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Home My Public Portal About5109 FARAGO AVE_Building__ WORKERS-COMPENSATION DECLARATION insure,ora certificatfffrm e of Workers' Compensat on Insurance, APPLICATION FOR BUILDING PERMIT or a certified copy thereof (Sec. 3800, lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY' Policy No. Company BUILDING ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS ❑ Certified copy is filed with the county building inspec- FSIZEt LDING G r_ Ave A*.* tion department. DRESS ®rr1/'A O �j Y ✓L/it /'8 (�� ZIP 117�7 o LOCALITY Date Applicant NO. OF BLDGS. CERTIFICATE OF EXEMPTION FROM WORKERS' OF LOT X 210 NOW ON LOT NEAREST Z CROSS ST. COMPENSATION INSURANCE ASSESSOR, y (This section need not be completed if the permit is for one TRACT 1417 BLOCK L� LOT NO. � MAP BOOK �� PAGE -'90(f PARCEL ell hundred dollars ($100) or less.) jj TEL.�Z/3 / USE ZONE, MAP OWNER J H Kt&S #/06f NO.2,,% 07e,1, NO. I _.1l —'2 7 7 1 certify that in the performance of the work for which this SPECIAL } permit is issued, I shall not employ any person in any manner ADDRESS��°'�S �YA O Verde- G ':z— CONDITIONS a- so as to become subject to the Workers' Compensation Laws. !j 0 CITY S '0444 I L Elide" u Zip J1030 Date Applicant ARCHITECT OR c TEL.bi DISTRICT GROUP TYPE FIRE PROCESSED BY Q NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER TPN 9_ . rljL/ NO. - 2Tj CONST. ZONE U Exemption, you should become subject to the Workers' A,� �Q O �f� Compensation provisions of the Labor Code; you must forth- ADDRESS Ov � M0,9J1 0i' !J � !/ S •�� V a- with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION _.APT. CONDO. Z deemed revoked. CONTRACTOR NO. — LICENSED CONTRACTORS DECLARATION �� LI CLASS NO. d DWELL. UNITS Cis ADDRESS I hereby affirm that I am licensed under provisions of Chapter 9 � �!C� SEWER MAP '`"- ' °IF (commencing with Section 7000)of Division 3 of the Business LIC. / .-� and Professions Code,and my license is in full force and effect. CITY CLASS BK G �/ -='L{/'ALIDATION SQ. FT. / / NO. OF NO. OF CHECK License Number Lic. Class SIZE e✓�t>7� STORIES Z FAMILIES ONE VALUATION Contractor Date DESCRIPTION OF WORK NEW ® 0 ''slit- �� 2 3 ADD 101 _ ❑I am exempt under Sec. ALTER '' - B.&P.C. for this reason ❑REPAIR $ �� Doo• o� jj� t^ of f El Date: 'USE OF fJ EXISTING BLDG. :J;1V e_ :,1 - 5 N le DEMOL ❑ APPLICANT TEL. X d:�,a_ Signature g OWNER-BUILDER DECLARATION (PRINT)T�nO Rf Y• /�oy NO.2� -�!lJlp FINAL I hereby affirm that I am exempt from the Contractor's License / 14A5Ad /DSeHA GA rra�o o 5Cr' DATE �M Law for the following reason (Section 7031.5, Business aADDRESS 509UA 'and eq FINAL •�'-' Professions Code): PRESENTr10 "SLI FA,-L , A 4,ve �PW � G' By El1, BUILDIN G 7 I, as owner of the property, omy 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. {�► a CONTRACTOR NO. 0 s I, as owner of the property, am exclusively contracting p with licensed contractors to construct the project (Sec- ADDRESS r _'- Tion 7044, Business and Professions Code.) REQUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP.AINE WIDTH I hereby affirm that there is a construction lending agency for FRONT the performance of the work forrwhich this permit is issued P.L. r7 _ (Sec. 3097, Civ. C.). SIDE _ ,'' P.L. Lender's Name. t :. LDMA Ref. It m P.C. Fee$ lr/ Permit Fee i Lender's Address ? I certify that I have read this application and state that the 74" •3 Issuance Fee �l Jr LDMA P/C# above information is correct. I agree to comply with all County Investigation Fee 0 ordLn s and Store laws relating to building construction,' Total Fee LDMA Perm. N a anby authorize representatives of this County to enter -�:� s �;-: ; upabove-mentioned property for inspection purposes. J4, H 2 41 J b 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, APPLICATION FOR: BUILDING" P E RM I T or a certified.copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company BUILDING ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS rCP ❑ Certified copy is filed with the county building inspec- BUILDING O tion department. ADDRESS. CITY' ZIP IRO LOCALITY Date Applicant NO. OF BLDGS. CERTIFICATE OF EXEMPTION FROM-WORKERS' SIZE OF LOT —7 X �JIO NOW ON LOT 4 NEAREST CROSS ST. COMPENSATION INSURANCE ASSESSOR (This section need not be completed if the permit is for one TRACT �' BLOCK LOT NO. MAP BOOK PAGE PARCEL hundred dollars ($100) or less.) TEL Z13 USE ZONE MAP n OWNER. NO. NO. I.certify that in the-performance of the work for which this _� SPECIAL permit is issued, I shall not employ any person in any manner ADDRESS 2 (� L CONDITIONS a so as to become subject to the Workers' Compensation Laws. O CITY ZIP t 03 d Date Applicant ARCHITECT OR TEL. 0 ENGINEER NO DISTRICT GROUP TYPE FIRE PROCESSED BY NOTICE TO APPLICANT: If, after making this Certificate of CONST: ZONE Exemption, you' should become subject to the Workers' �/ w Compensation provisions of the Labor Code, you must forth- ADDRESS /�J j LD7 1 p„ with comply with such provisions or this permit shall beTEL. ( STATISTICAL CLASSIFICAT N deemed revoked. CONTRACTOR �, NO. T Z a LICENSED CONTRACTORS DECLARATION C� //�q LIC. CLASS NO. of_DWELL. UNITS 1 hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS?IDC / NO.r7� 5 (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 License Number Lic. Class SIZE �j� STORIES �j FAMILIES ONE VALUATION Contractor Date DESCRIPTION OF WORK NEW E ADD ❑1 am exempt under Sec. Pilo. ALTER BAP.C. for this reason REPAIR ❑ $ Date: USE OF EXISTING BLDG. DEMOL Q^ I L.' Signature OWNER-BUILDER DECLARATION (PRINT)APPLICANT_Ctkwul� NQ. F,+ Z FINAL 1 hereby affirm that I am exempt from the Contractor's License DATE. Law for the following reason (Section 7031.5, Business and ADDRESS 2IPAFINAL Professions Code): PRESENT ey s ❑ I, as-owner of theproperty,' ro ert or m employees with BUILDING P P Y= YADDRESS +.7t` 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 Pro property, am exclusively contracting CONTRACTOR AO. ACCT.s with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code.) .REQUIRED TOTAL SETBAQ FROM EXIST., CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTHt _ =N— I hereby affirm that there is a construction lending agency tor FRONT V"""• 1- the performance of the work for which this permit is issued P.L. J ;t_,i(L m 69- (Sec. 3097, Civ. C.). SIDE t_a E�_. i=+ t Lender's Name �--/ m P.C. Fee$ :Z 1710 ;� LDMA'Ref. # .H; 1ft,; aI(i � Permit Fee _ Lender's Address I certify that I have read this application and state that the ( a Issuance Fee+ �� LDMA PIC# above information is correct. I agree to comply with all County Investigation Fee i3 1-III-u-0 H •`13t_'i_' i7,�a!` 6 ordinances and State laws relating to building construction, Total Fee 6 _i LDMA Perm. # c�: p. a and hereby authorize representatives of this County to enter •L AN J upon ove-ment' property for inspection purposes. a e 9 SEE REVERSE FOR EXPLANATORY LANGUAGE n Signaturp6f A plicant or Agent Dote