN 1000 FT of SCHOOL? ves No (This section need not be completed If the permit Is for one hundred ADDR S 0�i DISTRICT GROUP /' - dollars ($100)Or less) O/T d NGC C' TY CONST FIRE ZONE PROCESSED BY 1 certify that in the performance of the work for which this permit CIT�H /�1 TU ZIP /7 4"0, of Is Issued I shall not employ any person in any manner s0 as t0 ARCHITECT OR ENGINEER 7 - TEL NOQ v Ir �� become subject to the Workers Compensation Laws STATISTICAL CLASSI KATION APT CONDO Date Applicant ADDRESS 4 CLASS N( DWELL UNITS NOTICE TO APPLICANT If after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST Exemption you should become subject t0 the Workers CONTRACTaR� �� TEL NO SET BACK YARD HWY PROP LINE WIDTH x' Compensation provisions of the Labor Code you must forthwith /V/ 'n FRONT comply with such provisions or this permit shall be deemed revoked ADDRESS LIC NO P L LICENSED CONTRACTORS DECLARATION SIDE CITY LIC CLASS P L I hereby affirm that I am licensed underprovisions of Chapter 9 SEWER MAP (commencing with Section 7000)of Division 3 of the Business and SQ FT SIZE NO OF STORIES NO OF FAMILIES Professions Code and my license Is In ull force and effect NEW BK PG DES IPTION F W K VALUATIO License Number Llc Class ' Y� , ADD ❑ $ �J ftOO w O� 0 Contractor Date / ALTER ❑ t/J L� cS � Cer "9 cc El REPAIR 1:1 $ OO I am exempt under Sec 1� ,r B&PC for this reason S14"TJ DEMOL ❑ LDMA P/C# W Date USE OF EXISTING BLDG URM ❑ Signature APPLICANT(PRINT) TEL NO LDMA Perm# ❑ I as owner of the property or my employees with wages as ZT their sole Compensation will do the work and the structure Is ADDRESS O fjt t 1 g 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 OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE ElI as owner of the property am exclusively contracting with AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDES FINAL BY // �� — i CG licensed contractors to construct the project (Section 7044 Business and Professions Code) YES 1-1 No El �? =�t�� WILL THE INTENDED USE OF THE BUIDUNG BY THE APPLICANT OR FUTURE BUILDING _ OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH CONSTRUCTION LENDING AGENCY COAST AIR QUAUTY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR GUIDEUNES I hereby affirm that there is a construction lending agency for YES❑ No❑ i EIS 7�IJ N the performance of the work for which this permit is issued(Sec MAI rn I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING l ! 1 N 3097 CIV C) 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 MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD o Lenders Address 7 -/:)z' O OMER OR AGENT I{i 00 JG.L o I certify that I have read this application and state under penalty o PC FEE PERMIT FEE of perjury at the b Lationorrect I agree to comply -4'o rll� yiwith all oudl ncelaws relating to building 00 constr on h eby asentatives of this County ISSUANCE FEEto ente upo a ve mey for Inspection urposes / yA INVESTIGATION FEE TOTAL FEE SEE REVERSE FOR EXPLANATORY LANGUAGE T