Loading...
HomeMy Public PortalAbout5233 FARAGO AVE_Building__ APPLICATION FOR BUILDING PERMIT COUNTY OF LOS ANGELES BUILDING AND SAFETY WO`RKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING BUILDING ADDRESS J ATj:,3 I hereby affirm that I have a certificate of consent to self insure, or a certificate of Workers' Compensation Insurance,or a certified A'd 10 copy thereof(Spc.300,Lab.C.) �/ �� \ CITY ZIP �J Policy No.�/S-7� U4 ��/ ,CLL LOCALITY Company SIZE OF LOT NO.OF BLDGS.NOW ON LOT ❑ Certified copy is hereby furnished. NEAREST CROSS S;/� '�rtified copy is filed with the coun building in ecti, TRACT BLOCK LOT NO. rr d artment.t USE ZONE MAP NO. /� �l Date 2 b`S� Applicant ASSESSOR BOOK PAGE PARCEL /O� • `� �i� � � SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM O ERS' oW ER TE J1�Q, COMPENSATION INSURANC a+/ WITHIN 1000 FT.OF SCHOOL? YES NO (This section need not be completed if the permit is for one hundred ADDRESS DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY dollars($100)or less.) Q I certify that in the performance of the work for which this permit CITY ZIP is issued, I shall not employ any person in any manner so as to become subject t0 the Workers'Compensation Laws. ARCHITECT OR ENGINEER TEL NO. p STATISTICAL CLASSIFICATION APT CONDO Date Applicant ADDRESS CLASS NO. DWELL UNITS NOTICE TO APPLICANT If, after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST Exemption, you Should become Subject to the Workers' NTRACTOR p NO. SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith /P&-I.+T'► Yi C 1 yi FRONT comply with such provisions or this permit shall be deemed revoked. DRESS // f� IC.�NO. O t� �( PL . 4A-+ Ct L f ' ;/47 IlJ SIDE LICENSED CONTRACTORS DECLARATION LI� CLASS PL C I hereby affirm that I am licensed underprovisions of Chapter 9 EWER MAP (commencing with Section 7000)of Division 3 of the Business and SQ.FT.SIZE NO.OF STORIES NO.OF FAMILIES Professions Code and y III se is in full force and effecs. NEW BK PG a License Number I Lic.Class !� DESCRIPTION OF WORK ADD ❑ VALUATION , O ContractorDate -�—�97 ALTER ❑ $ U • Ile C, /L c JJ I-eCcc REPAIR ❑ $ OO ❑ 1 am exempt under Sec. /► BAP.C.for this reason C � DEMOL ❑ U LDMA P/C# III Date: USE OF EXISTING BL URM ❑ (- Signature Z hA)QDRE�iS ANT( INT ® T / LDMA Perm#❑ I, as owner of the property, or my employees with wages as Z ( CCM their sole compensation, will do the work and the structure is / O ��r� 107.25 not intended or offered for sale (Section 7044, Business and s O c _,f FINAL DATE Q -' Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL .-l( J OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE ❑ 1, as owner of the property, am exclusively contracting With AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? Q licensed coo of to construct the project (Section 7044, FINAL BY �� > y1.1T�� q1^�+�� o +�p ElEl ! F Business and Professions Code.) YES NO 107. ) WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING r �+ �4\ 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. �S `, ��I� I hereby affirm that there is a construction lending agency for YES❑ NO❑ jJj- G N the performance Of the Work for Which this permit Is Issued(Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING vv 3097,CIV.C.) CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, A �� -�Zr TITLE 2,CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING HAZARDOUS // 00100-000 j jf 3/26/93 Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD, / o Lender's Address �:�=8A1 =I1 O OWNER OR AGENT o I certify that I have read is application and state under penalty (((PPP O of perjury that the above formation i,correct.I agree t0 comply P.C.FEE PERMIT FEE N with all�cou ordinan and S to laws relating to building< con trucd hereby uthorize r presentatives of this County ISSUANCE FEE ofcoto t ove- entione perty for inspection purposes. INVESTIGATION FEE TOTAL FEE -� Sgnalure/ irant or Agent ate �� SEE REVERSE FOR EXPLANATORY LANGUAGE WORKERS' COMPENSATION DECLARATION insu e,boraafirm certif tate of Workers' Compensation Insuran of - APPLICATION. FOR BUILDING P E RM I T or a certified copy th rip (Se�� 00, Lab. C.) j V r*�p` COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy INb any 0 �'eftified copy is hereby furnis a CAM 4, FOR APPLICANT TO FILL IN ADDRESS (,� Certified co is fi4INSURAN but in ins ec- BUILDING/ �� copyp ADDRESS Jq ti n department. ,y-_ ,rte, CITY ' C Pi of i -17 ZI 1-719© LOCALITY Date ApNO. OF BLD S. NEAREST CERT KATE OF ESIZE OF LOT V�/ / NOW ON LOT CROSS ST. COMPENASSESSOR !l (This section need not bpermit is for e TRACT BLOCK LOT NO. MAPBOOK � PAGE��a PARCEL ��'•hundred dollars ($100) oUSE ZONE OP s OWNER � W:� � T CJFaIC3 O� I certify that in the performance of the work for which this I � J'� 2 17 SPECIAL } permit is issued, I shall not employ any person in any manner ADDRESS ���Q AAIiWow CONDITIONS a' so as to become subject.to the Workers' Compensation Laws. / y� Q CITY ZIP K� Ge [G lI� ��G� �' /7 v Date Applicant ARCHITECT OR ' TE' JaC pp QL �V�( DISTRI G P TYPE F E PROCESSED BY Q NOTICE TO APPLICANT: If, after rnakin this Certificate of V ENGINEER .. 576-7 F_ 9 V CONST. ZONE Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- ADDRESS 2 � S 6 +LH *dID�- ��P0 5 ✓ J w with comply with such provisions or this permit.sholl be ��y TEL. STATISTICAL CLASSIFICATION APT. CONDO. Z deemed revoked. CONTRACTOR �jf� m� l�V — LICENSED CONTRACTORS.DECLARATION LI CLASS NO. ©0 DWELL. UNITS / I hereby affirm t at 1 am licensed under provisions of Chapter 9 ADDRESS NO. (commencing w t Section 7000)of Division 3 of the Business LIC. SEWER MAP and Professions Co and li nse is in full fo a and effect. CITY CLASS BK G'PG. �1 VALIDATION SQ. FT. NO. OF .2 NO. OF CHECKFJ LicensPe Lic. ClassSIZE T � STORIES FAMILIES ONEVALUATIONContrate ESCRIPTION OF WORK NEW(') ADD ❑ aIa under 'Efh ► r-,•{- _.;,..s.. ALTER ❑ «• G_ ,. B.&P.C. for thi reason $ REPAIR ❑ Date. USE OF EXISTING BLDG. DEMOL ❑ 3,"t•;;L ,: r.,. Signature APPLICANT TEL. FINAL _. (PRINT) NO. I'lt OWNER-BUILDER DECLARATION DATE •� = -' ) = i I hereby affirm that I am exempt from the Contractor's License �� l i" Law for the following reason (Section 7031.5, Business and ADDRESS �y FINAL Professions Code): V� PRESENT By :.-.;::• BUILDING r��^��9 � i'f= '•! a ❑ 1, as owner of the property, or.my employees with gDDRESS 2Z� 7 A 6' 111 � _ I wages as their sole compensation,will do the work and !} ° ' - F. LOCALITY / the structure is not intended or offered for sale(Section ♦L` ! r.. t3! 7044, Business and Professions Code.) �l` MOVING TEL. ,f� _ .,- ❑ I, as owner of the property, am exclusively contracting s`1 CONTRACTOR NO. with licensed contractors to construct the project (Sec- ADDRESS '" t I I Tt• _ :_ ._ tion 7044, Business and Professions Code.) tY 7 REQUIRED TOTAL SETBACK FROM EXIST. ``"'' CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH ;ti I hereby affirm that there is a construction lending agency for FRONT r, j a:`:?='s'•:r the performance of the work for which this permit is issued P.L.' (Sec. 3097, Civ. C.). SIDE 4 Lender's Name, P.L. :1.�. . ..M1 ... _f }-r -,I ;te \ / LDMA Ref. # A i.• d P.C..Fee$ Permit Fee io ^' Lender's Addr soil 0 1 certify that I a read this application and state that the Issuance Fee a ZJ:_ LDMA P/C# 0 above informatio torr I agree to comply with all County Investigation Fee �� /I S or s tate la s re ing to building construction, Total Fee * `� LDMA Perm. # a and here y i ��epIres e s of this County to enter upon the o e- I ed operty for inspectio purg ses. a r� SEE REVERSE FOR EXPLANATORY LANGUAGE Signatur Iicant or ent Da e