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Home My Public Portal About5115 FARAGO AVE_Building__ K '= ' APPLICATION FOR BUILDING PERMIT i1 COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL INBUILDING ADDRESS BUILDING ADDRESS I hereby affirm that I have a certificate of consent to self insure, ) a or a certificate of Workers'Compensation Insurance,or a certified l I copy thereof(Sec.3800,Lab.C.) CIS l}_, ZIP 400 � LOCALIr �� tq SIZE OF OT G Policy No. Company NO.OF BLDGS.NOW LOT El Certified copy is hereby furnished. � 0 O NEAREST CROSS ST. ❑ Certified copy is filed with the county building inspection TRACT BLOCK LOT NO. department. USE ZONE MAP NO. AIAASSESSOR-MAP BOOK- PAGE PARCEL Date Applicant 0 O �_ SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' OWN R TEL.NO. COMPENSATION INSURANCEIAN WITHIN 1000 FT.OF SCHOOL? res No ADDRESS (This section need not be completed if the permit is for one hundred i (P1 DISTRICT GROUP TYPE CONST.' FIRE ZONE OCESSE Y dollars($hat or less.) /50yr Z 3CI ZIP1 "✓"� I certify that in the performance of the work for which this permit d �I s is issued, I shall not employ any person in any manner so as to ARCHIT Cj OR ENGINEER L O. become subject to the Workers'Compensation Laws. —rauyIs 1 LJ – i STATISTICAL CLASSIFICATION APT CONDO Date Applicant ADDRESS i�,� ,y_ 9 CLASS NO. �O DWELL UNITS ¢� NOTICE TO APPLICANT. If, after making this Certificate of ' """ =rf "" REQUIRED you TOTAL SETBACK FROM EXIST Exemption, Y 1tion, should become subject to the Workers' CONTRACTOR TEL.NO. �� Compensation provisions of the Labor Code, you must forthwith SET BACK YARD HWY PROP LINE WIDTHFRONT comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC.NO. PL LICENSED CONTRACTORS DECLARATION CITE' LIC.CLASS SIDE 3307 _3: , >. PL C I hereby affirm that 1 am licensed under provisions of Chapter 9 SEWER MAP i 1 1= v (commencing with Section 7000)of Division 3 of the Business and SO.FT.SI E NO.OF STORES NO.OF FAMILIES �+ Professions Code,and my license is in full force and effect. NEW BK C PG /02-� I I_'1((�L - 0 0; DESCRIPTION OF WORK VALUATI NLicense Number Lic.Class ADD , CHECK 191.i W Contractor Date , n ALTER ❑ ° CNAV113E .10E i_z C3I am exempt under Sec. REPAIR ❑ $ BARC.for this reason t\\ DEMOL ❑ 6/1-9/9101 i ��" LDMA P/C# {I�iI,��i^I�I11�i L;l 1'� 9(.i USE OF EXISTING BLDG. ' Date: s URM q •—z' Rc- Signature '„I6 9 \ APPLIS',"T(PRI T) L�jNO. LDMA Perm# _ ElI, as owner of the property, or my employees with wages as ®� /U /d �3 Z ' their sole compensation,will do the work and the structu4and DRESS _ pyy FINAL DATE ~ not intended or offered for sale (Section 7044, Business !V a G /ofessions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL ! �_l` `3 J 1, as owner of theproperty, am exclusive) contracting OR A MIXTURECONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN 4XY g THE AMOUNTS S EC FIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY ,'llcensed contractors to construct the project.(Section 7ves❑ No ' Business and Professions Code.) _ WILL THE INTENDED USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING16 `i�i OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTHJI •" .i._,„ •• - CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST i^ FOR GUIDELINES. �( O �� '.. - SMI•, I hereby affirm that there is a construction lending agency for YES El NO the performance of the work for which this permit is issued(Sec. „�!� "i 3097,CIV.C.. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD •�f, p� ) PERMITTING CHECKLIST.1 UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES 3:j_'•�";;•'�_:' COUNTYCODE,T RAFTER 2.205 10 .24100 THROUGH 2.20.140 CONCERNING - -•-- - Lender's Name HAZARDOU ERIA EPORTING F TAINING A PERMIT FROM THE SCAQMD. n 0. Cl Lender's Address OWNER OR ADEM Cl I certify that I have read this application and state that the above information IS correct. I agree to comply With all county PC.FEE PERMIT FEE (} „ ordinances and State laws relating to building construction,and 1 a. hereby authorize re resentatives of this County to enter upon 40"', � ISSUANCE FE �� - th menti pr per for inspection pur ose �J _ f" lay: a ..� INVESTIGATION FEE TOTAL FEE Siprie of ,R M Oe / -�O SEE REVERSE FOR EXPLANATORY LANGUAGE 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 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- BUILDING ADDRESS rl f tion department. �!} �7 Q Date Applicant CITY O. OF zip' f ` ® LOCALITY � dCSCi CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT S Z�rJ' NOW ON LOT NEAREST CROSS ST. COMPENSATION INSURANCE ASSESSOR (This section need not be completed if the permit is for one TRACT BLOCK I A, I LOT NO. MAP BOOK 5-7 PAGE PARCEL 0 hundred dollars ($100)or less.) OWNER NO~7 USE ZONE MAP t4--7 « Z NO. I I certify that in the performance of the work for which this _ '/�� 'Z SPECIAL d permit is issued, I shall not employ any person in any manner ADDRESS � '` CONDITIONS O so as to become subject to the Workers' Compensation Laws. CITY ZIP b U Date Applicant ARCHIT CT OR TEL. V97 DISTRICTGROUP TYPE FIRE PROCESSED BY O NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER —7Q 510 NO. CONST. ZONE V Exemption, you should become subject to the Workers' p � YY — .3 ua Compensation provisions of the Labor Code, you must forth- ADDRESS �1 �a N with comply with such provisions or this permit shall be TEL. gf TATISTICAL CLASSIFICMJCONDO.. Z CONTRACTOR NO. deemed revoked. LIC --y CLASS NO. 00 DWELL. UNITS LICENSED CONTRACTORS DECLARATION ADDRESS 0 NO. 3 I4'6 S / I hereby affirm that I am licensed under provisions of Chapter 9 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 r CLASS BK PG VALIDATION SQ. FT. rr NO. OF NO. OF., CHECK License Number Lic. Class SIZE ' G�' STORIES FAMILIES ONE VALUATION Contractor Date DESCRIPTION OF WORK NEW $ /j-O 000 ADD ❑ `"L"0 ► ❑I am exempt under Sec. _ ALTER ❑ B.&P.C. for this reason I AA 4 REPAIR ❑ $ Date: USE OF EXISTING BLDG. DEMOL ❑ Signature APPLICANT • p , TEL., ^�{ FINAL OWNER-BUILDER DECLARATION (PRINT]V NO. Z DATE I hereby affirm that I am exempt from the Contractor's License /�"C.l j4G Law,for the following reason (Section 7031'.5,,Business and ADDRESS FINAL Professions Code): PRESENT By ❑ I, as owner of the ro ert BUILDING + s p p y,.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 [ADDR ALITY 7044, Business and Professions Code.') VING TEL. 3 TRACTOR NO. I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec- Tion 7044; Business'and Professions Code.) ESS T QUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY T BACK YARD HWY PROP. LINE WIDTH ��• I hereby affirm that there is a construction lending agency for ONT the performance of the work for which this permit is issued L. (Sec. 3097, Civ: C.). SIDE 65 L. Lender's Name. '{=i ii '7.L m �+//' a LDMA Ref. # _r Fee$ ' VAC' Permit Fee � 'v3 z Lender's Addresspiol 0 1 certify that I'have read this application and state that the O Issuance Fee /' / LDMA P/C# above information is correct. I agree to comply with all County stigation Fee g Cp�J / 11F li E E—i t'-E_,i3j# s.+,•,4—�•;j''1 n ordinances and State laws relating to building construction, Total Fee �• LDMA Perm. # -- and hereb authorize representatives of this County.to enter upon t ove-me t' ne property for inspectioni purposes .csu; y AN€ e._,'i a - �j SEE REVERSE FOR EXPLANATORY LANGUAGE. Signature 97 Ap licant or Agent Date