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HomeMy Public PortalAbout5237 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, BUILDINGDRESS or a certificate of Workers' Compensation Insurance, or a certified !C7 copy thereof(Sec.3800, Lab.C.) CITY ZIP 49 - Policy No.lI� ?� Compan; AE� `�'� LOCALITY SIZE OF LOT NO.OF BLDGS.NOW ON LOT ❑ Certified copy is hereby furnished. NEAREST CROSS ST. - ❑ Certified copy is filed with the COU y buildingIn pection TRACT BLOCK LOT NO. NO. USE ZONE MAP department. Al� `�77 9� Applicant ASSESSO MAP BO K PAGE �y PARCEL �ry /� Dat• ©O d" 99O� ezlllt ��r.� SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WO ERS' OWNS T L NO. (/ COMPENSATION INSURAN E WITHIN 1000 FT.OF SCHOOL?LYES No (This section need not be completed if the permit is for one hundred ADDRESS dollars ($100)or less.) DISTRICT GROUP TYPE CONST. FIRE ZONE PROCE D BY CITY ZIP i'oV din''` r I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to ARCHITECT OR ENGINEER TEL NO. become subject t0 the Workers'Compensation Laws. STATISTICAL CLASSIFICATION APT C NDO 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' �/^p�[-py�N[T{R�ACTOR (� TE NO. SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith \\"f '0e-'.r,v1� t 6 �� 7 FRONT comply with such provisions or this permit shall be deemed revoked. ADD VSS LIC.NO. p L LICENSED CONTRACTORS DECLARATION f 5 3 2- SIDE CITY ., LICA_ P L I hereby affirm that I am licensed underprovisions of Chapter 9 ^� < (commencing with Section 7000)of Division 3 of the Business and SQ.FT.SIZE NO.OF STORIES NO.OF FAMILIES SEWER MAP Professions Code,and my license is in full force and effect. NEW BK PG d License Number 94141 k DESCRIPTION OF WORK Lic.Class GG—��o ADD ❑ VALUATION � Q Contractor P. Date 3 Z-L ALTER ❑ $ '�' cc ❑ I am exempt under Sec. REPAIR ❑ $ O BAP.C. for this reason p�C L� DEMOL ❑ '.LDMA PIC# W Dat USE OF EXISTING BLDG.19 URM ❑ co Signature 1 ffek APP T(PRINT 7� p z .. `` / LDMA Perm#❑ I, as owner of the property, yees with wages as IV ��2 0�� 7 10_/ � Z {-•s aADDRE l"'t �.• etheir sole compensation, willand the structure is Onot intended or offered for s7044, Business and S V Z FINAL DATE Q 307 107.25 Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL l l "� j ❑ 1, as owner of the OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE J L ITEMS', property, am exclusively contracting 44, AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? Q licensed contractors to construct the project (Section 7044, ves❑ No❑ - FINAL BY � TO I T�L �07 m 25 Business and Professions Code.) WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING CHECK f tS.lT7 +'C' OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH i•1 CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FORrJ GUIDELINES. aj J 1-•l1Ri,i/'C I hereby affirm that there is o construction lending agency for VES❑ NO❑ '��` �fF11117G J a the performance of the work for which this permit is issued(Sec. G/r� 0) I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING 3097,CIV.C.) CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, ///��J _ TITLE 2,CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING HAZARDOUS �� Il — � {y�=k�' Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD. 00 CL Lender's Address h� uv�F i tli�iQ e p OWNER OR AGENT v` 0 1 certify that I have rea this application and state under penalty of perjury that the ab e information is Correct.1 agree to comply P.C.FEE PERMIT FEE `. 6� N with all unty ordi nes a State laws relating to building `/ co str Ion, and her by But ze representatives of this County ISSUANCE FEE to ter upon boa ant' d property for inspectio7n purposes. �j 10 _P�i e G_�'��/ INVESTIGATION FEE TOTAL FEE s' of pucam or Ag— Gere v SEE REVERSE FOR EXPLANATORY LA GLIAGE WORKERS' COMPENSATION DECLARATION g I! hereby,affirm that I havea certificate of consent to self. APPLICATION FOR BUILDING PERMIT ,insure, or a certificate of Workers' Compensation Insurance, or a certfi d copy t r ofC�� I.Qiv C') COUNTY OF LOS ANGELES BUILDING AND SAFETY ,Policy y _ ❑ ertified co is hereb furnished. FOR APPLICANT TO FILL IN BUILDING py y ADDRESS �• Certified copy is filed with the cou uildi spec- BUILDIN ADDRES Z� — -3 / 1 —�2+& •ft• t" n d artment. Date• vA lic nt CITY' d ZIP �7Cb LOCALITY pp ,t NO. OF BLDGS. NEAREST CERT FICATE OF EXE N FRO SIZE OF LOT )C N I NOW ON LOT VN/ CROSS ST. COMPENSATI ANCE ASSESSOR pp o /v1 (This section need not be completed if the ermit is for one RACT BLOCK LOT NO. MAP BOOK F,� 7 PAGE mea PARC ��O hundred dollars ($100) or less.) NER '' T%..&�e"')oz USE ZONE MAP -N / / NO. 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner' ADDRESS 3/C,6IAqAvoymEo 'e— COND TIONS a so as to become subject to the Workers Compensation Laws. �l 0 CITY ZIP �7`f-� "i✓�L ,� �et r�G vt B'Cl�tE� j/ Date Applicant RCHITECT z TE0 + �' / DISTRICT �GIROUP TYPE IRE PROCESSED BY Q NOTICE TO APPLICANT: If, after making this Certificate of NGINEER i ` /P Nc u�S &7r� f. 9 _ CONST. ZONE Exemption, you should become subject to the Workers' ' G• ��/J 5 w Compensation provisions of the Labor Code, you must forth- ADDRESS , A-LPA-611 I `,3 i ✓ a with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION APT. CONDO. N deemed revoked. CONTRACTOR NO. S Z LICENSED CONTRACTORS DECLARATION SCJ LIC. CLASS NO. DWELL. UNIT I hereby affirm at I am licensed under provisions of Chapter 9 DRESS 6�D`T" NO. SEWER MAP (commencing i Section 7000)of Division 3 of the Business LIC. and Professions Co and my license is in full•force and effect. CITY CLASS BK PG• VALIDATION SQ. FT. NO. OF NO. OF CHECK License Numb R Lic. Class SIZE STORIES FAMILIES ONE VALUATION Co tractor Date DESCRIPTION OF WORK NEW ❑ a E]I a exempt un Sec. - an. U� r ADD ❑ l/ 1 ► '-.'=' G ALTER ❑ B.&P.C. for th' reason $ REPAIR ❑ Date: USE OF -;-:<•-. EXISTING BLDG. DEMOL ❑ i E u 11 APPLICANT _ TEL. Signature (PRINT) NOFINAL . OWNER-BUILDER DECLARATION _ DATE —'Al to -.: I hereby affirm that I am exempt from the Contractor's License �_•I{ Law for the following reason (Section 7031.5, Business and ADDRESS FINAL _- Professions Code): PRESENT By BUILDIN El I, as owner of the property, or my employees with ADDRESS '- wages as their sole compensation,will do the work and LOCALITY the structure isnot intended or offered for sale(Section 7044, Business and Professions Code.) MOVING TEL. V I I 1 CONTRACTOR NO. I ❑ I, as owner of the property, am exclusively contracting t' - with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code.) , ,_,,'{. =_ t-.;; -.i; b•-�; „a REQUIRED TOTAL SETBACK FROM EXIST. .:;?�' Sup-� =•+• CONSTRUCTION LENDING AGENCY SET BACK . YARD HWY PROP. LINE WIDTH ' I hereby affirm that there is a construction lending agency for FRONT ��`� .r"=t. ,�i -• �.?-�=3�','-;:`;- -__ the performance of the work for which this permit is issued 'P.L. (Sec. 3097, Civ. C.). SIDE. ' t P.L. s. a I .w.., - Lender's Name •. i � ---- --• '••- LDMA Ref. # r•` y' P.C. Fee$ IA Permit Fee _, _ ;, •-,S;ii_'t, +� Lender's Addr , 0 1 certify that I a read this application and state that the Issuance Fee LDMG P/C# 0 above information i orrec. I agree to comply with all County Investigation Fee go ordin s and at laws r ting to building construction, Total Fee LDMA Perm. # a an ere ize represent es of this County-to enter up n the c v - i d prperty for inspectioripurp9ses. y SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of A cont or A t Date APPLICATIONYOR. BUILDING PERMIT COUNTY OF LOS ANGEL S 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 r 7 or a certificate of Workers' Compensation Insurance,or a certified V ' copy thereof(Sec.3800,Lab.C.) CITY ZIP ^ v LOCALITY Policy No. Company SIZE'OF LOT 11 NO.OF BLDGS.NOW ON OT ❑ Certified copy is hereby furnished. NEAREST CROSS ST. ❑ Certified copy is filed with the county building inspection TRACT BLOCK LOT NO. USE ZONE MAP NO. department. ASSESSOR MAP 00 PAGE PARCEL Date Applicant r l/� oe P/ ,6�IAqv_ SPECIAL CONDITIONS G�/ CERTIFICATE OF EXEMPTION FROM WORKERS' OWNE TEL NO. COMPENSATION INSURANCE 'v 0' WITHIN 1000 FT.OF SCHOOL? YES NO (This section need not be completed if the permit is for one hundred ADDRES � / dollars ($100) or less.) S V DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY CITY f ZIP I certify that in the performance of the work for which this permit - ?°i is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws. ARCHITECT O ENGINEER TEL N �� STATISTICAL CLASSIFICATION APT CONDO �( Dat.-Z= Applicant jAm 1' r• ADDRESS CLASS NO. a/ DWELL UNITS !`NOTICE TO IklPPLICANT.' If, after making this Certificate Of REQUIRED TOTAL SETBACK FROM EXIST Exemption, you should become Subject to the Workers' CONTRACTOR TEL 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 deemed revoked. ADDRESS LIC.NO. PL LICENSED CONTRACTORS DECLARATION SIDE CITY LIC.CLASS P L I hereby affirm that I am licensed underprovisions of Chapter 9 (commencing with Section 7000)of Division 3 of the Business and SO.FT. Z� NO.OF STORIES NO.OF FAMILIES - SEWER MAP Professions Code,and my license is in full force and effect. c/Y NEW BK PG }' VALUATIONpoll- d DESCRIPTION OF WORK License Number Lic.Class ADD ❑ �'"' � Q Contractor Date ALTER ❑ $ /&/ d 0' U ❑ I am exempt under Sec. REPAIR ❑ $ B.&P.C.for this reason DEMOL ❑ LDMA P/C# W Date: USE OF EXISTING BLDG. URM ❑ Signature APPLICANT(PRINT), TEL NO. LDMA Perm# '"" _Z ❑ I, as owner of the property, or my employees with wages as Z their sole compensation, will do the work and the structure is ADDRESS not intended or offered for sale (Section 7044, Business and FINAL DATE Q Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL Xl, as owner.of the property, am exclusively contracting With OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE censed contractors to construct the project (Section 704¢, AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY F u Business and Professions Code.) VES El NO 11 N.-C-1 w WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH ---- CONSTRUCTION LENDING AGENCY COAST AIR QUAUTY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FOR GUIDEUNES. I hereby affirm that there is a construction lending agency for YES❑ NO❑ the performance of the work for which this permit is issued(Sec. i i =_ 1 a� z 6,fli HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING `" 3097,CIV.C.) CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, TITLE 2,CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING HAZARDOUS •(.yi'o Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD. - EL Lender's Address ti:> F,lr_ i[l O OWNER OR AGENT o I certify that I have read this application and state under penalty O of perjury that the above information is correct.I agree to comply P.C.FEE�O t-'a PERMIT FEE with all county ordinances and State laws relating to building V !J G/ �( I<<li l^s i'•._ � j ro construction, and hereby authorize representatives of this County ISSUANCE FEE —tet en er u oPhe ab o -me tioned property for inspection purposes. 10 ( �L V Z •-Z INVESTIGATION FEE TOTAL FEE / 1✓ \ISg at, poicant o,Agent A Oate SEE REVERSE FOR EXPLANATORY LANGUAGE