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Home My Public Portal About5828 AGNES AVE_Building_10/26/1994_reroof APPLICATION FOR BUILDING PERMIT COUNTY OF LOS ANGELES • BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN •• BUILDING AD ES BUILDIN ADDRE S �� I hereby affirm that I have a certificate of consent to self insure, or a certificate of Workers' Compensation Insurance, or a certified copy thereof(Sec. SOq,l,�b.C.) ZIP 171 7 y ( LOCALITY Policy No. Company 1n SIZ OF LOT NO.OF BLDGS.NOWON LOT G El Certified copy is hereby furnished. �� /' NEAREST CROSS ST. ❑ Certified copy is filed with the c0 y building inspection TRACT BLOCK - LOT NO. dep l tm®nt. // USE ZONE MAP NO. Date C/ L��.1J/ f�/dant ASSESSOR MAP BOOK PAGE PARCEL SPECIAL CONDITIONS CERTIFICATE OF EXEMPTIO OM WORKERS' �(� .gyp' EL WITHIN 1000 FT.OF SCHOOL? YES NO (This section need not be completed if the permit is for one hundred DDR DISTRICT GROUP TYPE r FIRE ZONE PROCESSED BY,ONS - dollars ($100)or less.) ZI I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to d become Subject t0 the Workers'Compensation Laws. [nARCIITOR GINEER TEL NO. P STATISTICALCLASSIIIIFFFF(CATION APT CONDO Date. Applicant - 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' �i TRRA`CTOR �---�_ TEL NO, 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 IESS P L LICENSED CONTRACTORS DECLARATION r PILE .CLL_ PL I hereby affirm that I am licensed underprovisions of Chapter 9 U SEWER MAP (commencing with Section 7000)of Division 3 of the Business and SQ.FT. IZE NO.OF STORIES NO.OF FAMILIES Professions Code,a my lice ns is in full force a effeeS _ NEW BK PG d DESCRIPTION OF WO ADD ❑ VALU Q License NumberCM — Lia Glass i� Contractor Date C�� --- 7 ��S. iG?Qr ALTER ❑ $� ❑ I am exempt oder a cc C/Cg� REPAIR ❑ 0 B.&P.C. for this reason 11^^ Q S �--g 4D MOL ❑ .VI �� f LDMA P/C# _ _ W Date: USE OF EXISTING BLDG. �" I AUR ❑ ••' �`? iLl':+az"I C0 SignatureAPPLICANT(PRINT) TEL NO. LDMA Perm# + 1 ❑ I, as owner of the property, or my employees with wages as ZO s '[t` __ m 45 their sole compensation, will do the work and the structure i , ADDRESS not intended Or offered for sale Section 7044, Business a d FINAL DATE Q ;,.jµ1.; "=� 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 _ f'• I^ a`4i.F ❑ 1, as owner of the property, am exclusively contracting w1 AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY 'T�� licensed contractors to construct the project (Section 0 4, VES❑ No ElBusiness and Professions Code.) WILL THE NDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING 1 - a •• i c UPA QUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH Q '/ (� �� '.�t?I i—•f jIti i LLQ'%yi{:r''r'j• CONSTRUCTION LENDING AGENCY AS uNR UALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR � I*(r\ "l V r,a d r 3 ri I hereby affirm that there is a construction lending agency for �IA�VE ❑ No❑ N the performance of the work for which this permit Is Issued( ESD THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING ° 3097, CIV,C.) LIST. UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, w TIT 2,CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING HAZARDOUS Lender's Name M ERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD. IL 111 IL Lender's Address O NER OR AGENT o I certify that I have read this application and state under penalty 0of perjury that the above information is correct.I agree to comply C.FEE PERMIT FEE 1.2 71 with all county ordinances and State laws relating to building m con ruction, and hereby authorize representatives of this County ISSUANCE FEE ato nter u he abo me n property for inspecti, n purposes. - / �-/Ca?,, INVESTIGATION FEE TOTAL FEE ,gnature pi Ap t or Agent J - (Date ,9l SEE REVERSE FOR EXPLANATORY LANGUAGE