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Home My Public Portal About5117 FARAGO AVE_Building__ APPLICATION FOR BUILDING PERMIT �1 COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS BUILT?AD RESS I hereby affirm that I have a certificate of consent to self insure, //�� / or a certificate of Workers'Compensation Insurance,or a certified CITY zIP 40 copy thereof(Sec.3800,Lab.C.) �r7� LOC �� l � • Policy NO. Company SIZE OF LOT NO.OF BLDGS. OW ON LOT l ❑ Certified copy is hereby furnished. �� NEAREST CROSS ST. ❑ Certified copy is filed with the county building inspection TRACT 1 1 BLOCK LOT NO. dUSE ZONE MAP NO. department. `F 77 ASSESSO AP B OK PAGE PARCEL Date Applicant OWNER /(O SPECIAL CONDITIONS ' L. O YES NO CERTIFICATE OF EXEMPTION FROM WORKERS' OF SCHOOL? COMPENSATION INSURANCE WITHIN 1000 F ADDRESS (This section need not be completed if the permit is for one hundred > DISTRICT GROUP TYPE CONST.' FIRE ZONE JESS BY dollars($100)or less.) CI zlp q r 6 g I certify that in the performance of the work for which this permit ��(� Al L is issued, I'shall not employ any person in any manner so as to ARCHITEC O EN INEER T L. O. become subject to the Workers'Compensation Laws. �� C C ?� r "Z�' STATISTICAL CLASSIFICATION APT CONDO Date Applicant AD RESS '{i CLASS NO. 42455 DWELL UNITS NOTICE TO APPLICANT. If, after making this Certificate Of b YA, • REQUIRED TOTAL SETBACK FROM EXIST Exemption, you should become subject to the Workers' CCNTRACTOR - TEL.NO. I � SETBACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith FRONT comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC.NO. PL LICENSED CONTRACTORS DECLARATION CITE' LIC.CLASS SID y'_ 0- I hereby affirm that I am licensed under provisions of Chapter 9 SEWER MAP Ff'_•=I>e a S ZE NO.OF STORES NO.OF FAMILIES (commencing with Section 7000)of Division 3 of the Business and eOz Professions Code,and my license is in full force and effect. NEW BK PG � 2 � , 33 i{ 7� o-3=0 DESCRIPTION OF WORK ADD ❑ VALUATION q Uva License Number Lic.Class z Contractor Date DACAMEP O ALTER ❑ o � N O O Z�• e� TOTAL "a ? ❑ I am exempt under Sec. REPAIR ❑ $ / CHECK �19.�I 1 B.BP.C.for this reason DEMOL ❑ LOMA P/C# CHANGE R DO%E OF EXISTING BLDG. URM ❑ Signature AP 2UCANT(P IN ) W x -y1 i qq r ,1_ O[GJJ �23 LDMA Perm# z hil„I130-1�1IJL.t C/17?r r� ❑ I, as owner of the property, or my employees with wages as � , their sole compensation,will do the work and the structure is ADDRESS O q +c i /1 Y'04 ( `9 + ' FINAL DATE Q t.i! 1 r9i<I�'1 a not intended or offered for sale Section 7044, Business and \ G firofessions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL lo —( A OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN J I, as owner of the property, am exclusively contracting with THE AMOUNTS S EC IED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY • ' {, ' Nowlicensed contractors to construct the project.(Section 7044, YES❑ No r,. Business and Professions Code.) WILL THE INTENDED USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING `•t•=`-°� "'"""' "•` OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR GUIDELINES I hereby affirm that there is a construction lending agency for YES❑ No the performance of the work for which this permit is issued(Sec. _ I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD (�I��/ +••L? C'i:: "•: 3097,CIV.C.). PERMITTING CHECKLIST.I UNDERSTAND MY REQUIRE TS UNDER THE LOS ANGELES 'A , 'f•_' •••--""I 7`�'� Lenders Name CAZA DCODE,TITL PTER2.20SECTIO 22�FIROUGH2.20.14000NCERNING HAZARDOUSM ALS ORTING ANDF OBT. APERMIT FROM THE SCAQMD. Lender's AddressJ4A IQ OWNER OR AGENT , o 1 certify that I have read this application and state that the above FEE FEE P.C. PERMIT information is correct. I agree to comply with all county "i3ri`:"El•-ii''( "s ;,/ ordinances and State laws relating to building construction,and ¢. hereby nze represe tatives of this County to enter upon /�O� z ISSUANCE FE �� t ov entioned. a or inspection pure es. ¢ INVESTIGATION FEE TOTAL FEE SID of Applicant or Dab /• a% 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, AP 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 BUILDING ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS ❑ Certified copy is filed with the county building inspec- BUILDING tion department. ADDRESS Date Applicant CITY i ZIP LOCALITY pp NQ. OF BLDGS. NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT 2NOW ON LOT CROSS ST. COMPENSATION INSURANCEQ ASSESSOR (This section need not be completed if the permit is for one TRACT I BLOCK A LOT NO. G MAP BOOK � PAGE PARCEL 1110 hundred dollars ($100) or less.) % TEL. f(i OWNERQgaA NO. USE ZONE MAP 14-1 (1 I certify that in the performance of the work for which this NO. permit is issued, I shall not employ any person'in any manner ADDRESS i �~v CONDITIONS O so as to become subject to the Workers' Compensation Laws. 7 V CITY ZIP 41 Date Applicant ARCHITECT O - TEL.�{a� DISTRICT GROUP TYPE FIRE PROCESSED BY t0 NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER//• TN — 2 CONST. ZONE U Exemption, you should become subject to. the Workers' ADDRESS(� �!O� R 3 w Compensation provisions of the Labor Code, you must forth- N with comply with such provisions or this permit shall be , 1 TEL. I STATISTICAL FI CLASS CONDO. Z deemed revoked. CONTRACTOR tLJ NO.— 1 / — LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. Cs O DWELL. UNITS 'FSZ V I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS'gG NO. b S 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 JIINO. OFNO. OF CHECK License Number_ Lic. Class SIZE , �j STORIES FAMILIES ONE yam{ VALUATION Contractor Date DESCRIPTION OF WORK NEW ADD ❑ $ t� , ❑I am exempt under Sec. ALTER ❑ BAP.C. for this reason REPAIR ❑ a Dare: USE OF EXISTING BLDG. DEMOL ❑ Signature APPLICANT TEL. -24 PRINT • ' /] g OWNER-BUILDER DECLARATION (PRINT) v tN�On - f _DATE L I hereby affirm that.1 am exempt from the Contractor's License ADDRESS )344,9s�v /-(/ 7 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 wages as their sole compensation,will do the work and 5 nt•; the structure is not intended or offered for sale(Section LOCALITY , ti J r t •..in 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 . Tion 7044, Business and Professions.Code.) REQUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH I hereby affirm that there is a construction lending agency for FRONT :y ;T the performance of the work for which this permit is issued P.L. (Sec. 3097, Civ. C.). SIDE m :. P.L.. Lender's Name. WLDMA Ref. # P.C. Fee$ Zi Permit Fee J -� ►' d {.t ;��. Leners Address • ' r 0 1 certify that I have read this application and state that the O 9'. Issuance Fee LDMA P/C# above information is correct. I agree to comply with all County nvestigotion•Fee 8 / fit R ordinances and State laws relating to building construction, Total Fee tB � LDMA Perm. # .:•._.}..: a and hereb utho"zeJ A representatives of this County to enter . J m f _ a upon t a ve-mentio d p perty for inspection purposes. Li 1 SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of pplicant or Agent Date '