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Home My Public Portal About5101 - 5107 FARAGO AVE_Building__ W(5RKE-PS' COMAFNSATiGN DECLARATION '- i h, 14nsUaffirm It"t I have a certificate of consent to self g p P L I CATION FOR B U I L D I N'G PERMIT )r a certificate of Workers' Compensation Insurance, or a certified eopy thereof (Sec. 3800, Lob. C.)- COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company BUILDING - h ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS I(i -63 ❑ Certified copy is filed with the county building inspec- BUILDING 51a/ 03 p4iijm6e) tion department. ADDRESS ; Date Applicant CITY-rG"FL4PLe - CtI21 ZIP LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT SX 2to ^NOW ON LOT CROSS NEARESST. COMPENSATION INSURANCE ff Q (This section need not be completed if the permit is for one - TRACT 1 �� ` ASSESSOR hundred dollars ($100)or less.) BLOCK LOT NO. MAP BOOK PAGE PARCEL TEL ��a USE SONE MAP OWNER MVV L P.nC�G ulC TEL. CCJZZ (nf^/J I certify that in the performance of the work for which this NO. QCl/l� >_ permit is issued, I shall not empfr .�, rson in any manner ��, tt�F+ p_-QS- SPECIAL CL so as to become subject to the ompe sati'on La s. ADDRESS CONDITIONS O CITY C�.� I��r— .��ft r!C Date Applica0 NOTIC TO APPLICANT: If, afthis ertificate of ARCHITECT TEL. `ENGINEER 6 cS�}/�d�J NO. ` 4S y(��a DISTRICT GROUP TYPE FIRE PRO ESSED BYExemption, you should becoe suject to The 'Workers' �-,.o� CONST., / ZONE Compensation provisions of the Labor Code,' you must forth- ADDRESS c31 1�V1 TE �� V - 9L •with comply with.such provisions or this permit shall be TEL STATISTICAL CLASSIFICATION APT. ONDO. 4A deemed revoked. CONTRACTOR '��"L- N . �s6 �� /+ LICENSED CONTRACTORS DECLARATION - -- q LIC. . / q CLASS NO. DWELL. UNIT hereby affirm that I am licensed,under provisions of Chapter 9 ADDRESS �o�S NO. (� y y/ (commencing with Section 7000)of Division 3 of the Business and LIC. SEWER MAP Professions Code, and my license is in full force and effect. CITY CLASS 115 BK. 6_PG -VALIDATION SQ. FT+ NO. OF NO. OF q _CHECK L' ense Number Lic.Class SIZE t�3� STORIES Z FAMILIES /i ONE 15-3-3 Sq. = 32 ��- s .�r, VALUATION RIPTION Contractor Date DESCOF'IT/ORK NEW ADD ❑ $ ❑ I am exempt under Sec. ��- C� �~Lst ALTER ED] OVi , B.&P.C. for this reason REPAIR ❑ $ - '2 4 6'0;-1 A Date: USEEXIOF F BLDG. DEMOL ❑ ✓oo # 0 0 0- o '�3 Signature APPLICANT' e , 1 R' TEL' FINA OWNER-BUILDER DECLARATION PRwT w�EI( Ivi� U Il? NOSS� DA - (.° 5.1 2.5 5 I hereby affirm that I am exempt from the Contractor's-License 10 I 1 4I,G i� �LAk31� Oo ° 5.1 25-510 Law for the following reason (Section 7031.5, Business and ADDRESS A 'Professions Code): PRESENT ,Zl 0 0 ]- ❑ BUILDING I, as owner of the property, or my employees with _ADDRESS wages as their sole compensation,will do the work and the structure is not intended or offered for sale(Section LOCALITY ' 7044, Business and Professions Code). MOVING TEL" I, as owner of the property, am exclusively contracting CONTRACTOR NO. 9 5 3 9:4 A with licensed contractors to construct the project (Sec- ADDRESS # o 0.0, 0 tion 7044, Business and Professions Code). �(� !Q 2`3 REQUIRED. TOTAL-SETBACK FRO IS . 1 - / CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH / �� ° 3 5'Q O O I hereby affirm that there is a construction lending agency for FRONT the performance of the work for which this permit is issued P.L. = (Sec. 3097, Civ. C.). SIDE J O P.L. - Q Q p Q Lender's Name # ° 6 / 15 LDMA Ref. # Lender's Address P.C. Fee$ LSS Permit Fee" / i 1.O 2 5 2 5 ' > I certify that I have read this application.and state that the 3 {�� Issuance Fee 1�d LDMA`P�C4' ', ° 1.O 2 5 2 5 c=� a above information is correct. I agree to comply with all County Investigation Fee J� C J 1 ordinances and State laws relating 1a building construction, 9 Total Fee /1/ '�V LDMA Perm. # �`a 9`�,`8 6 U a d h by authorize represe tatives of this County to enter t m u h abov - _tio terty for inspection purposes.. er CG o I I-T%J SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Age t _- ate-- - - " ' - '' Q�) W61iKERS"COM,4ENSATION DECLARATION I herd y affirm that I have a certificate of consent to self F ,insurr a certificate of workers' Compensation Insurance, :APPLICATION. -� . FOR ' BUILDING P E RMI T ora certified copy thereof (Sec. 3800, Lab. C.) i - COUNTY,OF LOS,ANGELES BUILDING.AND SAFETY Policy No. Company - ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL INS.' BUILDING ADDRESS Certified copy is filed with the county building inspec- BUILDING E F40 L�. tion department. ADDRESS S 0�J �r4C_Z4 C r 510-`i F�-K�VZ Date' ' Applicant CITY ` PCG �lr ZIP -1 P LOCALITY SS CERTIFICATE OF`EXEMPTION FROM WORKERS' 1 y NO. OF BLDGS. NEAREST COMPENSATION INSURANCE• SIZE OF LOT 1 S G�O NOW ON LOT CROSS ST. (This section need not'be completed if the permit.is for one 1 ASSESSOR hundred dollars ($100)or less.) TRACT 1 t 4 BLOCK LOT NO. ( MAP BOOK PAGE PARCEL /� TEL., USE ZONE MAP OWNER [L &AC,&.10.3, NO.35.5-462 I certify that in the performance f the work for which this >, permit is issued, I shall not empl y person in any manner 1 ' '�- SPECIAL p, so as to become subject to the W s' m satio t -ADDRESS'201-1 l-�1ut+LAAs-b OSS CONDITIONS O C Q � J t A-. zip 9[0042_. CITY Date Applicant - -- ARCHITECT ORS TEL. NOTICE TO APPLICANT: If, afte making this Certificate o ENGINEER 1.��1 ��'Jl��jl} � NO. 4�j' DISTRICT GROUP TYPE FIRE- P O SSED BY - � Exemption, you should becom subject to the Worker ' /fu 2 CONST.' ZONE Compensation provisions of the Labor Code, you must forth- ADDRESS .E t7(. ARTS �Z,D- ��L/U RAJ - d with comply with such provisions or this permit shall be H deemed%revoked. CONTRACTOR _ s TEL./amu 058 STATISTICAL CLAS IFI'C�TION 1 APT. J/ONDO. Z LICENSED CONTRACTORS DECLARATION - LI / CLASS NO. DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS N 7lC/ f (commencing"with Section 7000)of Division 3 of the Business and �iLIC SEWER MAP Professions Code, and my license is in full force and effect. CITY S T'T eQek (LN)T CLASS /'� VALIDATION SQ. FT NO.OF NO. OF CHECK BK. Cj n-011 License Number Lic.Class SIZE STORIES 2 FAMILIES ONE —IM11: VALUATION Contractor Date DESCRIPTION OF WORK NEW C�IVS'T i'LVCT L' (.91�itU ALPO ADD ❑ $ { ❑ I am exempt under Sec. ALTER ❑ - , 1 4 6 0 0 A B.&P.C. for this reason REPAIR 1 # .2 3 I 000 Date:- USEEXIOF F BLDG. DEMOL ❑ S �� Q - 5 1 2.55 Signature APPLICANTTEL. FINALOWNER-BUILDER DECLARATION PRINT k_-iL Me61NLS NO _';bR 17-- DATE ® ° - 5 12555 I hereby affirm that I am exempt from the Contractor's License 201 1 14l&� 5,:0 7-'8-6'86 Law for the following reason (Section 7031.5, Business and ADDRESS L{ IJfl �rK.S FI Professions Code): " ' PRESENT❑ 2539,'6A "BUILDING I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and ` the structure is not intended or offered for sale.(Section LOCALITY ' # o 0 0 0:23 7044, Business and Professions Code). MOVING' TEL. 3 5 Q'0 0 (V� CONTRACTOR NO. }Ly' I, as owner of the property, am exclusively contracting , with licensed contractors to construct the project (Sec- ADDRESS ° ° 3 5 0.'0 0 c=a tion 70A4, Business and Professions'Code). REQUIRED _TOTAL SETBACK FROMO'Q 9'9_8 b CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH hereby affirm that there is a construction lending agency for FRONT ; the performance of the work for which this permit-is issued P.L. ! �5 3 9. 7 A- (Sec. 3097, Civ. C.). SIDE - 1 m _ P.L. _ `y� t'+ _} '� - # 0 0 0 0''° Lender's Name LDMA Ref. #- Lender's Address P.C. Fee'$ o�S Permit Fee Q L _ _ 1,0.2 a'2 5. _ r kD "P%C*-1- 1, ° 1,02=525 I certify that I have read•this application and state that the 3�D of�.. Issuance Fee a above information is correct. I agree to comply with all County Investigation Fee t ordinances and State laws relating to building construction, Jg 121 1 ''L '• t_ 0,9-A•-�8 6 u a ereby authorize re resentatives of this County to enter Total Fee tv/ CDMA Perm. # p n he abov -menti ed roperty for inspection purposes. a z —�- SEE REVERSE FOR EXPLANATORY LANGUAGE o ' Signature of Applicant or A nt - Date i