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HomeMy Public PortalAbout5113 FARAGO AVE_Building__ WORKERS'COMPENSATION DECLARATION tAir that te of Worke s' Compensat on eInsuran of sure bor acertificate APPLICATION FOR BUILDING PERMIT or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDIADDRESG /V- Certified Certified copy is filed with the county.building.inspec- BUILDING tion department. ADDRESS S 1// 7 CITY,, e� ie CA ZIP / / �'D LOCALITY Date Applicant NO. OF BLDGS. CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT �X Z j NOW ON LOT 2 NEAREST CROSS SL COMPENSATION INSURANCE If ASSESSOR (This section*need not be completed if the permit is for one TRACT /149'7 9 BLOCK ZD 7 LOT NO. MAP BOOK � PAGE PARCEL dam/ hundred dollars ($100) or less.) T i�' r, TEL. zt3 USE ZONE MAP ' • OWNER I b ^, / l VL4 NO.2 -tliEt NO. I certify that in the performance of the work for which this permit is issued, I sholl.not employ any person in any manner ADDRESS 1f`/� /p �� G -�— SPECIAL a CONDITIONS O so as to become subject to'The Workers:Compensation:Laws. U CITY SO �A .( e"I ZIP /it 3 a Date Applicant ARCHITECT OR TEL. / W DISTRICT GROUP TYPE FIRE PROCESSED BY NOTICE TO.APPLICANT: If, after making this Certificate of ENGINEER N. 5;a NO. 35 7 L3, CONST. ZONE 0 Exemption, you should become 'subject.to the Workers' �q U Compensation provisions of the Labor Code, you must.forth- ADDRESS 3�'C - 1dl CDS! J' M� 1I N 3 with comply with such provisions or this permit shall be TEL" STATISTICAL CLASSIFICATION APT. CONDO. ' N deemed revoked. CONTRACTOR NO. , Z69,1 LICENSED CONTRACTORS DECLARATION U CLASS NO. 69,1 DWELL. UNITS v— I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS SEWER MAP '(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 �^*�—PG � ,_`"VALIDATION SQ. FT. / NO. OF NO. OF f CHECK SIZE " fi'�1p' STORIES Z FAMILIES ` ONE ^� License Number Lic: Class' tt,t:i a s VALUATION p Contractor Date DESCRIPTION OF WORK NEW `ADD ❑ r ', C, ❑I am exempt under Sec. ALTER ❑ ��iB.&P.C. for this reason REPAIR ❑ S gad }r_r' Z a 2:3 USE OF f{ CHECK t Date: EXISTING BLDG. el(r'n — sllr �ki I'CAM DEMOL ❑ _�7 g APPLICANT Z 1 FINAL t•hi{:'�t3 Signature ;] TEL. Li OWNER-BUILDER DECLARATION (PRINT) pi�fti f rJ N0:7-5-7—,mp o9_s I hereby affirm that 1 am exempt from the Contractor's License j ]fei,1 A ��� /p DATE Q�- Law for the followingreason Section 7031.5, Business and ADDRESS/0T /-p .1 Y R N�t4 FINAL Professions Code): PRESENT. _ By r21 BUILDING 5/O Ci 11 YBr s� /Q• / t ❑ I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,wil l'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. U :. i r• with licensed contractors To construct the project.(Sec- ADDRESS tion 7044, Business and Professions Code..) REQUIRED, TOTAL SETBACK FROM : EXIST. M71 CONSTRUCTION LENDING AGENCY SET.BACK YARD HWY PROP. LINE WIDTH "'--' _".._, .:.. I hereby affirm that there is a construction lending agency for FRONT t - F •i.:4; the performance.of the work for which this permit is issued P.L. 2_0 (Sec. 3097, Civ..C.). SIDE P.L: . f - Lender's Name 4s r aOo /' � LDMA Ref. # P.C. Fee$ (Qf` Permit Fee e ESL 3 Lender's Address , NGE Lt o 1 certify that I have read this application and state that the9 . 3 L. Issuance Fee �S LDMA P/C# 8 above information is correct. I agree to comply with all County Invesrigation:Fee J Gj d ordinances and State laws relating to building construction, Total Fee /� /• LDMA Perm. # a and he by authorize representatives of this County to enter " upon t eabove-mentioned property for inspection purposes. { !"� (.tn� � Z SEE REVERSE FOR EXPLANATORY LANGUAGE Signature df Applicant or Agent Date WORKERS' COMPENSATION DECLARATION to sf insure, or a certif carte of Workers' Compensat on I have a certificate of coent Insuran e, APPLICATION FOR_ BUILDING PERMIT or a certified copy.therebf (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 11 '25 ❑ Certified copy is filed with the county building inspec- BUILDING p tion department. ADDRESS 1 Date A licant CITY ZIP ( LOCALITY pp NO. OF BLDGS. NEAREST dr CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF.LOT d NOW ON LOT CROSS ST. COMPENSATION INSURANCE tASSESSOR _ Q j (This section need not be completed if the permit is for one TRACT i` �� BLOCK LOT NO. MAP BOOK PAGE U PARCEL r ' hundred dollars ($100) or less.) TEL. 7.43 OWNER _ NO. USE ZONE MAP I certify that in the performance of the work for which this SPE } SPECIAL permit is issued, I shall not employ any person in any manner ADDRESS �`� CONDITIONS d O so as to become subject to the Workers' Compensation Laws. p U CITY ZIP Date Applicant ARCHITECT O TEL. ?(7 DISTRICT GROUP TYPE FIRE PROCESSED BY 0 NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. _ -2 CONST. ZONE 0 Exemption, you should become subject to the Workers' t l iII� w Compensation provisions of the Labor Code, you must forth- ADDRESS �iffhl /� a with comply with. such provisions or this permit shall be r TEL. ��$ STATISTICAL CLASSIFIC TI O. Z deemed revoked. CONTRACTOR NO. L� J� ' / — LICENSED CONTRACTORS DECLARATION UC. CLASS NO.�_DWELL. UNITS J_${� V I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO' _ SEWER MAP (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 PG VALIDATION SQ. FT. NO. OF 0 NO. OF CHECK License Number Lic. Class SIZE STORIES v FAMILIES ONE VALUATION Contractor Date DESCRIPTION OF WORK NEW /.t/e/J ADD S , EI �I am exempt under Sec.' ALTER ❑ B.BP.C. for this reason REPAIR ❑ $ Date: USE OF EXISTING BLDG. DEMOL ❑ Signature APPLICANT TEL. FINAL q ) Q 7 OWNER-BUILDER DECLARATION (PRINT) (f NO. . n — DATE f PJB f _q I hereby affirm that I am exempt from the Contractor's License ADDRESS © /' �D�c� Law for the following reason (Section 7031.5, Business and FINAL /(� �•_ Professions Code): PRESENT BY BUILDING ❑ I, as owner of the property, or my employees with ADDRESS t' wages as their sole compensation,will do the work and plop the structure is not intended or offered for sale(Section LOCALITY --"=a' 7044, Business and Professions Code.) MOVING TEL. — I, as owner of the property, am exclusively contracting CONTRACTOR NO. with licensed contractors to construct the project (Sec- ADDRESS is' tion 7044, Business and Profession's Code.) REQUIRED TOTAL SETBACK FROM EXIST. !:Z 'D}. 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.I. } (Sec. 3097, Civ, C.). SIDE i°E} `��€ ``;, P.L. Lender's Name3� :,;j-%:"4'A 9 1r! 7 � LDMA Ref. # m P.C.'Fee$ (/ Permit Fee f; j'y?J Lender's Address Poo I certify that I have read this application and state that the '��O Issuance Fee 7S LDMA P/C# 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. # �•'`j.'='-'` a and hereby authorize.representatives of this County to enter upon the ove-menti ed operty for inspection purposes. a •o P- G- SEE REVERSE FOR EXPLANATORY LANGUAGE Signature Ap icant or Agent Date