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Home My Public Portal About5225 FARAGO AVE_Building__ 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 Pplicy Nol- ^7710 Company �� ,&&— BUILDING ❑��// Certified copy is hereby furnished. _ FOR APPLICANT TOFILLIN ADDRESS 5z2�. L Certified copy is filed with the c unty builAg g inspec- BUILDING ADDRESS Z 3? tion department. L Pi l i Date �'7— pplicant __)V CITY �'y-t C =- ?" ZIP LOCALITY N . OF BLDGS. NEAREST CERTIFICATE OF EXEMPTI F M WO RS' SIZE OF LOT N WON LOT CROSS ST. COMPENSATION INSURANCE ASSESSOR n ¢� d (This section need not be completed if the per it i for one TRACT BLOCK LOT NO. MAP BOOK g�5 PAGE'"1 PARCef/ hundred dollars($100) or less.) TEL.p �/ USE ZONE MAP / OWNER LN /O NO. �T / 1 certify that in the performance of the work for which this 15V SPECIAL >_permit is issued, I shall not employ any person in any manner ADDRESS —v CONDITIONS O so as to become subject to the Workers' Compensation Laws. U CITY ZIP Date A licant ARCHITECT OR TEL. PP DISTRICT ;GROUP TYPEFI PROCESSED BYNOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO.-Exemption, you should become subject to the Workers' U Compensation provisions of the Labor Code, you must forth- - ADDRESS � 3 with comply with such ,provisions or this permit shall be TEL. L STATISTICAL CLASSIFICATION APT. CONDO. N deemed revoked. CONTRACTOR 6S1 0C-1.+TLv1\ A No ? LICENSED CONTRACTORS DECLARATION, LIC. 6 CLASS NO. DWELL. UNITS — I ESS I hereby affirm that I am licensed under provisions of Chapter 9 S7 NO' 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��l(y BK PG. '" VALIDATION / SQ. FT. . NO. OF NO. OF CHECK License Number 2 T�/ `T 1 Lic. Class SIZE STORIES FAMILIES ONE VALUATION Contractor Date /a�2 7— DESCRIPTION OF WORK NEW ADD �!1 � v 1C ADD ❑ G/ Elam exempt under Sec. ALTER ❑ , �� B.&P.C..for this re son REPAIR ❑ $ ate: S'L_ USE OF EXISTING BLDG DEMOL ❑ Signature APPLICANT TEL. '/ g W R-BUILDS ARATION (PRINT) Z J 61,,Z..j! No Y`'✓y�Y FINAL DATE Z Z a I hereby affirm that I arri exem t c the Contractor's License i Law for the following reason Se ion 7031.5, Business and ADDRESS 3 p!C FINAL s Professions Code): PRESENT By ❑ I, as owner of theproperty, or m em to employees with BUILDING .'r JL Y P Y ADDRESS wages as their sole compensation;will do the work.and '''e l 107.25 '5 = .the structure is not intended or offered for sale(Section LOCALITY 7044, Business and Professions Code.) MOVING TEL. 1 ITEMS ❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO. C with licensed contractors to construct the project (Sec- ADDRESS TOTAL (3-7 m .�P tion 7044, Business and Professions.Code.), L� r i07.24s REQUIRED TOTAL SETBACK FROM EXIST. CHECK CONSTRUCTION CONSTRUCTION LENDING AGENCY SETBACK YARD HWY PROP. LINE WIDTH I hereby affirm that there is a construction lending agency for FRONT ,/l CHANGE a i the performance of the work for which this permit is issued P.L. �f (Sec. 3097, Civ. C.). SIDE. i [ P.L. ►11s � �1 f ,3f 2Gi•5123 Lender's Name, ?`.7 P.C. Fee$ � - Permit Fee LDMA Ref. # , J,` Lender's Address Ctt r' U V 0 1 certify that I have read this application and state that the Issuance Fee LDMA P/C# 8 above information is co ect. I agree to comply with all County Investigation Fee n d ordinance nd State s relating to building construction, Total Fee fc7 LDMA Perm. # a and here authoriz r pr sentatives of this County to enter up n t above-me t' n property for inspection purposes. UV a SEE REVERSE FOR EXPLANATORY LANGUAGE 'gnature opplqnt or Agent- Date WORKERS' COMPENSATION DECLARATION <� ( hereby offifm that I have a certificate of consent to self J _ q'p p Lel CATION' FOR �B U I L D I N G P E RM I T insure, or o certificate of Workers' Compensation 1psurance, or a certi d copy t e 3'840, C.) �t o COUNTY OF LOS ANGELES t BUILDING AND SAFETY Policy NoN • p�ny a BUILDING 21ertified copy is hereby furnish > FOR APP�tIyANT TO FILL ADDRESS Certified copy is filed with the cou but ing inspec- BUILDING ' n d a+rt�melnt. ADDRESS Date yApplic nt CITY �" �`Fy ZIP ��Q LOCALITY L CERT ICATE OF EXE FRO SIZE.OF LOT °r 3 NO. OF BLDGS: CROSSNEAREST. '�f'IV( NOW ON LOT COMPENSATIO INSURANC ASSESSOR ,/ CJD (This section need not be completed if t permit is for e TRACT BLOCK LOT NO. MAP BOOK �inT PAGE 00e PARCEL OrJ-7-- hundred dollars ($100) or less.) ° �� TE �r ��O OWNER C� N �70 USE ZONE NOP I certify that in the performance of the work for which this 12,.70 - �D �7 permit is issued, I shall'not employ any person in any manner, ADDRESS J \ /U CONDITIONS n' so as to become subject to the Workers' Compensation Laws. r 0 CITY 9> ZIP /•w_ /� C. �i/JL< Gt Date Applicant ARCHITECT OR r ° TEL//6�•• DISTRI UP TYPE FI� PROCESSED BY 0 NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER ��L � V NC9aU�S 7 CONST. p p / / ONE (•- Exemption, you should become subject to the Workers' L _'O ADO J V W Compensation provisions of the Labor Code, you must forth- ADDRESS r t' '`] '`v ,&t, � 1 0- with with comply with such provisions or this permit shall be TEL STATISTICAL CLASSIFICATION APT. CONDO. NZ deemed revoked. CONTRACTOR NO. LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. At!!5>Q DWELL. UNITS/ I hereby affirm that am licensed under provisions of Chapter ADDRESS NO. (commencing with tion 7000)of Division 3 of the Business LIC. SEWER MAP and Professions Code, d my license is in full for and effect. CITY CLASS gK.0 PG.�� VALIDATION SQ. F . NO. OF y NO. OF CHECK License Lic. Class SIZE •� STORIES -L FAMILIES ONE o VALUATION Contract Date v DESCRIPTION OF WORK , NEW ❑ S (e-.��f] ,� �f�� ADD ❑ ❑I am xempt under -vr� �"`' ALTER ❑ B.&P.C. for Thi_ eason `x REPAIR ❑ _ Date: USE OF IT EXISTING BLDG. DEMO' ❑ - Signature APPLICANT TEL. FINAL - :f •.',' OWNER-BUILDER DECLARATION (PRINT) NO. DATE I hereby off irm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and ADDRESS FINAL Professions Code): PRESENT By .r: ❑ BUILDING I, as owner of the property, or my employees with ADDRESS- wages DDRESS QQ wa es as their sole compensation,will do the work and 9 P LOCALITY r G .,s,;,r -� _•_. the structure is not intended or offered for sale(Sectiong�, _ 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- '1 "• s ( - 7 r-` ADDRESS _•,! tion 7044, Business and Professions Code.) °y ~�J3 ;»s -;r; c Y• REQUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH I hereb affirm that there is a construction lendingagency for FRONT the performance of the work for which this permit is issued PA.* (Sec. 3097, Civ. C.). SIDE P.L. Lender 's Name. �/' �j P.C. Fee$ o // Permit Fee 60/• LDMA Ref. # -Li;, Lender's Address a I certify th have read this application and state that the Issuance Fee 7 LDMA P/C# , above mforma n is correct. I agree to comply with all County Investigation Fee 3 3 3 8 ordinances an ate ws relating to building construction, Total e LDMA Perm. # a - artd'h thorize re eseMotives of this County to enter upon t e entione perty for inspectio purp ses�1, a Y SEE REVERSE FOR EXPLANATORY LANGUAGE 0 ^ Signa t of Applicant.pr nt DatWl P