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HomeMy Public PortalAbout5111 FARAGO AVE_Building__ �.WGRKERS'•COMPENSATION DECLARATION r insure, orhereyaa certificate of Worke s' Compensat on ensuran of APPLICATION . FOR BUILDING RERMIT or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company ❑ py BUILDING Certified co is herebyfurnished: FOR APPLICANT TO FILL IN ADDRESS ❑ Certified copy is filed with the county building-inspec- BUILDINGr_ tion department. . ADDRESS S lArQ ® Q CITY Te�"t Ie'G� ZIP V 7Bo LOCALITY Date Applicant NO. OF BLDGS. NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT 5 7-1d NOW ON LOT CROSS ST. COMPENSATION INSURANCE ASSESSOR (This section need not be'completed if the permit is for one TRACT 114-q7 BLOCK Zv 7 LOT NO. 9 MAP BOOK �r1�7 PAGE day PARCEL hundred dollars ($100) or less.) TEL.Z13 USE ZONE MAP OWNER r1 oW44 Y. Aaa NO.4,5l .1 certify that in the performance of the work for which this f' A� +���� C _ SPECIAL a permit is issued, I shall not employ any person in any'manner ADDRESS fd35'P7�r0 O V CONDITIONS so as to become subject.to the Workers' Compensation Laws. // O CITY SOa�i'9 ///��fn' S.Je"A ZIP 1 o3D U Date Applicant. ARCHITECT OR TEL. NOTICE TO APPLICANT: If, after making this.Certificate of ENGINEER 100 �• Sim NO.2e.0-631S DISTRICT GROUP TYPE FIRE PROCESSED BY Q Exemption, you should become .subject to the Workers' 3 �� ���,/ CON ZONE U Compensation provisions of the Labor Code, you must forth- ADDRESS ✓ A CA'9'!"rf� ar/ r� with comply with such provisions or this STATISTICAL CLASSIFICATION APT, CONDO. N p y p permit shall be TEL. � Z deemed revoked. CONTRACTOR NO. _ LICENSED CONTRACTORS DECLARATION LIC CLASS NO. 6—/ DWELL. UNITS �`r— I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS LIC. SEWER MAP (commencing with Section 7000)of Division 3 of The Business , and Professions Code,and my license is in full force and effect. ITY CLASS BK —VALIDATIONl� SQ. FT. NO. OF NO. OF / CHECK License Number Lic. Class V� SIZE 1��� STORIES FAMILIES / ONE VALUATION '..r:j Contractor Date DESCRIPTION OF WORK NEW ❑I am exem 1 under Sec. /'3 47@di^DO�YI C.OH®D ADD ❑ r H� _ V P ALTER ❑ �� O OC3•a0 ►. . . x`s L-1 i:_% B.&P.C. for this reason REPAIR ❑ $ r lHL 7 Date: USE'OF � n_ _a EXISTING BLDG.biil@ ll!�15 DEMOL ❑ CHECK Jl o y- Signature APPLICANT (( �/ TEL. 213 / FINAL (PRINT). Y. /-/Va NO. 2 7-OOd�7 +_•i [IFIL.`_ OWNER-BUILDER DECLARATION n DATE O" =f=ibs I hereby affirm that I am exempt from the Contractor's License �e`L�� �L' sOu��i 7" c��1�3� 'Law for the following reason (Section-7031.5, Business and ADDRESS/035'Q'✓r0 v Aya ,1'r. FINAL Professions Code): PRESENT By BUILDINGvj'1D •'S 11 j tom! © �. Te::, le L. ( •, ; -- - i r 4 ❑ I, as owner of the property, or my employees with ADDRESS ^ f} wages as their sole compensation,will do the work and U n� ,2r N ( _'r the structure is not intended or offered for sale(Section LOCALITY Y �' 7044, Business and Professions Code.) MOVING TEL. �_ CONTRACTOR NO. J. I, as owner of the property, am exclusively contracting `, .-• 4 ' =t _ with licensed contractors to construct the project (Sec- ` ADDRESS tion 7044, Business and Profess ions.Code,.) REQUIRED TOTAL SETBACK FROM EXIST. S i CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH 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. 717, 7� (Sec. 3097, Civ. C.). SIDE t a,-.•: €� P.L.. Lender's Name p ; r,_..'_"+. O 1!" f Permit Fee Q LDMA Ref. # -A,, ul ^ Lender's Address P.C..Fee$ t�� a L o I certify that I have read this application and state that the 11 Issuance Fee 7 Jr LDMA P/C# �j 0 8 above information is correct. I agree to comply with all County Investigation Fee _ � 0 ordinances and State laws relating td building constructiona� ✓, Total Fee a7 LDMA Perm. # • - �f•. •'• a and hpreby authorize representatives of this County to enter .��. :314z•"'"' upon he above-mentioned property for inspection pur`[po�s. - - j .10f"*��� dun i' T 9 L SEE REVERSE FOR EXPLANATORY LANGUAGE Signature A Applicant or Agent Date WGRKERS' COMPENSATION DECLARATION insure,oraffirm that te of Workers' Compensation eInsuran e, APPLICATION FOR BUILDING PERMIT or a certified copy thereof (Sec. 3800, Lab: C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company BUILDING j Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS ❑ Certified copy is filed with the county building inspec- BUILDING tion department. ADDRESS CITY' ' ZIP [ �0 LOCALITY41 Date Applicant, NO. OF BLDGS. NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF.LOT f2 O NOW ON LOT CROSS ST. COMPENSATION INSURANCE ASSESSOR 7 (� (This section need not be completed if the permit is for one TRACT BLOCK A LOT NO. MAP BOOK, )S7 PAGE O PARCEL hundred dollars ($100) or less.) TEL. USE ZONE MAP //� OWNER [ i NO. Z Z� 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 AM 2 SPECIAL d CONDITIONS O so as to become subject to the Workers' Compensation Laws. V _ CITY �� ,! ZIP qfD30 UU Date Applicant ARCHITECT OR—r- TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY 0 NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER [ NO. 2 U 9 CONST. ZONE Exemption, you should become subject to the. Workers' Q Compensation provisions of the Labor Code, you must forth- ADDRESS /"f�k / 4.c) b 3 to with comply with, such provisions or this permit shall be TEL. I STATISTICAL CLASSIFI T deemed revoked. CONTRACTOR NO. - Z LICENSED CONTRACTORS DECLARATION LIC. JtF' CLASS N0.0DWELL. UNITS v I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS fI LIC _ LIC. SEWER MAP (commencing with Section 7000)of Division 3 of the Business CITY CLASS VALIDATION and Professions Code,and my license is in full force and effect. BK. PG. SQ. FT. r NO. OF NO. OF CHECK License Number Lic. Class SIZE STORIES FAMILIES ONE VALUATION Contractor Date DESCRIPTION OF WORK NEWC3Z� ADD ❑ f ..r ElPoo.I am exempt under Sec. Kn ALTER ❑ B.&P.C. for this reasonREPAIR ❑ $ Date: USE OF EXISTING BLDG. DEMO' I Signature APPLICANT TEL. FINAL OWNER-BUILDER DECLARATION (PRINT) e-/," (, NO. o DATE I hereby affirm that I am exempt from the Contractor's.License ADDRESS �2J y� .Q� :t wJ CCd Law for the following reason (Section 7031.5, Business and 9/d FINAL Professions Code): PRESENT by '- BUILDING. { ❑ I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and '7– the the structure is not intended or offered for sale(Section LOCALITYPoo. f,_,_: 7044, Business and Professions Code.) MOVING 'TEL. , IAI I, as owner of the property, am exclusively contracting CONTRACTOR NO. L with licensed contractors to construct the project (Sec- ADDRESS '•_ °a tion 7044, Business and Professions Code.) _ REQUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP.'HNE WIDTH. J_Fl I hereby affirm that there is a construction lending agency for FRONT L +, , the performance of the work for which this permit is issued P.L. t (Sec. 3097, Civ. C.). SIDE. - 3 F-r z` 4 1 = 69 -P.L. Lender's Name LDMA Ref. # P.C. Fee$ Permit Fee { )i••. �,_•� ;,-- Lender's Address D Piloti:.__ 0 1 certify that I have read this application and state that the o Issuance Fee, LDMA P/C# 8 above information is correct.1 agree to comply with all County Investigation fee _ R . ordinances and State laws relating to building construction, Total Fee `� LDMA Perm..# ¢i Xlltn. =–(i? Is tri_+J�?,` a and hereby authorize representatives of this County to enter upon th e-mentio d property for inspection purposes. _ E, ? SEE REVERSE FOR EXPLANATORY LANGUAGE Signatureo pplicant or Agent Date