HomeMy Public PortalAbout5752AGNES AVE_Building (3) APPLICATION FOR BUILDING PERMIT �1
_ COUNTY OF LOS ANGELES . BUILDING AND SAFETY
BUILDING ADDRESS
WORKER'S COMPENSATION DECLARATION !
hereby affirm that I have a certificate of consent to self insure, BUILDING ADDRESS FOR APPLICANT TO FILL IN h
or a certificate of Workers'Compensation Insurance,or a certified _
copy thereof(Sec.3800 Lab.C.) CITY ZIP
,//�� 1 ��� 12L C LocnuTY
Policy No.'t Z �1 1 I Companr SIZE OF LOT Nb.OF BLDGS.NOW ON LOT
Certified copy is hereby furnished.
NEAREST CROSS ST.
Certified copy is filed with the county building inspection TRACT BLOCK LOT NO.
de 8rtm t+ ^ �T s /, USE ZONE MAP NO.
1 a f\-\J IV1\-�1 4-I^JDC••J1C ASSESSOR MAP BOOK PAGE PARCEL
Date Applican SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' O NER n n TEL. O. YES NO
COMPENSATION INSURANCE E" 4A �� GI WITHIN 1000 Fr.OF SCHOOL?
ADDRESS
(This section need not be completed if the permit is for one hundred S >!S DISTRICT GROUP TYPE CONST.' FIRE ZONETS�SED Ydollars 100)orless.) CI ®(/ 3 /4
I certify t tin the performance of the work for which this permit � (JJC r
is issued, I all not employ any person in any manner so as to ARC I C O ENGINEER TEL.NO.
become subje to the Workers'Compensation Laws. STATISTICAL CLASSIFICATION APT CONDO
Date Applicant ADDRESS CLASS NO. DWELL UNITS
NOTICE TO APP CANT., If, after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST
CONTRACT R TEL.N
Exemption, you s ould become subject to the Workers' � l C h 91 (D SET BACK YARD HWY PROP LINE WIDTH
Compensation provisi s of the Labor Code, you must forthwith �J FRQNT
comply with such provis ns or this permit shall be deemed revoked. .CRESS ` 1 L Q P L
LICENSED CONTRACTORS DECLARATION LIC.CLAGGSS d SIDE
PL O
1 hereby affirm that I am licensed under provisions of Chapter 9 ��1 —� SEWER MAP CS
(commencing with Section 7000)of Division 3 of the Business and SQ.FT.SIZE NO.OF STORES NO.OF FAMILI �
Professions Code,and my license is in full force and effect. NEW ❑ BK PG , 0
2�7S Z� —2�` DES RIPTION OF WORK ADD ❑ VALUATION
Lic�n-se Nymber Lic.Class _
Co7ftrec or � � tom` Date I ALTER ❑ z_
�`
❑ I am exempt under Sec. REPAIR ruC,
B.&P.C.for this reason DEMOL
Signature
Date: USE OF IST G URM ElLDMA P/C q
9 APPLI NT PRINT pp c TEA�_b L.NO.('y- Z
LDMA Perm q
L. n
11I, as owner of the property, or my employees with wages as OSS �O •r•o a
their sole compensation, will do the work and the structure is AD 0 �i_,�;}SS f
not intended or offered for sale (Section 7044, Business and r\J FIS Q = ,7 :
Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL J }g S rEt
OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN Q 1 I�I e•.?
❑ 1, as owner of the property, am exclusively contracting With THE AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL _
licensed contractors to construct the project.(Section 7044, ves❑ No❑ % I !'}!SL _ , �
Business and Professions Code.)
WILL THE INTENDED USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING• j'•i„IC/'•L' -7.,r'
CONSTRUCTION LENDING AGENCY OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH t•. ECK, f.
COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST !
FOR GUIDELINES. ':.i 11ANGE
I hereby affirm that there is a construction lending agency for YES 1:1No El
themanC@ Of the Work for which this permit IS ISSUed($@C. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD
3097,,Civ.CIV.C.). PERMITTING CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES
m. COUNTY CODE,TITLE 2,CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING {�rl `.{"e i§_i(�I
is Lender's Name HAZARDOUS MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD.
Lender's Address ifl 1 AN
_ 52
IO OWNER OR AGENT
o` I certify that I have read this application and state that the above
$ information is correct. 1 agree to comply with all county P.C.FEE PERMIT FEE
ordinances and State laws relating to building construction,and �I . 3V
a. hereby authoriz representatives of this County to enter upon ISSUANCE FEE
le abov a Io d propfIty for inspection purpose, ;�a 3 ,
a INVESTIGATION FEE TOTAL FEE
SlgaW of ApolcaM wAgeM Deb
SEE REVERSE FOR EXPLANATORY LANGUAGE