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Home My Public Portal About5121 FARAGO AVE_Building__ APPLICATION FOR BUILDING PERMIT COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS I hereby affirm that I have a certificate of consent to self insure, BUILDING ADDRESS_� 1-5 or a certificate of Workers'Compensation Insurance,or a certified Cl �� ZIP Tr 1I � �• (O copy thereof(Sec.3800,Lab.C.) LOCALITT '' LC Policy No. Company SIZE OF OT NO.OF BLDGS.Nr ON LOT JJ l� El copy is hereby furnished. C) NEAREST CROSS ST. ❑ Certified Copy Is filed with the county building inspection TRACT BLOCK LOT NO. � � C USE ZONE MAP NO. department. Date Applicant ASSESSOR MAP B OK PAGE PARCEL �� /-7 —17 Q /J_ SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER I UL.NO. 3� WITHIN 1000 FT OF SCHOOL? YES NO COMPENSATION INSURANCE OMP A5ffjAai/ADRESS (This section need not be completed if the permit is for one hundred DISTRICT GROUPI. FIRE ZONE OCESSE Y dollars($hat or less.) CITY zIP I, 3 3 I certify that in the performance of the work for which this permit � � is issued, 1 shall not employ any person in any manner so as to ARCHITECT R EN EER L. Oy F become subject to the Workers'Compensation Laws. ��' r- STATISTICAL CLASSIFICATION .L APT CONDO Date Applicant DRESS CLASS NO. 4120 DWELL UNITS NOTICE TO APPLICANT: If, after making this Certificateof CONTRACTOR TELNO. REQUIRED TOTAL SETBACK FROM EXIST Exemption, you should become subject to the Workers' 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 FIDE 1 s s (i 1� clrr uc.cLAss 3311 i�� o I hereby affirm that I am licensed under provisions of Chapter 9 SEWER MAP NUNS U (commencing with Section 7000)of Division 3 of the Business and SQ.FT.SI E/ NO.OF STORES NO.OF F MILIES 0 Professions Code,and my license is in full force and effect. S 1O r� NEW BK PG T i IAL 619 - 019-- DESC IPTION OF WORK ADD ❑ VALLILLJ License Number Lic.Class _.•a Contractor Date ALTER ❑ PAL };jam ❑ I am exempt under Sec. PAIR RE ❑ DOO�c*o LHANGi BARC.for this reason DEMOL ❑ LDMA P/C#URM Date: #-_-i t �' USE OF EXISTING BLDG. i UIUri Li ''I 1 =tf 1't ❑ Signature APPLICANT PRINT TEL. -` i i �`� °[I`I 9 ( 9 LDMA Perm y1 ❑ I, as owner of the property, or my employees with wages as 1 & J J p their sole compensation,will do the work and the structure isAPDRESj not intended or offered for sale (Section 7044, Business and Y. UTJ,�M INIK12 FINAL DATE a rofessions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS Q MATERIAL OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN -C ,h^'•.' a /11"censed as owner of the property, am exclusively contracting with THE AMOUNTS P FIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY contractors to construct the project.(Section 7044, YES❑ NO Business and Professions Code.) WILL THE INTENDED USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST ''\Vt ' FOR GUIDELINE /Y' ^�, I hereby affirm that there is a construction lending agency for ves❑ No ' the performance of the work for which this permit is issued(Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD 3097,CIV.C.). PERMITTING CHECKLIST.I UNDERSTAND MY REQUIR MENTS UNDER THE LOS ANGELES �'•'is_"' ,'v•' " �. COUNTY CODE.TITLE PTER 2.20 SE fIRI :OO'rHROUGH 2.20.140 CONCERNING e-y- o Lender's Name HAZARDOUS ALS PORTING A TA ING A PERMIT FROM THE SCAOMD. _, „,_L c J._ Lender's Address OWNER OR AGENT o I certify that I have read this application and state that the above ,..,�, _ .,, •• •_ Q information is Correct. I agree to comply with all County RC.FEE PERMIT FEE -i;.:i_:h•••a;; i.:,. Xz ordinances and State laws relating to building construction,and ® I a. hereby authorize re esentatives of this County to enter upon �j / ISSUANCE FEE y,('� '"I•j j`•-`'` ov menti p y for inspection purposes. " O� 6 /cJ a INVESTIGATION FEE TOTAL FEE mIna--y-2— D— — �}D Signe oo pli rA D— O SEE REVERSE FOR EXPLANATORY LANGUAGE, WORKERS' COMPENSATION DECLARATION ihsure bora certif carte of Workers' ComtpensaT on ent to Insuranc self 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 ZIP LOCALITY '75;X -2.+0 / OF BLDGS. NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT /5;X ZI V W ON LOT CROSS ST. COMPENSATION INSURANCE ASSESSOR ff (This section need not be completed if the permit is for one TRACT ( BLOCK LOT NO. MAP'BOOK PAGE PARCEL !0 hundred dollars ($100) or less.) TEL' L* USE ZONE MAP OWNER NO. - NO. I certify that in the performance of the work for which this SPECIAL rq� } permit is issued, I shall not employ any person in any manner ADDRESS 3 -Ci CONDITIONS n' so as to become subject to the Workers' Compensation Laws. OU CITY ZIP Date Applicant ARCHITECT O . TEL. DISTRICT GROUP TYPE FIREL.PROCESSED BYNOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. CONST. ZONE �Exemption, you should become' subject to, the Workers r (j 7 -7TwCompensation provisions of the Labor Code, you must forth- ADDRESS C � ✓f 7 JL- r a- with comply with such provisions or this permit shall be T L. FrSTATISTICAL CLASSIFICA NDO. Z deemed revoked. CONTRACTOR O. ` / - LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. DWELL. UNITS—� V I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO.j- (commencing with'Section 7000)of Division 3 of the BusinessLIC. SEWER MAP and Professions Code,and my license is in full force and effect. CITY CLASS BK. PG. VALIDATION SQ. FT. af NO. OF NO. OF CHECK License Number Lic: Class SIZE f . STORIES ?z FAMILIES 1 ONE VALUATION ' Contractor Date DESCRIPTION OF WORK NEW $ �JO El am exempt under Sec. CV /9.t� ADD ❑ `'� pop. ALTER ❑ B.&P.C:for this reason REPAIR ❑ $ Date: USE OF EXISTING BLDG. DEMOL ❑ Signature APPLICANT TEL. FINAL OWNER-BUILDER DECLARATION (PRINT) p s!V NO. - DATE I hereby affirm that I am exempt from the Contractor's Licensepp Law for the following reason (Section 7031.5, Business and ADDRESS D WFINAL Professions Code): PRESENT By _ ❑ I, as owner. of theproperty, or m em to employees with BUILDING Y P Y ADDRESS i''�"1 °•" wages as their-sole compensation,will do the work and the structure is not intended or offered for sale(Section LOCALITY ,. _ '»'r` -• ,"a 7044,•Business and Professions Code.) MOVING TEL. i 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.) UIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY BACK YARD HWY PROP:LINE WIDTH I hereby affirm that there is a construction lending agency for NT the performance of the work for which this permit is issued _ (Sec. 3097, Civ. C.). 3_[E; ,_ 69' Lender's Name �b � LDMA Ref. # _. =a•.as ee$ Permit Fee t; t ?:;Lender's Address --I certif that I have read this a lication and state That the �O o Issuance Fee LDMA P/C# t' IY PP above information is correct. I agree to comply with all County igation Fee / ons d ordinances and State laws relating to building construction, Total Fee C. /✓ LDMA Perm. # a and hereby authorize representatives of this County to enter »- ci i o upon above-m ntio d property for inspection purposes. »--»•"•1-'�3'-== •e .c,•:;''':_. o I yr r SEE REVERSE FOR EXPLANATORY LANGUAGE _ i') =is Signatur Ulf Applicant or Agent l Date