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Home My Public Portal About5021AGNES AVE_Building (2) i t APPLICATI®MFC:R BUILDING PERMIT COUNTY OF LOS ANGELESt BUILDING AND SAFETY WORKER S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS �O / I hereby affirm that I have a certificate of consent to self Insure BUILDING ADDRESS or a certificate of Workers Compensation Insurance or a certified WIZ 5 - copy thereof(Sec 3800 Lab C) CITy ZIPq ` mI ! � LOCALIT Policy No Company SIZE OF LOr NO OF BLDGS NOW ON LOT L ❑ Certified copy Is hereby furnished NEAREST CROSS ST ❑ Certified Copy Is flied with the county budding Inspection TRACT BLOCK LOT NO ' department USE ZONE MAP NO ` Date Applicant ASSESSOR MAP BOOK PAGE PARCEL v SPECIAL CONDITIONS a CERTIFICATE OF EXEMPTION FROM WORKERS ow TEL NO COMPENSATION INSURANCE £L elf 0?Vs Z61 WITHIN 1000 FT OF SCHOOL? YES No (This section need not be completed If the permit Is for one hundred ADDRESS ` DISTRICT GROUP TYPE CONST FIRE ZONE PROCESSED BY dollars 1$100)or less) G I certify that in the performance of the work for which this permit r Is Issued I shall not employ any person In any manner so as to CITY L£ ^ ` i ZIP C� D 0 Lr �`3 become subject to the Workers Compensation Laws ARCHITECT O ENGINE R TEL NO 5r', V STATISTICAL CLASSIFICATION APT CONDO Date Applicant ADDRESS CLASS NO DWELL UNITS NOTICE TO APPLICANT If after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST Exemption you should become subject to the Workers CONTRACTOR -TEL NO- SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code you must forthwith FRONT comply with such provisions or this permit shall be deemed revoked ADDRESS I LIC NO - PL LICENSED CONTRACTORS DECLARATION USIDE CITY C 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 FjT.� NO OF ST RIES NO OF�AMILIES NEW ❑ BK PG Professions Code and my license Is in will force and effect {�® a License Number Llc Class DF4CRIPTION OF WORK `�� (�•i(}� ADD ❑ VALUATION g Q W 1 (iNF�, $ p U Contractor Date ALTER L cc ❑ I am exempt under SecREPAIR El $ 0 B&PC for this reason DEMOL ❑ LDMA P/C# W Date USE OF EXISTING BLDG URM ❑ d ` 'SI nature�y � / AP ANT(PRIJT) M ^ ` G TEL NO _ Z LDMA Perm 0 0 f 1 Z as owner of the property or my employees with wages as LI L` Z their sole compensation will do the work and the structure Is ADDRESS j c O ACCLAT not Intended or offered for sale (Section 7044 Business and U /7 /�G S FINAL DATE Q Professions Code) —Z—�� 303 92. 9 WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE C1 I a5 owner Of the property am exclusively contracting with AMOUNTS SPEGFI DON THE HAZARDOUS MATERIALS INFORMATION GUIDES Q licensed contractors to construct the project (Section 7044 l�.! FINAL BY > 1 ITEMS GM7 Business and Professions Code) WILL ❑ No TI ITtAI 92 -25 WILL THE INTENDED USE OF THE BUIDUNG BY THE APPLICANT OR FUTURE BUILDING +,ti t OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH 1 9 7C CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FOR Chet N7 as GUIDELINES thI hereby affirm that there Is a construction-lending agency for YES❑ NO'fig- CHANGE •00 N e performance of the work for which this permit Is issued(Sec I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING 3097 Civ C) N CHECKLIST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE � f 3 TITLE 2 CHAPTER 2 20 SECTIONS 2 20 100 THROUGH 2 20 140 CONCERNING HAZARDOUS i WOQ^aoo �, /^`r � Lenders Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD $ Lenders Address O O 2203 1 PM 5:21 WNER OR AGENT o I certify that I have read this application and state under penalty 0 of perjury that the above Information IS correct I agree to comply PC FEE PERMIT FEE i with all county ordinances aAStatews relating to building co cons uCtlon rid hereby authontatlVeS of this County ISSUANCE FEE to e r up he;pbove ment for Inspection purposes 3o s �V INVESTIGATION FEE TOTAL FEE r sg f Aad Ape I G, l f SEE REVERSE FOR EXPLANATORY LANGUAGE 1