HomeMy Public PortalAbout5749AGNES AVE_Building (3) APPLICATION FOR BUILDING PERMIT
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q COUNTY OF LOS ANtELES'' 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, BUILD GDD ES «- y
or a certificate of Workers' Compensation Insurance,or a certified �S
copy thereof(Sec.3800,Lab.C.) CITY zIP
7/-30
SIZE
LOCALI Y
Policy No. Company SI E OF LOT NO.OF BLDGS.NOW.ON LOT
❑ Certified copy is hereby furnished. 0 Z. NEAREST CROSS ST.
❑ Certified copy is filed with the county building inspection TRACT BLOCK LOT NO.
department. USE ZONE MAPO
Date Applicant ASSESSOR MO� PAGE PARCEL
G� SPED IONS
CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER TEL NO.
COMPENSATION INSURANCE L-• Z> Z.I WITHIN 1000 FT.OF SCHOOL? YES NO
(This section need not be completed if the permit is for one hundred ADDRESS
dollars($100)or less.) 574q 1k,,cAffsDISTRICT GROUP TYPE CONST, FIRE ZONE PROCESSED BY
I is issued, I shall not employ any person in any manner o as to CITY certify that in the performance of the work for which this permit �"F �O
ZIP
d
become subject to the Workers'CO Sati S.
STATISTICAL CLASSIFICATION APT CONDO
Date — 2--J�Applicant ARCHITECT OR ENGINEER TEL NO.
ADDRESS CLASS NO..._:�L DWELL UNITS
NOTICE TO APPLICANT.- If, after ma cing this CertificaOf REQUIRED TOTAL SETBACK FROM EXIST
Exemption, you should become Subject t0 the Workers' CO3tJrRACTOR TEL NO. SET BACK YARD HWY PROP LINE WIDTH
Compensation provisions of the Labor Code, you must forthwith 9 L - 61 FRONT
comply with such provisions or this permit shall be deemed revoked. ADDRESS a LIC.NO. P L
LICENSED CONTRACTORS DECLARATION 5,9 Z_ 5 SIDE
CIT LIC.CP L
I hereby affirm that I am licensed underprovisions of Chapter 9
(commencing with Section 7000)of Division 3 of the Business and S .FT.SIZE NO.OF STORIES NO.OF FAMILIES SEWER MAP
Professions Code,and my license is in full force and effect. NEW ❑ BK PG U
License Numb 8 2 Z DESCRIPTION OF WORK VALUATION ,• p
Lic.Class � ADD �7
Contractor Date S Z""1 I x 0 I_J ALTER ❑ $ CL
��d• v
W
❑ I am exempt under Sec. REPAIR ❑ $ z
B.BP.C.for this reason DEMOL ❑ LDMA P/C#
Date: USE OF EXISTING BLDG. ' URM ❑
Signature APP CANT(PRINT) TEL NO. LDMA Perm#
❑ I,:as owner of the property, or my employees with wages as [ G , Ak 2136-3/0/ - "Z A?_ T,a
�. -
their sole compensation, will do the work and the structure is ADDRESS O -�-: =1�In_I.:
not intended or offered for sale (Section 7044, Business and ( {i FINAL DATE a `'=0'=
Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL
C1 I, as owner of the property, am exclusively contracting with OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE J
AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? Q
licensed contractors to construct the project (Section 7044, FINAL B
Business and Professions Code.) YES El NO
WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING ti (J_
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH
CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR TTEl-12
GUIDELINES. 1
I hereby affirm that there is a construction lending agency for [ �� : —ate
VES❑ NO 1
a the performance of the work for which this permit is issued(Sec. _)��t i-. 236 _ 3_�•
Ol IHAVEREAD THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING ,�/�f•--y.s�� _ —1.
3097,CIV.C.) CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, `(�LL4 L G�17L2� 'H S.' ... is ¢?F
TITLE 2, APTER 2.20 ECTION 2.20 00 THROUGH 2.20.140 CONCERNING HAZARDOUS �( '�;'--iV
3 Lender's Name MATE EP TIN AND F OB ING A PERMIT FROM THE SCAQMD.
o Lender's Address �C
OWAR'bgAGE
o I certify that I have read this application and state under penalty 5/5" ,a .2
o P.C.FEE PERMIT FEE /
d of perjury that the above information is correct.I agree to comply D� ✓ i 17
�.,
cv with all county ordinances and State laws relating to building
/, moi{ !_t-i �I 1 . .
mconstru ion, and h eby au rize representatives of this County (ISSUANCE FEEj,= i t:} y,;I�y
a to en r n t a ve-me i property for inspection purposes. f
(0 7- .. INVESTIGATION FEE TOTAL FEE �j•-�
SoyMalum.of APPII t`Agent Dete
SEE REVERSE FOR EXPLANATORY LANGUAGE