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HomeMy Public PortalAbout5732AGNES AVE_Building (2) APPLICATION FOR BUILDING PERMIT COUNTY OF LOS ANGELES 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, BUILDING ADDRESS or a certificate of Workers' Compensation Insurance,or a certified Y, LOCALITY copy thereof (Sec.3800,Lab.C.) CITY C M D ZIP pl Q C v Policy No. - Company SIZE OF LOT i- NO.OF BLDGS.NOW ON LOT �JJL ❑ Certified copy is hereby furnished. SS NEAREST CROSS V. ❑ Certified copy is filed with the county building inspection TRACT BLOCK LOT NO. department. USE ZONE MAP NO. Date Applicant ASSESSOR MA BOOK PAGE n PARCEL S '� Q l ® SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER _/yam TEL NO, COMPENSATION INSURANCE, e WITHIN 1000 FT.OF SCHOOL? YES NO This section need not be completed if the permit is for one hundred ADDRESS ( P p � �L DISTRICT GROUP TYP CONST. FIRE ZONE PROCESSED BY dollars($100)or less.) CITY LC City ZIP o `�� J� � ��/ I certify that in the performance of the work for which this permit d�j is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws. ARC ITECT O ENGINEER TEL NO. p wye I^ STATISTICAL CLASSIFICATION APT CONDO Date Applicant ADDRESS CLASS NO. �2 Z_ 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 p 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. PL 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 ZE NO.OF STORIES NO.OF FAMILIES Professions Code,and my license is in full force and'effect. I two NEW BK PG ► License Number Lic. Class DE CRIPTION OF WORK ADD ❑ VALUATION ADADO j Contractor Date ALTER ❑ $ f ?©� t' L-�1 2.Co�C rfY ❑ 1 am exempt under Sec. REPAIR ❑ $ ::�:.3 oT.-. F BAP.C.for this reason DEMOL ❑ ��;( h.:�ta�..1 LDMA P/C# L Date: USE OF EXISTING BLDG. URM ❑ 1 !TEMS Signature HA APPLICANT PRINT TEL NO. LDMA Perm# - — ° —'� I gyp. 7 LD�Z, Z ?[ITrtL - e, _, rkl, as owner of the property, or my employees with wages as _, ii 5 their sole compensation, will do the work and the structure is ADDRESS Azle) j ( �.,,• t•�'f a i•1 not intended or offered for sale (Section 7044, Business and 7 ( CII 7 FINAL tt�� ``'� Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A H ZARDOUS MATERIAL J ❑ OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE Q I, as owner of the property, am exclusively contracting 4AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL licensed contractors to construct the project (Section 70444,, Business and Professions Code.) YES❑ No'011 —`ZY t(01-1_I=00 j 7 1`22/Of WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING _ OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH r {. w{{j a 7 CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR //,� �} ��y/ GUIDELINES. y °/ /4� ... I hereby affirm that there is a construction lending agency for YES❑ No' � N the performance'of the WOfk for which this permit IS ISSUed(.SBC. IHAVE READTHE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING 3097,Civ.C.) CHECKLIST.I UNDERSTAND MY REQUIREMENTS UN R THE LOS ANGELES COUNTY CODE, TITLE 2,CHAPTER 2.20 SECTIONS 2.20.1 0 THRO GH 2.20.140 CONCERNING HAZARDOUS Lender's Name MATERIALS REPORTI GAN OR TAI NG A P MIT FROM THE SCAQMD. o Lender's Address OWNER OR AGENT O 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 P.C.FEE PERMIT FEE With all county ordinances and St?e laws relating to building Construction, and hereby But oriZe presentatives of this County ISSUANCE FEE CO to enter upon the abo - non roperty for inspection purposes. a `'� •,.. �� INVESTIGATION FEE TOTAL FEE SgnaNre OI ApplifAnl or A- Da�B 3 . 3 SEE REVERSE FOR EXPLANATORY LANGUAGE