HomeMy Public PortalAbout5739AGNES AVE_Building ICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING/�DDD�tESS
I hereby affirm that I have a certificate of consent to self insure, BUIL D cz:•J[_J�
or a certificate of Workers' Compensation Insurance, or a certified
copy thereof(Sec. 3800,Lab.C.) ` ZI
LOCALITY _
Policy No. Company4S`�v SIZE OF LOT NO,OF BLDGS.NOW ON LOT
erhfied CO tEAREST CROSS ST.
B'G� copy is hereby furnished.❑ Certified copy is filed with the count building inspection TRACT BLOCK LOT NO.
department. SE ZONE MAP NO.
Date Applicant r ASSESSOR MAP BOOK PAGE PARCEL
SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FR ORKERS' o N TEL oS
COMPENSATION INSU N WITHIN 1000 FT OF SCHOOL? YES NO
(This section need not be completed if the p it is for one hundred ODR
DISTRICT GROUP TYP CONST. FIRE ZONE PRO ESSED BY
dollars ($100) or less.)
Y \ f
I certify that in the performance of the work for which this permit ZIP e C;
is issued, I shall not employ any person in any manner so as to
become Subject to the Workers'Compensation Laws. ARCHITECT O ENGINEER TEL NO.
STATISTICAL CLASSIFICATION APT CONDO
Date Applicant ADDRESS CLASS NO. 42) 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 �— T 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. ADD S LIC PL
LICENSED CONTRACTORS DECLARATION L SIDE
Y LI LAS 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 SO.FT.SIZE NO.OF STORIES NO.OF FAMILIES
NEW ❑ BK PG a
Professions Code,a d �e {gjll force effe� ,
License Number v cL�! Class DESCRIPTION OF WORK ( ADD ❑ VALUATION Q
Contractor v �.S Date — ` ALTER ❑ $ 16511 OWD,
El am exempt under Sec. `,t REPAIR ❑ $ F-
B.&P.C. for this reasonEMOL ❑ LDMA P/C# W
Date: USE OF EXISTING DG.BLD y� URM ❑ i co
Signature APPLICANT(PRINT) / TEL NO. LDMA Perm# Y Z
ACCT.4
El 1,I, as owner of the property, or my employees with w es a 7 t
their sole compensation, will do the work and the stru ure is ADDRESS O 3303 276.45
not intended or offered for sale (Section 7044, Business and FINAL DATE �_ ITEMS
Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL
OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE J
❑ 1, as owner of the property, am exclusively contracting With AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL B > TOTAL 276- 45
licensed contractors to construct the project (Section 7044,
Business and Professions Code.) VES El NO 1:1 CHECK 276.45
WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH CHANGE
a�4
CONSTRUCTION LENDING AGENCY GUIDE AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR 1rf�ANG
GUIDELINES.
I hereby affirm that there is a construction lending agency for YES❑ NO❑
N the performance of the work for which this permit is issued(Sec.
5/95O� [HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING 0000-0001 g/
3097, CIV.C.) CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, L
Lender's Name MATERIALS REPORTING AND FOR OBTAININGTITLE 2,CHAPTER 2.20 SECTIONS 2.20.100 PERMIT FROM HE HROUGH 2.20.140 CONCERNING
G HAZARDOUS 2144 { AM 6-'27 3 _ 1 1`fl! 7
o Lender's Address
0 OWNER OR AGENT
0 1 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
with all county ordinances and State laws relating to building
m const on, and hereby authorize representatives of his County ISSUANCE FEE
oo to er n the ab me i ned propert for inspe to pur es� i
� INVESTIGATION FEE TOTAL FEE/,
co p1 /j.
� (/ S' �u Applicant or A0 Dat (`
SEE REVERSE FOR EXPLANATORY LANGUAGE