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Home My Public Portal About5119 FARAGO AVE_Building__ WORKERS' COMPENSATION DECLARATION affirm that I have kspn ;oene insure, racertifcate of Wore ' ComesanIsurance, 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 ElCertified copy is filed with the county building inspec- BUILDING x= tion department. ADDRESS V CITY' ZIP '790 LOCALITY Date Applicant O. OF BLDGS. CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT lif i) NOW ON LOT NEAREST CROSS ST. COMPENSATION INSURANCE ASSESSOR (This.section need not be completed if the permit is'for one TRACT ' �I` BLOCK / LOT NO. MAP BOOK PAGE PARCEL hundred dollars ($100) or.less.) OWNER TEL.NO. ` USE ZONE MAP I certify that in the performance of the work for which this SPE r permit is issued, I shall not employ an person in an manner ADDRESS ? SPECIAL O •. P P Y Y P Y � ` CONDITIONS so as to become subject to the Workers'Compensation Laws. Q s// _ V CITY ZIP -( L ! b U Date Applicant ARCHITECT ORS- TEL.-Za3 DISTRICT GROUP TYPE FIRE PROCESSED BY O NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. - 2� CONST. ZONE Exemption, you should become subject to .the Workers' �y j 51 o� -�j "j7" f W Compensation provisions of the Labor Code, you must forth- ADDRESS f -• r N with comply with such provisions or this permit shall be TEL I STATISTICAL CLASSIFIC TI PT O O. Z deemed revoked. CONTRACTOR O. — LICENSED CONTRACTORS DECLARATION IC. CLASS NO. DWELL. UNITS d I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS b NO. 1 46�5 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 7U INO. OFCHECK License Number Lic. Class SIZE 5 STORIES �/ FAMILIES ' ONE , VALUATION Contractor Date DESCRIPTION OF WORK NEW gp � ADD - ❑ a � ► ElI am exempt under Sec. 2pl3dL"LA L&A 2:g ALTER ❑ B.BP.C. for this reason REPAIR ❑ $ Date: USE OF EXISTING BLDG. DEMOL Signature APPLICANT TEL.'Z( g OWNER-BUILDER DECLARATION (PRINT)-rO� 910 NO. l FINAL DATE . 16-1.A3 ¢Q� 1�(� I hereby affirm that I am exempt from the Contractor's License ADDRESS 1� I��L l'=l!" Law for the following reason (Section 7031.5, Business and FINAL _» Professions Code): PRESENT By ) :,i-, _:F : ❑ I, as owner of the property, or my employees with ADDRESS BUILDING }�- wages as their sole compensation,will do the work and , Z-if. 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. - - with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code.) [!iETotal TOTAL SETBACK FROM EXIST. »-- + - •_ -- CONSTRUCTION LENDING AGENCY YARD HWY PROP. LINE WIDTH I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued w.� r (Sec. 3097, Civ.'C.). '• i,'-;L. k. _ 6 a Lender's Name, (J'-•4{ c-/ LDMA Ref. #i 3�b PermitFee 31 Lender's Address1 certify that I have read this application and state that the 7, Issuance Fee �r LDMA P/C# above information is correct. I agree to comply with all County e - d ordinances and State laws relating to building construction, Total Fee LDMA Perm. # `=(�''`ti-'s4`�i •, +--• ',•• a and hereb authorize representatives of this County to enter r•-; - upon t a ove-men' ned -toperty for inspection purposes. -- - AN t°'-'4) < 3 SEE REVERSE FOR EXPLANATORY LANGUAGE Signature oQkpplicant or Agent Date APPLICATION FOR BUILDING PERMIT COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS BUILDINGDDRESS I hereby affirm that I have a certificate of consent to self insure, ( O � �� Or a certificate of Workers'Compensation Insurance,or a certified 129A 61 CIN ZIP I IT copy thereof(Sec.3800,Lab.C.) �( �/Q Policy No. Company i 1 1 j r! LOCALITY SIZE OF LOT NO.OF BLDGS.NOW ON LOT ❑ Certified copy is hereby furnished. S X Zl I NEAREST CROSS ST. ❑ Certified copy is filed with the county building inspection TR BLOCK LOT NO. department. USE ZONE MAP NO. L,f Date Applicant ASSESSOR MAP BOOK PAGE PARCEL yn A/ 7 \ -"qSPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER ' TFL.NO. _ 2 / lar 8 YES NO COMPENSATION INSURANCE WITHIN 1000 FT OF SCHOOL? ADDRESS (This section need not be completed if the permit is for one hundred DISTRICT GROUP ITYPECONST' FIRE ZONE YESSWBY dollars that or less.)p I ZIP I ,D(j I certify that in the performance of the work for which this permit O176 � Ux is issued, I shall not employ any person in any manner so as to ENGI EER T L.NO. 3 become subject to the Workers'Compensation Laws. p / ,� 23 STATISTICAL CLASSIFICATION APT DO Date Applicant ADDRESS - CLASS NO. 400 DWELL UNITS NOTICE TO APPLICANT. If, after makingthis Certificate of 0 F, O� Exemption, NEY 1179 REQUIRED TOTAL SETBACK FROM EXIST you ShOUId become subject to the Workers' CONTRACTOR T L.NO. SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith FRONT comply with such provisions or this permit shall be deemedrevoked. ADDRESS LIC.NO. PL LICENSED CONTRACTORS DECLARATION CITE' LIC.CLASS SIDE a PL I IO I hereby affirm that I am licensed under provisions of Chapter 9 SO. .SIZE NO. STORES NO. JIE SEWER MAP tC (commencing with Section 7000)of Division 3 of the Business and / W �( BK Q PGA� - Professions Code,and my license is in full force and effect. �p! 2 Y`x ► PT I— DESCRIPTION OF WORK VALUATION _.L g w License Number Lic.Class (JNID ❑ _ 'f 619.01 0- Contractor Date TER ❑ z PAIR ❑ $ D®o 49-0 1 i i EMS — ❑ I am exempt under Sec. i IHL , B.BP.C.for this reason MOL ❑USE OF EXISTING BLDG. LDMA P/C#Date: M. ❑ CHECK 'e�t i Signature APPLICANT PRINT) T L. O. _�'.Iyl NGE LDMA Perm# . •. !•. ❑ I, as owner of theproperty, or m em to employees with wages as Z •%Y P Y 9 S p Vii:_• their sole compensation,will do the work and the structure is AD RESS not intended or offered for sale (Section 7044, Business and 0OFINAL DATEJ� Q [#000_--00 [ vI s•�f.moi;) Professions Code.) WILL THE APPLICANT OR FUTURE BUILDINGOCCUPAN HANDLE AHAZARDOUS MATERIAL v -/♦q 1358 A�lu }�a�° OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN l ' 3 l- ❑ 1, as owner Of the property, am exclusively contracting With THE AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL eY licensed contractors to construct the project.(Section 7044, v9' YES 1:1 NO ' ' r Business and Professions Code.) _ ,,_,•:,. WILL THE INTENDED USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING - .1••: •••• OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH ^ " CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR GUIDELINE , I hereby affirm that there is a construction lending agency for YES 1:1 No 'V`�`r�I Y "_:',`5' 13 the performance Of the Work for which this permit IS ISSU@d(Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD 3097,,Civ.CIV.C.). PERMITTING CHECKLIST.I UNDERSTAND MY QUIRE ENTS UNDER THE LOS ANGELES m. COUNTY CODE,TITLE2 ER 220 SECT 52 THROUGH 2.20.140 CONCERNING s Lender's Name HAZARDOUS MA S RTING AND TAINING A PERMIT FROM THE SCAQMD. Lender's Address i( OWNER OR AGENT o' 1 certify that I have read this application and state that the above - information is correct. I agree to comply with all county P.C.FEE PERMIT FEE ordinances and State laws relating to building construction,and a. hereby authorize representatives of this County to enter upon �0 ISSUANCE FEE thga a-menti d p perty for inspection purposes. n i INVESTIGATION FEE TOTAL FEE SEE REVERSE FOR EXPLANATORY LANGUAGE,