HomeMy Public PortalAbout5227AGNES AVE_Building (4) APPLICATION FCS ' BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDIN(yAq Ess
I hereby affirm that I have a certificate of consent to self insure, BUIL !Ry KESS
or a f l�—
ca�A
certificate of Workers' Compensation.Insurance,or a certified CAY%A
t copy thereof (Seo 3800,Lab.C.). CITY. - ZIP,
° LOCALITY
Policy No. Company SIZE OF-LON t NO.OF BLAGS.NOW ON LOT
❑ Certified copy is hereby furnished. Sr [ L_ NEAREST CROI S
❑ Certified copy is filed with the county building inspection TRACT BLOCK LOT NO. �}
department. USE ZONE �PNASSESSOR MAPBOOK PAGE PARCEL
Date Applicant ONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' QWN YES NO
T�L, Q,
COMPENSATION INSURANCE !/N`'�v�� WITHIN 1000 FT.OF SCHOOL?
(This section need not be completed if the permit is for one hundred ADD,— ,
DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY
dollars ($100)or less.) l�
CITY/J,� ZIP e j V n
I certify that in the performance of
'the work for which this permit ( G� ( !z:[ lJG/� �
i J
is issued, I Shall not employ any per in any mann SO as t0 ARCHITECT ENGINEER TEL NO.
become Sub{I t t0 t Workers'CO nS�atlOn Laws. STATISTICAL CLASSIFICATION v APT CONDO
Date�_�J� Applicant ADDRESS CLASS NO.: DWELL UNITS
NOTICE TO APPLICANT If, -after maki this Certificate Of REQUIRED TOTAL SETBACK FROM EXIST
Exemption, •you Should become subject t0 the Workers' CON ACTOR TEL [� SET BACK YARD HWY PROP LINE WIDTH
Compensation-provisions of the Labor Code, you must forthwith r; FRONT
comply with,such provisions or this permit shall be deemed revoked." ADD SSSS LIQ.NO&)3 PL
LICENSED CONTRACTORS DECLARATION O' (Q SIDE
CIT --: LIC.GLASS PL
I hereby affirm that I am licensed underprovisions of Chapter 9 C^ 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 license is in full force and ffect. NEW BK PG ® a
License Number 0�> Lic.Class DESCRIPTION OF WOR ADD ❑ VALUATION /�_ C� Q
Contractor Date
t?.. P ALTER ❑ s® ,l U
h0
cc
El am exempt under Sec. `J REPAIR ❑ $ �
BAP.C.for thisre on DEMOL ❑ LDMA P/C# W
Date: USE OF EXISTING BLDG. URM ❑
SignatureAPPLICANT(PRINT) TEL NO. LDMA.Perm# Z
❑ I, as owner of the propert my employees with wages as Z
their sole compensation, will do the work and the structure is ADDRESS O
'FINAL DATE
not intended or offered for sale (Section 7044, Business and
Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL ` �,S _
OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE J is .e•-
❑ I, as owner of the property, am exclusively contracting with AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY } Y-••_�'• F m O
licensed contractors to construct the project (Section 7044, YES❑ No❑
Business and Professions Code.) = -' -
WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH L -""•
CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FORv'-
GUIDELINES.
I hereby affirm that there is.a construction lending agency for YES❑ NO y )�
w the performance Of the Work for which this permit IS ISSUed(Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING -'i.
O1 3097,CIV.C.) CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE,
N TITLE 2,CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING HAZARDOUS { -
3 Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD.
EL Lender's Address
OWNER OR AGENT
O
o1 certify that I have read this application and state under penalty
S P.C.FEE PERMIT FEE
of perjur that the above information is correct.I agree to comply
o With all
l county ordinances and State laws relating to building /
a cons ion and hereby horize re entatives of this County ISSUANCE FEE
m
o) to ent n t above- ned perty for insp .tion
m [l�7
< - INVESTIGATION FEE TOTAL FEE I'
i
n r�syoar APPI—t or Age o e
+` SEE REVERSE FOR EXPLANATORY LANGUAGE