HomeMy Public PortalAbout5226AGNES AVE_Building APPLICATION FOR BUILDING PERI-IT
COUNTY OF LOS ANQEL`ES: BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS
I hereby affirm that I have a certificate of consent to self insure, BUILDIN D R S
or a certificate of Workers' Compensation Insurance,or a certified
copy thereof (Sec.3800, Lab. C.) CITY ZIP S�
LOCALIT�
Policy No. Company SIZE OF LOT NO.OF BLDGS.NOW ON LOT
El Certified copy is hereby furnished. IOC/ V I 7 .3 NEAREST CROSS ST.
❑ Certified copy is filed with the county building inspection TRACT ^ BLOCK LOT NO�. w/A
department. /�9.6 rte' c.�tJ USE ZONE MAP NO.
Date Applicant ASSESSOR IOAP BOOK PAGE PPAARCEL
Jam" SPECIAL CONDITIONS �� n ^/
CERTIFICATE OF EXEMPTION FROM WORKERS' OWN TEL NO. fl U
COMPENSATION INSURANCE tl D WITHIN 1000 FT.OF SCHOOL? YES No
(This section need not be completed if the permit is for one hundred ADDR S
DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY
dollars ($100)or less.) .f
_ Q
I certify that in the performance of the work for which this permit CITY ZIP
f176 0 �O�
is issued, I shall not employ any person in any manner so as to
become Subject t0 the Workers'Compensation Laws. ARCHITECT OR NGINEER TEL NO.
STATISTICAL CLA SI;YATION �/ APT CONDO
O.
Date Applicant ADDRESS CLASS NDWELL 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 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.F $IZ NO.OF STORIES NO.OF FAMILIES
Professions Code,and my license is in full force and effect. (/p NEW 04 BK PG
License Number Lic.Class DESCRIPTION OF WORK ADD ❑ VALUATION , O
Contractor Date ALTER ❑ $C;V/ Aev` C9a
cc
❑ I am exempt under Sec. REPAIR ❑ $ 0
BAP.C.for this reason DEMOL ❑ V'
LDMA P/C# W
Date: USE OF EXISTING BLDG. URM ' ❑ a-
�+ Signature APPLICJT JPRINT) �D TEL O. LDMA Perm# Z Z
171 I, as owner of the property, or my employees with wages as a
their sole compensation, will.do the work and the structure is ADDRESS ��+ O
not intended or offered for sale (Section 7044, Business and , • Aile, FINAL DATE
Professions Code.) — l tp-�14p -J } 4_J }
WILL THE APPLICANT OR FUTURE LDING OCCUPANT HANDLE A HAZARDOUS MATERIAL J OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE
C1ff
I, as owner of the property, am exclusively Contracting with AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY t I .i.'I=}i
licensed contractors to construct the project (Section 7044, YES❑ NO❑
Business ac d Professions Code.) 1 s!rryE c
WILL 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(SCAQMD)SEE PERMITTING CHECKLIST FOR t-H4K_t_ 427.r,r
GUIDELINES.
I hereby affirm that there is a construction lending agency for YES❑ No❑ C.-HAb G-) _; I
N the 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.) 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
Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD. { II}jt[•_j�j};j? }•+ :-c
dE._S�i•} }.}
o Lender's Address i tEt} Lj
0 OWNER 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 P.C.FEE PERMIT FEE v�
with all county ordinances and State laws relating to building
m construction, and here5��nred
e representatives of this County ISSUANCE FEE Q
_ � �p•e t r upon the b prop �for inspectio pur ses.
INV
7 /
INVESTIGATION FEE TOTAL FEE �-
ature of Applicant pent Date
SEE REVERSE FOR EXPLANATORY LANGUAGE