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Home My Public Portal About5117AGNES AVE_Building (8) APPLICATION FOR BUILDING PERMIT COUNTY OF LdS ANGELtS BUILDING AND SAFETY WORKER S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN A BUILDING ADORES �/�' `-' C� C v I hereby affirm that I have a certificate of consent to self Insure BUILDING ADDRESS r/ or a certificate of Workers Compensation Insurance or a certified copy thereof (Sec 3800 Lab C) I E G/T ZI�>/7�D LOCALITY Policy No Company SIZE OF LqT J NO OF BLDGS NOW ON LOT ❑ Certified copy Is hereby furnished 6p X 123 AIE� NEAREST CROSS ST_ ❑ Certified copy Is filed with the county building Inspection TRACT U' BLOCK LOT NO department 1 USE ZONE MAP -Al,ry Date Applicant ASSESSOR MAP BOOKgS�� PAGEOD p PARCELDD O`er 9 DO ® / SPECIAL CONDITIONS /�!/ CERTIFICATE OF EXEMPTION FROM WORKERS OWNER TEL NO _ _ - V_ D / COMPENSATION INSURANCE r a' 29 —0/Z 1 WITHIN 1000 FT OF SCHOOL; ves No x (This section need not be completed If the permit Is for one hundred ADDRESS- , D KESS_, 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 CITVz— �`Zt /zfp�_ Is Issued I shall not employ any person In any manner so as to C•' v� become subject to the Workers omp n W ARCHITECTOR ENGINEER TEL NO 9 STATISTICAL CLASSIFI,ATION APT CONDO Dat —6L Appllcan ADDRESS CLASS NO BULL // DWELL UNITS NOTICE TO APPLICANT rafter making this CertiflC t2 Of REQUIRED TOTAL SETBACK FROM EXIST Exemption you should become Subject t0 the Orkers 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 LIC NO P L SIDE LICENSED CONTRACTORS DECLARATION CITY LIC CLASS PL I hereby affirm that I am licensed underprovisions of Chapter 9 SEWER MAP CL (commencing with Section 7000)of Division 3 of the Business and SQ FT IZE NO OF STORIES --NO OF FAMILIES Professions Code and my license Is In full force and effect [/LhAV�(/G NEW �❑! BK PG O DESCRIPTION O WORK VALUATION License Number LIc Class ADD o 1k71+P'0/T/ON �l41 Date L� Contractor ALTER ❑ $ v W CL ❑ I am exempt under Sec REPAIR El $ z B&PC for this reason DEMOL ❑ LOMA P/C# Date USE OF EXISTING BLDG�/�� /5 URM ❑ _ F . 4 Signature APPLICANT(PFVN ) T� O LDMA Perm# a ❑ I as owner of the property or my employees with wages as T v ; �� Z their sole compensation will do the work and the structure is A KESS O y 1 g not Intended or offered for sale (Section 7044 Business and �� G/Tt FINAL DATE Q __ �j Professions Code) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL R'I � -'' lY,l I as owner Of the property am exclusive) contract) OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE p pe y y ng with AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDES FINAL BY licensed contractors to construct the project (Section 7044 YES❑ No Business and Professions Code) N -tet/ I F 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 AlR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING GHECKL ST FOR GUIDELINES 7 L I hereby affirm that there Is a construction lending agency for YES ElNO!� j ' _ T T ,-1 N the performance of the work for which this permit Is Issued(Sec 01 I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING 3097 Civ C) CHECKLIST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODEa- TITLE 2 CHAPTER 2 20 SECTIONS 2 20 100 THROUGH 2 20 140 CONCERNING HAZARDOUS Lender s Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD LEE k ! } y o Lenders Address - OWNER OR AGENT .- o I certify that I have read this application and state under penalty O of perjury that the above Information Is correct I agree to comply PC FEE 0 �� PERMIT FEE N with all county ordinances and State laws relating to building CO c.0.struction and hereby authorize representatives of this County ISSUANCE FEE co to enter�u on h ed property for Inspection purposes ID / / INVESTIGATION FEE TOTAL FEE ? / / L` I_ .t i'it ^\, Sg tt/ App t 1 �(1A SEE REVERSE FOR EXPLANATORY LANGUAGE