HomeMy Public PortalAbout5758AGNES AVE_Building (3) 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 ADD
or a certificate of Workers' Compensation Insurance, or a certified ��'�
copy thereof
-(ySec.(3800, Lab.C.) CITY ZIP 111' ��
Policy No.S�-`�`T Company o � _ LOCALITY
SIZE OF LOT NO.OF BLDGS.NOW ON LOT
❑ Certified copy is hereby furnished. NEAREST CROSS ST.//
(Certified co y is filed with the county building inspection TRACT BLOCK LOT NO.
depar Le
�, USE ZONE MAP NO.
Date Applicant S Y p ASSESSOR MAP BOOK PAGE PARCEL
SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER., TEL NO.
COMPENSATION INSURANCE 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.) C' �� DISTRICT GROUP TYPE,CONST. FIRE ZONE PROCESSED BY
CITY ZIP
I certify that in the performance e work for which this permit
s issued, I shall not employ person in any manner so as to
become subject to the W era'Compensation Laws. ARCHITECT OR ENGINEER TEL NO.
STATISTICAL CLASSIFICATION APT CONDO
Date plicant ADDRESS CLASS NO.
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 TEL NO. SET BACK YARD HWY PROP LINE WIDTH
Compensation provisions of the Labor Code, you must forthwith W o � � FRONT
comply with such provisions or this permit shall be deemed revoked. A DRESS^J_ LzwLI .N . ( P L
LICENSED CONTRACTORS DECLARATION SIDE
CI LIC.CL 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 SQ.FT.SIZE NO.OF STORIES NO.OF FAMILIES
Professions Code,and my li�Lenf is in full force and effect. NEW C3 BK PG
License Number _ ` Lic.Class —�� DESCRIPTION OF WORK ADD E] VALUATION
License Number" O
Contractor Date , ALTER 1:1 � V
❑ I am exempt under Sec. REPAIR $ Q
B.AP.C.for this reason `; DEMOL ❑ LDMA P/C# W
Date: URM 0TMIS
a(CD
L
Signature APPLICA ( I T .. TEL NO. LDMA Perm# - `+`+01 � -1JY{rfR +{�i CD
El 1, as owner of the property, or my employees with wages as ro S-S Z MI IlV U't
their sole compensation, will do the work and the structure is ADDR SS 9
not intended or offered for sale (Section 7044, Business and FINAL DATE a
Professions Code.)
WILL THE APPLICANT OR TUBE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL �o�� J
❑ 1, as owner Of the property, am exclusively contracting Wlth OR A MIXTURE CONTA G A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE FINAL BY
AMOUNTS SPECIFIE N THE HAZARDOUS MATERIALS INFORMATION GUIDE?
licensed contractors to construct the project (Section 7044, YES Ell N
Business and Professions Code.)
WILL THE INTENDED USE THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING
OCCUPANT REQUIRE A P IT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH
CONSTRUCTION LENDING AGENCY COAST AIR QUALITY AGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKUST FOR
GUIDELINES.
I hereby affirm that there is a construction lending agency for VES❑ N
the Of the Work for which this permit IS ISSUed(Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING
30977,,Civ.
IV..C.)C.) CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE,
N
TITLE 2,CHAPTER 2.20 SECTIONS 20.100 THROUGH 2.20.740 CONCERNING HAZARDOUS
Lender's Name MATE EPORTING AND FO B AINING A PERMIT FROM THE SCAQMD.
EL Lender's Address -/'�C�—
O OWNER ORA T
o I certify that I have read this application and state under penalty
O of perjury that the above information is correct.I agree t0 comply P.C.FEE PERMIT FEE �/ O
with all county ordinances and State laws relating to building
earm4rkction, and hereby authorize representatives of this County ISSUANCE FEE 3G
to enter n the above- ntioneEl property for inspection purposes.
a
-�.r"� � INVESTIGATION FEE TOTAL FEE j0 Q`, 9�
r SreneWre&Applicant or Agent Date (J V
SEE REVERSE FOR EXPLANATORY LANGUAGE