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HomeMy Public PortalAbout5135 FARAGO AVE_Building__ r. 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 o certified copy thereof (Sec. 3800, Lab. C.) S" y1�1A_ tin COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy NdfOH� �— Company S `�.IG T BUILDING �� ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN �J ADDRESS ❑ Certified copy is filed with the county building inspec- BUILDING tion department. /e�y / �/J, //�//,, ADDRESST '?128'0 Date 131' Applicant 7✓!k� �fLtx�r!" ['/k CITY / QMj e (f/ ZIP _ LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' NO. OF BLDGS. j NEAREST SIZE OF LOT NOW CROSS 57. COMPENSATION INSURANCE �r"C� /`�^• ON LOT � (This section need not be completed if the permit is for one l ASSESSOR - f 9 Z hundred dollars ($100)or less.) TRACT / �?� BLOCK LOT NO. MAP BOOK PAGE PARCEL TE Z f �2 USE ZONE MAP I certify that•in the performance of the work for which this OWNE ' ce L.h Q'/ N J� NO. permit is issued, I shall not employ any person in any manner ADDRESS l /��� �r-Qe�l &D Lam � SPECIAL so as to become subject to the Workers'Compensation Lows. p ff CONDITIONS (�7 PP ��7 CQ� `-►Lt i7 firC�! CITY � ZIP Date A licant ARCHITECT OR 7E�.,QJ NOTICE TO APPLICANT: If, after making this Certificate of Q t DISTRICT -GROUP TYPE FIRE PROCESSED BY ENGINEER NOY. 2411 CONST ZONE Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- ADDRESS W z -L 6S- �' 3 with comply with such provisions or this permit shall be /�//"" deemed revoked. CONTRACTOR T &:U j(Oq jL Z1_ STATISTICAL CLASSIFICATION APT. DO. LICENSED CONTRACTORS DECLARATION LIC, CLASS NO. r DWELL. UNITS - I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. 37 (commencing with Section 7000)of Division 3 of the Business and / LIC p SEWER MAP Professions Code, and my license is in full force and effect. CITY A-(Uatza 'CLASS /J BK PG VALIDATION } .t SO. FT. NO. OF NO. OF CHECK t1 License Number �¢ 3 7 Lic.Class SIZE STORIES FAMILIES ONE 0 m;my VALUATION U YteQ 1f( I—3 -O DESCRIPTION OF WORK NEW /i J1 O Contractor Lei/fi Date ADD ❑ $ 110 LYS` ❑ I am exempt under Sec. ALTER b ❑ , i LU B.BP.C. for this reason REPAIR ❑ $ Date: USE OF DEMOL ❑ z EXISTING BLDG. APPLICANT y� /' /� �) ( TEL A 4 Signature PRINT) IlKuC� U� JENO�y`F FINAL OWNER-BUILDER DECLARATION 4/� _ DATE I hereby affirm that I am exempt from the Contractor's License ADDRESS 0,1-whw Zd w PWIlk FINAL Low for the following reason (Section 7031.5, Business and Professions Code): PRESENT By El1, I, as owner of the property, 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 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). CONSTRUCTION LENDING AGENCY SETT BACKK YARD HWY. TOTAPROP.ETBLCNE dWIDTHK FROM I hereby affirm that there is a construction lending agency for FRONT the performance of the work for which this permit is issued P.L. '(Sec. 3097, Civ. C.). SIDE - -�i .t ,.., Tit jLd l�i(�c C//Lt.l P.L. ' fT 1 f Lender's Name LDMA Ref. # L 1 '"! y �' -' m f�� -�•- Ap. P.C. Fee$ Permit Fee t Lender's Address4cbSA'1..&��L�C, &&d T1 I certify that I have read this application and state thatthe Issuance Fee LDMA P/C# --above information is correct. I agree to comply with all County Investigation Fee '0ordinances and State laws relating to building construction, Total Fee ILDMA Perm. # R and h_ereby authorize re entatives of this County to enter up upo he above-menti n property.for inspection purposes. F e r.a SEE REVERSE FOR EXPLANATORY LANGUAGE01 ;� `�..•• � ��.yl y' Signature of Applicant or Agent Date :_tT •O CM C.0 [Q WORKERS' COMPENSATION DECLARATION �. I tfereby affirm ,;hat I have a certificate of consent to self AP PLICATION_.Y.F.O RBUILDING PERMIT insure, or a certificate of Workers' Compensation Insurance, or o 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 C' Y �O tion department. ADDRESS J /l Date Applicant CITY � 'C (_...L ZIP LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' NO. OF BLDGS. NEAREST COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS ST. (This section need not be completed if the permit is for one ASSESSOR hundred dollars ($100)or less.) TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL 11 TEL. n USE Z NE NO. _�� I certify that in the performance of the work for which this OWNER _tXtJ NO. 'V0� permit is issued, I shall not employ any person in any mannerADDRESS 0� �� CONDITIONS SPECIAL so as to become subject to the Workers'Compensation Laws. U CITY ZIP V Dote Applicant ARCHITECT OR TEL. NOTICE TO APPLICANT: ,If, after making this Certificate of ENGINEER NO. DISTRICT GROUP TYPE FIRE PROC SED BY O Exemption, you should become subject to the Workers' �/) CONS`T./ ZO E U Compensation provisions of the Labor Code, you must forth- ADDRESS -5 t v �3 Y � a, with comply with such provisions or this,permit shall be TEL. /,. STATISTICAL CLASSIFICATION _ APT. DO. deemed revoked. CONTRACTOR N NO.�(Y Z LICENSED CONTRACTORS DECLARATION //)� LIC. ' 3 I CLASS NO. DWELL. UNITS — I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESSA /LSO NA,(AL. NO.J�J 7 SEWER P (commencing with Section 7000)of Division 3 of the Business and LIC. Professions Code; and my license is in full force and effect. CITY O�lI�-+A CLASS �—2 BK PG L� VALIDATION SQ. FT INO. OF NO.OF CHECK Z License Number f Lic.ClassSIZE OD STORIES FAMILIES ONE �' �A'�� 2 ^ [3 VALUATION Coritractor /T Date DESCRIPTION OF WORK NEW ❑ 1 am exempt under Sec. �A 5 ADD ❑ s ALTER ❑ B.BP.C. for this reason REPAIR ❑ $ t Date: USE OF DEMOL 9 LG 1.9 A l EXISTING BLDG. i Signature APPLICANT C� ( �" '� � TEL.. o FINAL # o ® o 0 01 OWNER-BUILDER DECLARATION PRINT NODATE t I hereby affirm that I am exempt from the Contractor's License /�� Law for the following reason (Section 7031.5, Business and ADDRESS 1Z �^ � /" �/t FIN I is:o b Q 5 0 Professions Code): �� B BUILDING = ❑ I, as owner of the property, or my employees with ADDRESS o 0 6 6 c: wages as their sole compensation,will do the work and �- Q 5 0 the structure is not intended or offered for sale(Section LOCALITY 0 1 9.,-,88 7044, Business and Professions Code). MOVING TEL. ® j j ? CONTRACTOR NO. ❑ I, as owner of the property, am exclusively contracting with licensed contractors o construct theproject (Sec- ADDRESS tion 7044, Business and Professions Code). CK TW57W__ CONSTRUCTION LENDING AGENCY SETT REQUIRED YARD HWY TOTAPROP.SETBALINE 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.L. (Sec. 3097, Civ. C.). SIDE P.L. Lender's Name � LDMA Ref. # P.C. Fee$ Permit Fee �az L er's Address 3 I e if t at I have rqdh application and state that the l oPP Issuance Fee LDMA P/C# o a ov i fo motion is cgree to comply with all County Investigation Fee 0 o in n es and Stateting to building construction, Total Fee ff 1�+ LDMA Perm. # o a d er b authorizeatives of this County to enter u nth a o mentirty for inspection pur ores. D NColo y oo- ,� SEE REVERSE FOR EXPLANATORYt GUAGE Signature of,4pplicanf or A nt Date 6 �� / p� ` a� + 'WORKERS' COMPENSATION DECLARATION iRsureboraafirm certif cane of WorkersrtComte of pensat on Insuran nt to self APPLICATION FOR BUILDING PERMIT or a.certified copy thereo fISec. 3800, Lob. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy NoJ4D ompony s� 1:1Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING aJ_ 13 ADDRESS Certified copy is filed with the county building inspec- BUILDING E] tion department. /� 'l /�c ADDRESS Date Appl icant&14 `• /7 //^� CITY MP h� Ck ZIP LOCALITY [- CERTIFICA E OF EXEMPTION FROM WORKERS' SIZE OF LOT 1 1 X Z I NOW ON LOT NO. OF BLDGS. NEARESST. COMPENSATION INSURANCECROSS (This section need not be completed if the permit is for onea` 1C� A ASSESSOR hundred dollars ($100)or less.) TRACT ( (4 1 1 BLOCK / ` LOT NO. — MAP BOOK PAGE I PARCEL l' USE)IONE MAP t I certify that in the performance of the work for which this OWNER QWk N �SEJ l= NO.l1 l f� 2/ NO. !i permit is issued, I shall not employ any person in any manner • .4 yl, �-�f LNC( 1 L_k_o -,,J � � h !/ SPECIAL ADDRESS !! �� CONDITIONS so as to become subject to the Workers'Compensation Laws. n p p Applicant br�� �+ n6 CITY ILpW L/�N n ZIPq-14l b Date ARCHITECT OR TEL. �� �1 eqq NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT SC�Q�� LIs.� TEL. ,D—�Y 1' DISTRICT GROUP TYPE FIRE PROCf5,SEDBY 0 f CONST. ZONE C Exemption, you should become subject to the Workers' , ,� �I(r� 1 U Compensation provisions of the Labor Code, you must forth- ADDRESS 3a`S S PcZIAtITI'� IJ.�L� �n A M.P. 0 ��' ) �� _? a; with comply with such provisions or this permit shall be ` TE , STATISTICAL CLAS IFICATION APT. CONDO. N deemed revoked. CONTRACTOR W C_CG &A NO. 3Z LICENSED CONTRACTORS DECLARATION / LIC, �4 3 71fCLASS NO. DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS'*//J -F L,f�_0 v /o bNO. (commencing with Section 7000)of Division 3 of the Business andLIC SEWER MAP Professions Code, and my license is in full force and effect. CITY CLASS BK 9 PG rZ-f VALIDATION SO. FT. N OF NO.OF CHECK License Number 441 32 f Lic.Class SIZE ) FAMILIES 1 ONE 1n ,, VALUATION / Contractor -,e a t� Date 4— (6 DESCRIPTION OF WORK NEW $ 1�5'6q t_3Q ❑ I am exempt under Sec. L 5W ccoa W v-A,I ADD ❑ ALTER B.BP.C. for this reason REPAIR ❑ $ Date: USE OI F BLDG. DEMOL ❑ 22 9 8 Q 8 A EXISignature APPLICANT TEL. FINAL # o 0 0, o 23 ' OWNER-BUILDER DECLARATION PRINT c� N11O. L6 �,t DATE .1(} I hereby affirm that I am exempt from the Contractor's License ADDRES53�0 ��`a N��` RJp 1'Z�4&It ` I P FINA ) - 587. 1 5 Law for the following reason (Section 7031.5, Business and _ _ Professions Code): s ___' o .° 5 8 7. 1 5 "t ? cr, E] 1, �` 7SF pc > - I, as owner of the property, or my employees with ADDRESSj; wages as their sole compensation,will do the work and 6,-1'3`x_ 8 8 the structure is not intended or offered for sale(Section LOCALITY j -.•-: •—n,^^ICT '25 7044, Business and Professions Code). MOVING TEL. `� ` } r—`�s °"'-6 ❑ I, as owner of the property, am exclusively contracting CONTRACTOR 1" NO. t'p ; r�;�:-_ -c Vit: with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). •:r! M EXIST. CONSTRUCTION LENDING AGENCY SET BACKUIRED TOTAL SETBACK 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.L. (Sec. 3097, Civ. C.). SIDE T�� �lx� I3 =r - P.L. Lender's Name m q ���� �l LDMA;Ref. # r� Lender's Address S /7 /rJ '�>✓T.Y��yl/le� P.C. Fee$ Permit Fee l(/ /©r�✓ , 3 1 certify that I have read this application and state that the `�..,1 , o Y PP Issuance Fee •�J `' kLD P/C# above information is correct. I agree to comply with all County Investigation Fee h 0 ordinances and State laws relating to building construction, Total Fee �l1 LDMA Perm. # and hereby authorize rep esentatives of this County to enter < upon t above-menti property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date 1 WORKERS' COMPENSATION DEC!_ARATION to insure, or afcertif carte of Wo ke srlificate Compensa ion consent Insuran elf APPLICATION FOR BUILDING PERMIT or a certified copy thereof (Sec. 3800, Lal:%. C. COUNTY OF LOS ANGELES BUILDING AND SAFETY PolicyNd ?� -Cbmpany S 'u' ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING J T ADDRES,. ❑ Certified copy is filed with the county building inspec- BUILDING a 7� tion department. 1Ll�� ADDRESS 'N�S \�1\`_ �AFp` /S14S Date —3—4 Applicant �l" �!? tom- /J � 6 '"'C CITY Tt_�t_�z 'C��lT-4 ZIP LOCALITY CERTIFICAT9 OF EXEMPTION FROM WORKERS' SIZE OF LOT -ISS XZ, f NOW ON LOTNO. OF S NEARESST. COMPENSATION INSURANCECROSS (This section need not be completed if the permit is for one1 U ASSESSOR hundred dollars ($100)or less.) TRACT t1� �� ,+ BLOCK ` \ LOT NO. 1� MAP BOOK PAGE PARCEL OWNER �� t^V� �`�vw NO., 1� Srs USE ZONE MAP I certify that in the performance of the work for which this (,� `1 NO. permit is issued, I shall not employ any person in any manner gDDRESSt 1��� �-`����`����� �'� SPECIAL so as to become subject to the Workers'Compensation Law ES �1 �7 CONDITIONS 0 r e,/J CITY 1���13 L td U �� ZIP �� L4 0 G� Date Applicant �P NOTICE TO APPL ANT: If, after makingthis Certificate of ARCHITECT OR TEL DISTRICT GROUP TYPE FIRE PROCESSED BY NO. .�S��"+ �� CONST. ZONE 0 Exemption, you should become subject to the Workers' (� Compensation provisions of the Labor Code, you must forth- ADDRESS�,�� %`. P+j�NZl� l� T' Z • W with comply with such provisions or this permit shall be CL deemed revoked. CONTRACTOR ` Te(.$I STATISTICAL CLASSIFICATION APT. CONDO. (q `fL (�� N , LICENSED CONTRACTORS DECLARATION /(. I ) CLASS NO. DWELL. UNITS Z l� f /Cp NO. I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS4/ � (commencing with Section 7000)of Division 3 of the Business and //�� ff LIC. Q SEWER MAP Professions Code, and my license is in full force and effect. CITY A Y&id-eCk CLASSJ BK I VALIDATION SQ. FT.( O. OF 7 NO. OF ` CHECK License Number y� Lic.Class '✓ SIZE441 6^ILA TORIES Gam- FAMILIES A ONE VALUATION Contractor ►�C ��cuc Date 'L~ DESCRIPTION OF WORK NEW $ ' /Q 1 , �� 9 8 6.7 A p ❑ 7 �i ` l , I • 587, fi5 ❑ I am exempt under Sec. 2 � ID1`-� Lf`N�n S''E 1 N '� ❑ ALTER B.BP.C. for this reason REPAIR ❑ $ • • 'R1 7 C Date: USE OF 1 Q 6 J EXISTING BLDG. DEMOL ❑ APPLICANT p TEL.( Signature OWNER-BUILDER DECLARATION (PRINT)S T�I NES �� EL.C#6 �� kS( FINAL z �p DATE f O Z I hereby affirm that I am exempt from the Contractor's License ADDRESS �l. S P P A r-TL,ta_vO iVZA7b�II •{ Law for the following reason (Section 7031.5, Business and FINAL Professions Code): PRE EN B ❑ BUILDING �t3� �D •�� . I, as owner of the property, 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 LOCALITY 7044, Business and Professions Code). MOVING ATEL. ❑ 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). CONSTRUCTION LENDING AGENCY REQUIRED YARD HWY TOTAL SETBACK SET BACK 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.L. (Sec. 3097, Civ. C.). SIDE all P.L. Lender's Name lQ J ( LDMA Ref. M m f P.C. Fee$ ^ Permit Fee ' /L/ Lender's Addre��2'� ' J r�- $ I certify that I have read this application and state that the Issuance Fee LDMA P/C above information is correct. I agree to comply with all County Investigation Fee 0 ordinances and State laws relating to building construction, Total Fee LDMA Perm. q and hereby authorize repres iptives of this County to enter m upon the-pbove-mentione p perty for inspe tion purposes. M SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applic r Agent Date WORKERS' COMPENSATION DECI,ARATION I or reby afcertif cairm rte of Workers' Compensation on e of eInsuran ont to f APPLICATION FOR BUILDING PERMIT or a certified copy thergc} (Sec. 3800, Lob. C. U-�Cl/A1 COUNTY OF LOS ANGELES BUILDING AND SAFETY PolicyNo(� '^+ Company p BUILDING ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS Certified copy is filed with the county building inspec- BUILDING { tion department. jj �f department. /1 ADDRESS '31 I !v �] y Dat O Applicant • d jklCITY-AV-I 1 C--LTJ ZIP 14' LOCALITY CERTIFICATe OF EXEMPTION FROM WORKERS' NO. OF SIZE OF LOT �Sl ��-� NOW ON LOTS NEARESST. COMPENSATION INSURANCECROSS (This section need not be completed if the permit is for one � A ASSESSOR TRACT hundred dollars ($100)or less.) BLOCK LOT NO. MAP BOOK s PAGE PARCEL TEL. 1 certify that in the performance of the work for which this OWNER �.L'LN tA-3i=-I 1A IST: Np-At S"t�"� USE ZONE O. L " permit is issued, I shall not employ any person in any manner 1n� F� �1 — N�(( � 3 ` N SPECIAL so as to become subject to the Workers'Compensation Lawjs. ADDREPSS 1 1 1 n �( CONDITIONS 0 I_//L�°�T CITY 1. k�L^i - +7 t`T 5 ZIP Date Applicant D: ARCHITECT OR n ��qq� TEL. NOTICE TO APPLI NT: If, after making this Certificate of � S-tTe C I�E L.K NO. 'w S-In DISTRICT GROUP TYPE FIRE PROCESSED BY 0 Exemption, you should become subject to the Workers' �a A _ t ..� CONST. ZONE U Compensation provisions of the Labor Code, you must forth- ADDRESS3t D S. A (V K_t_t ,V-A9 ���7 A 1 kA, d - i W with comply with such provisions or this permit shall be D.. deemed revoked. TEL/Q� Z STATISTICAL CLASSIFICATION APT. CONDO. U) CONTRACTOR NOIOv or Z LICENSED CONTRACTORS DECLARATION /L, L1C. CLASS NO.' DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS 4!1�& L►Y`r //V 6 NO. 4 1 (commencing with Section 7000)of Division 3 of the Business and LIC SEWER MAP Professions Code, and my license is in full force and effect. CITY 7 L t-11CLASS / BK PG VALIDATION 1 y SQ. FT. tyO. OF INF CHECK License Number �¢ -( Lic.Class SIZE 1 L1,0111L1,0111L1,0111 ><DRIES L FAMO.ILES ONE z 9 8 7.O A r� NEW VALUATION 23 Contractor J rl—�t s� Date �' " / DESCRIPTION OF WORK ADD 1 -3 r 1 •- 587. 1 5 I am exempt under Sec. Qc �'J ALTER B.BP.C. for this reason REPAIR $ • • 5 8 7. 1 5 c=i Date: USE OF DEMO" Q 0 613-88 EXISTING BLDG. APPLICANT Signature PRINT S�Q � NTEO. Sl "�� FINAL Q� OWNER-BUILDER DECLARATION DATE I hereby affirm that I am exempt from the Contractor's License ADDRESS3 �- ATL#N�``'��� Z'�u IN' M" P' Law for the following reason (Section 7031.5, Business and FIN - Professions Code): PRESENT DING 1, as owner of the property, or my employees with ADDRESS 50s wages as their sole compensation,will 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 T� f� NO, with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY SET)BACK YARD HWY UIRED TOTAPROP.LIINESETBCKFROM 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.L. (Sec. 3097, Civ. C.). SIDE �/xi./1 V�LL'�'-��'�"('l P.L. Lender's Name _ ¢�� S� qq / ,(, P.C. Fee$ 1 Permit Fee LDMA Ref. # Lender's Address /-Y �t L Mb� 3 I certify that I have read this application and state that the o Y PP Issuance Fee 0 LDMA P/C# P above information is correct. I agree to comply with all County Investigation Fee 0 ordinances and State laws relating to building construction, Total Fee ti �' R and hereby authorize rep r tatives of this County to enter LDMA Perm. # upon th -above-mention roperty for inspection purposes. a H / SEE REVERSE FOR EXPLANATORY LANGUAGE a Signature of Appli nt or Agent Date l WORKERS' COMPENSATION DEC.ARATION f� • i.tsure, Freborafcertif cote of Workers' Compensation rm that I have a certificate of eInsuran ent to lf APPLICATION FOR BUILDING PERMIT `7ILIJI or a certified copy thereof (Sec. 3800, Lab. C.) TT COUNTY OF LOS ANGELES BUILDING AND,SAFETY Policy N:) b4( " Company 3. `f Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS - ❑ Certified copy is filed with the county building inspec- BUILDING S13 tion department. ADDRESS ,1 Date �i Applicant p�uCQ CJ. !/ CITY'��` ��� �� ZIP LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' �S�2��I NOW ON LOTNO. OF S NEARESST. l COMPENSATION INSURANCE SIZE OF LOT _]"' CROSS (This section need not be completed if the permit is for one �,`� ! / X 1 ASSESSOR TRACT hundred dollars ($100)or less.) ,4 `BLOCK rt LOT NO. 1(� \ MAP BOOK PAGE PARCEL OWNER COL N �+vG l ��SE Ng3t 517 Sid USE ZONE MAP t: "! I certify that in the performance of the work for which this �+-� NO. I permit is issued, I shall not employ any person in any manner ADDRESS I �, /_� >`i Vt`'� ` SPECIAL so as to become subject to the Workers'Compensation Laws. 1` fT� - + CONDITIONS Date__2____6 Applicant /3 e t N h� CITY`W, 3`.�I`I� t^ l S ZIP 1 1141 U ARCHITECT ORTEL. ,7 NOTICE TO APPLI ANT: If, after making this Certificate of S�P�N �a+vl NO. �� ��n•�-D� DISTRICT GROUP I TYPE FIRE PROCESSED BY O Exemption, you should become subject to the Workers' ?] CONST. ZONE U Compensation provisions of the Labor Code, you must forth- ADDRESS7�� t' TLi�fJ�\l � ^'�Ai 1, LLJ with comply with such provisions or this permit shall be (- deemed revoked. p TE R�. �� STATISTICAL CLASSIFICATION APT. CONDO. C) CONTRACTOR I�_C�iUl� N v z LICENSED CONTRACTORS DECLARATION J LIC. 7 CLASS NO. DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRES JJ k LI yJ ��06 NO. � 13 / (commencing with Section 7000)of Division 3 of the Business and /� LIC. SEWER MAP Professions Code, and my license is in full force and effect. CITY CJ-" CLASS VAF�►bGkg A 7 SQ. FT. NO. OF NO. OF CHECK BK. �' • • • • 3 License Number �� / S Lic.Class SIZE A * RIES FAMILIES I ONE L �r� �,[� 1�p� VALUATION x - 587. 1 5 Contractor ! rQ L`�A Date .9 - DESCRIPTION OF WORK 5 Y,)'y COWCn NEW Id1 $ 1„�k Q b-ikA ADD ❑ (� O 7 , • • 5 8 7. 1 5 ❑ I am exempt under Sec. ALTER ❑ Q 6, 13-88 B.BP.C. for this reason I REPAIR ❑ $ Date: USE OF ❑ EXISTING BLDG. DEMOL Signature APPLICANT TEL,(- � " FINALTS `k,, OWNER-BUILDER DECLARATION PRINNOS(` �/ c ,� �l , DATE I hereby affirm that I am exempt from the Contractor's License ADDRESS�Z D S- P+T�. �1�`��V 2r rt�t Law for the following reason (Section 7031.5, Business and FINA Professions Code): PRESENT � All ❑ BUILDING 5135 I, as owner of the property, 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 LOCALITY 7044, Business and Professions Code). MOVING 7i 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). " ROM EXIST. CONSTRUCTION LENDING AGENCY REQUIRED YARD HWY TOTAL SETBACK F SET BACK 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.L. (Sec. 3097, Civ. C.). // SIDE Lender's Name Lha" NQ�/4-f isa_4 P.L. 0., /�./�M 4_­)k0ffLDMA A Ref. q y ze_ (WW / !Vim'/�� i� P.C. Fee$ Permit fee Lender's Address ���" V� �+v..��r I certify that I have read this application and state that the Issuance Fee A P/C M above information is correct. I agree to comply with all County Investigation Fee n0 ordinances and State laws relating to building construction, Total Fee 17P Perm. N and hereby authorize re entatives of this County to enter M upon the bove-mentio property for inspection purposes((. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date