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HomeMy Public PortalAbout5107 FARAGO AVE_Building__ ,r \, t AORKERS-COMPENSATION DECLARATION ' brI have a certificate nconsent self affirmthat of Workers' Compensation Insurance, APPLICATION, FOR- BUILDING PERMIT or a certified copy thereof (Sec. 3800, Lab. C.) z COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. � Company ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL jl ADDRESS GToLIi ❑ Certified copy is filed with the county building inspec- BUILDING �r✓� tion department. ADDRESS /$ / rCi G CITY /erty /£ Ci„ ZIP Y7f30 LOCALITY Date Applicant NO. OF BIDGS. CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT 16 X 2 /0 NOW ON LOT Z NEAREST � CROSS ST. COMPENSATION INSURANCE ASSESSOR, (This section need not be completed if the permit is for one TRACT 114-97 BLOCK ZD LOT NO. 9 MAP BOOK .AGE Ode PARCEL OX/ hundred dollars ($100) or less.) _//� TEL.Z! USE ZONE MAP OWNER /h0e1)AS fit• �OLI NO.25 ©O6 NO. lT I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner ADDRESS `�J HPI' d t/er�le a�i ^� CONDITIONS d so as to become subject to the Workers' Compensation Laws. �/) q O CITY SPaA/NSL�pPHti ZIP !/03,0 U Date Applicant ARCHITECT OR TEL.$j a NOTICE TO APPLICANT: If, after makingthis Certificate of ENGINEER To.•, /7. 5/14 NO. - 32 j DISTRICT GROUP TYPE ZONE PROCESSED BY CONST. ZONE O Exemption, you should become subject Ao the Workers' ^ Compensation provisions of the Labor Code, you must forth- ADDRESS OD �� MODite D,,. 3 MPk //7sO �, Uli �' JV_,' a with comply with such provisions or.this permit shall beEL STATISTICAL CLASSIFICATION APT. CONDO. N deemed revoked. CONTRACTOR 4, Z LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. Q( DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. (commencing with Section 7000)of Division 3 of the Business LIC. SEWER MAP and Professions Code,and my license is in full force and effect. CITY CLASS BK(;'-PG.� _ VALIDATION SQ. FT. NO. OF NO. OF CHECK a W License Number Lica Class SIZE /°d/r/� STORIES Z FAMILIES / ONE VALUATION ~•~~ Contractor Date DESCRIPTION OF WORK NEW 31 I a z• �^+ � / ADD ❑ a ❑I am exempt under Sec. �"3 &Jr00++ C01 "de ► » � _, _ "'` ''`' ALTER ElB.&P.C. for this reason S 9� n�p,ers9 Lis: REPAIR ❑ Date: USE OFAA )) J,h s:"+t EXISTING BLDG. V ctJZ//i 4 - 5r.+ /e A,,";ADEMOL ❑ I�'€�= �t i � _ Signature APPLICANT (( y J/ TEL. t3 FINAL - °''"`' (PRINT)�h1awnA,f I, q&a NO.ZS" ©,p OWNER-BUILDER DECLARATION `� DATE �d-/ -9 '.iFii uI- .F I hereby affirm that I am exempt from the Contractor's License f Ve/dB �G � y A -- ADDRESS/O35 VO O fAde-4�. „p Law for the following reason (Section 7031.5, Business and FINAL Professions Code): PRESENT d nnt By BUILD El I, as owner of the property, or my employees with ADDREINSSG r ,�....%� i ' 1' '••` - wages as their sole compensation,will do the work and � � "' ,',•�'�:. �i�"n`,;�w•: :L }:.;(t ._,_�, the structure is not intended or offered for sale(Section LOCALITY 7044, Business and Professions Code.) MOVING TEL. , h. r�V1j CONTRACTOR• NO. 18J 1, as owner of the property, am exclusively contracting es, with licensed contractors toconstruct the project (Sec- rADDR tion 7044,Business and Professions Code.) - ;•' , , ?::_ D TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY K YARD HWY PROP. LINE WIDTH I hereby affirm that there is a construction lending agency for / / the performance of the work for which this permit is issued 2Or 1 "9`;"l': s, a (Sec. 3097, Civ. C.). Lender's Name, o ¢ O 0 LDMA Ref. III, (J �� Permit FeeLender's Address 1 certify that I have read this application and state that the0+"'3 Issuance Fee / /v LDMA P/C# iu ' :above information is correct. I agree to comply with all County n Fee a ._ _ordinances and State laws relating to building construction, - Total Fee i• LDMA Perm. # ..;..,.: ... . ..f' a and heby authorize representatives of this County to enter upon mentioned property for inspectjon purposes. J[Ln C , Z SEE REVERSE FOR EXPLANATORY LANGUAGE _� Signature of Applicant or Agent' Date WORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self insure, or a certificate of Workers' Compensation Insurance, A P P L I CATION FOR BUILDING" PERMIT or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company ❑ Certified co is hereby furnished. FOR APPLICANT TO FILL IN BUILDING copy y ADDRESS ❑ Certified copy is filed with the county building inspec- BUILDING tion department. ADDRESS J l " CITY ZIP "Y17160 LOCALITY1 Date Applicant NO.OF BLDGS. CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT 6; Z V NOW ON LOT NEAREST -' CROSS ST. COMPENSATION INSURANCE ASSESSOR (This section need not be completed if the permit is for one TRACT i BLOCK LOT NO. MAP BOOK PAGE PARCEL hundred dollars ($100) or less.) TEL. 3 OWNER /' NO. _2 O Z' USE ZONE OP Z1 I certify that in the performance of the work for which this Kn SPECIAL a permit is issued,'I shall not employ any person in any manner ADDRESS " Z CONDITIONS so as to become subject to the Workers' Compensation Laws. OU CITY ZIP Date Applicant ARCHITECT OR, TEL.St 3 DISTRICT GROUP TYPE FIRE PROCESSED BY NOTICE TO APPLICANT: If, after makingThis Certificate of ENGINEER CC. E{ Si NO. — '7 ,^ CONST. ZONE 0 Exemption, you should become subject to the Workers' ,D� p:?J TF w Compensation provisions of The Labor Code, you must forth- ADDRESS �J _j g ` .Y 0- with with comply with such provisions or this permit shall beEL" 1 STATISTICAL CLASSIFICATI C� N deemed revoked. CONTRACTOR , � NO. + 1 �' ' � Z LICENSED CONTRACTORS DECLARATION ` LIC. p y CLASS NO. 01 UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESSNb. (commencing with Section 7000)of Division 3 of.the Business LIC. SEWER MAP and Professions Code,and my license is in full force and effect. CITY CLASS BK PG VALIDATION SQ. FT. NO. OF NO. OF. CHECK i :. License Number Lic. Class SIZE STORIES 21 IFAMILIES ! ONE VALUATION - Contractor Date DESCRIPTION OF WORK :;i; ' NEW $ voca Z. ElI am exempt under Sec. ` ADD 0] A? - 5 ALTER ❑ _ BAP.C. for this reason REPAIR El3 USE OF Date: EXISTING BLDG. s): DEMOL ❑ i Signature APPLICANT--" TGA'�� FINAL s.. OWNER-BUILDER DECLARATION (PRINT) O. DATE !I � 1 hereby affirm that I am exempt from the Contractor's License i{• j Law for the following reason (Section 7031..5, Business and ADDRESS FINAL Professions Code): PRESENT t- By T-7 "•�r= BUILDING El 1, as owner of the property, or my.employees with ADDRESS !) j _ `;7,:._a m 1 wages as their sole compensation,will do the work and the structure is not intended or offered for sale Section LOCALITY - C i 7044, Business and Professions Code.) MOVING -TEL r CONTRACTOR NO. CHANGE �` 1, as owner of The property, am exclusively contracting 3 }•jNGE =1)i_; with licensed contractors to construct the project (Sec- x ADDRESS tion 7044, Business and Professions Code.) REQUIREDTOTAL SETBlQCK FROM EXIST. - CONSTRUCTION LENDING AGENCY SET BACK YARD WY PROP.NINE WIDTH. ;_i 1€0--,"1 0 in -n=t/Cr I hereby affirm that there is a construction lending agency for FRONT i ° the performance of the work for which this permit is issued P.L. _i=0w Ht€ t=.,Lr (Sec. 3097, Civ. C.). SIDE P.L. Lender's Name v� v �� !� LDMA Ref. # i$ P.C. Fee$ •�/O Permit Fee O Lender's Address loop above I certify that I have read this application and state that the Issuance Fee / �! LDMA.P/C# 8 above information is correct. I agree to comply with all County Investigation Fee R ordinances and State laws relating To building construction, Total Fee LDMA Perm. # a and hereby authorize representatives of this County to enter upon the above-menti ne , perty for inspection purposes. a _ SEE REVERSE FOR EXPLANATORY LANGUAGE Signature f Applicant or Agent Date