HomeMy Public PortalAbout5817AGNES AVE_Building (4) t - APPLICATION FOR BUILDING PERMIT .
COUNTY OF LOS ANGELES BUILDING AND SAFETY
WORKERS COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS
I hereby affirm that I have a certificate of consent to self Insure BUILDING ADDRESS1-7 466(46
or a certificate of Workers Compensation Insurance or a certified
copy thereof(Sec 3800 Lab C) CIT ZI�/-7 f� LOCALITY
Policy NO J 7w0L' ll#+ ( "
Company " SIZE OF LOT NO OF BLDGS NOW VON LOT
ElCertified Copy Is hereby furnished 2— NEAREST CPISS ST
0al-I rhfled copy Is filed with the county building Inspection TRACT BLOCK LOT NO
department I I USE ZONE MAP NO
Date Applicant ` ASSESSOR MAP -r��r7�K PAGE PARCEL
� / D� QO� SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKEIIS OWNS TEL NO
COMPENSATION INSURANCE 1 VU7_ Merb IN IG S ►CLL 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)
DISTRICT GROUP TYPE CONST FIRE ZONE PROCESSED BY
CITY ZIP
I certify that in the performance of the work for which this permit ' Q J`
is Issued I shall not employ any person in any manner s0 as t0 ARCHITECT OR ENGINEER (TEL NO O
become subject to the Workers Compensation Laws STATISTICAL CLASSIFICATION APT CONDO
Date Applicant ADDRESS CLASS NO -4 DWELL UNITS
NOTICE TO APPLICANT If after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST
Exemption you Should become subject t0 the Workers CONTRACTOR TEL NO SET BACK YARD HWY PROP LINE WIDTH
Compensation provisions of the Labor Code you must forthwith L, Z -0 2 7 FRONT
comply with such provisions or this permit shall be deemed revoked ADDRESS LIC NO PL
LICENSED CONTRACTORS DECLARATION L 5& AW545V ��` SIDE ao
CITx,/ LIC C SS PL
1 hereby affirm that I am licensed underprovisions of Chapter 9 �G SEWER MAP U
(commencing with Section 7000)Of Division 3 of the Business and SO FT SIZE NO OF STORIES NO OF FAMILIES
Professions Code and m license Is In full force and effect NEW ❑ BK PG - O
DESCRIPTION OF WORK VALLI 0 , U
License Number L. Class ADD ❑
LIJ
Contractor Date 4j-0/'g4 U �' I ALTEROA
$ C��
❑ 1 am exempt under Sec REPAIR ❑ $ z
BBPC for this reason DEMOL ❑ LOMA P/C#
Date USE OF EXISTING BLDG URM ❑
Signature
APP AN (PRIT O LOMA Perm#
❑ I_as owner of the property or my employees with wages as NT , _< Z �► `8s
their sole compensation will do the work and the structure Is ADDRESS 90_ 3-603 2Q�te£c
not Intended or offered for sale (Section 7044 Business and �.C� AK C. Q
FINAL DATE L
Professions Code) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL V 1 ITEMS
❑ I as Owner Of the property am exclusively contracting with OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE ; I 'I I-gh� + �
AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDES itt"'11
licensed contractors to construct the project (Section 7044 YES❑ No❑ FINAL BY „ �� CHE( "` 1 iQ� J�
Business and Professions Code) (HE( K 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
e�('';
CONSTRUCTION LENDING AGENCY COAST AIR OUAUTY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FOR `TT1t�1'"'1I�j 1i LL v
GUIDELINES
I hereby affirm that there Is a construction lending agency for
VES C3 NO❑
the performance of the work for which this permit Is Issued(Sec �}
3097 Civ C) I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMDPERMITTING 0000-I 001 2/ 196
CHECKLIST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE
TITLE 2 CHAPTER 2 20 SECTIONS 2 20 100 THROUGH 2 20 140 CONCERNING HAZARDOUS / L j rrI ('�
Lender s Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD ,,696 1 A,1 7 K
m
Lenders Address
Q OWNER OR AGENT
3: 1 certify that I have read this application and state underpenalty
p of perjury that the above Information Is correct I agree to comply PC FEE PERMIT FEE /� J
with all county ordinances and State laws relating to building /
m construction and hereby authorize representatives of this County ISSUANCE FEE r�
to enter 9WM-e Q property above ti n dfor Ins ectio o�
g
i
0
INVESTIGATION FEE TOTAL FEE
N
SEE REVERSE FOR EXPLANATORY LANGUAGE