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Home My Public Portal About5324 FRATUS DR_Building__ d. 11 WO?�KEQ%' CPMPENSATION DECLARATION a � i1 W r certCompe of cion InT to selfAPPLICATION FOR BUILDING PERMIT r,,,ar�.ra � c, of Workers' Compensation Insurance, ora certify(58 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 _-5,73,-R IVvs� ❑ Certified copy is filed with the county building inspec- BUILDING tion department /J ADDRESS j 1"�Z� LOCALITY �r.--rG/ 7��- NEAREST Date Applicant CITY ZIP CROSST CERTIFICATE OF EXEMPTION FR W K S' AO OF BLDGS ASSESSOR COMPENSATION INSURANCE SIZE OF LOT 2z( NOW ON LOTMAP BOOK PAGE PARCEL LOT NO Z (This section need not be completed if the permit is for one U NE hundred dollars ($100)or less ) TRACT BLOCK U J� NO /7 Z TEL• \v��' SPECIAL I certify that in the performance of the work for which this OWNER ,�aNO G�� v�G CONDITIONS d permit is issued, I shall not employ any person in any manner / DISTRICT GROUP TYPE FIRE ESSED BY O so as to become subject to the Workers'Compensation Laws ADDRESS ��$ /,�y� J-"G �� '2 CONST y ZONE O J -fV�7 faC Date Applicant CITY iC ZIP �d�� STATISTICAL CLASSIFICgTION APT CONDO NOTICE TO APPLICANT If, after making this Certificate of ARCHITERT OR TEL ,yL, rJ Exemption, you should become subject to the Workers' ENGINCLASS NO DWELL UNITS Compensation provisions of the Labor Code, you must forth- ADDRESS SEWER MAP with comply with such provisions or this permit shall be Z CONTRACTOR deemed revoked /El No BK L- PGVALIDATION LICENSED CONTRACTORS DECLARATION LIC MIN I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO Zlv��'� VALUATION (commencing with Section 7000)of Division 3 of the Business and LIC f�p OG Professions Code, and my license is in full force and effect CITY CLASe $ SQ FT ST OF / NO OF CHECK ► License Number �e5g�'E Lic Classes SIZE �6'G STORIES A FAMILIES ONE � H Contractor Date DESCRIPTION OF WORK NEW oPA ❑ I am exempt under Sec s ADD ❑ 65025 ALTER ❑ FINAL 1,25-860 B&P C for this reason ❑ DATE REPAIR Date USE OF all EXISTING BLDG DEMOL Sign atue' APPLICANT TEL p / R'4;OWNER-B ER CLAAA (PRINT) NOZd�jE'�ro I hereby affirm that I a exemp fro Th ontractor's License Law for the following reason (Section 7031 5, Business and ADDRESS Professions Code) PRESENT BUILDING 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 kADDRE 7044, Business and Professions Code) TEL ❑ I, as owner of the property, am exclusively contracting TOR NO ^ ' �7 5 1.6 A with licensed contractors to construct the project (Sec- # o ° ° e o tion 7044, Business and Professions Code) D YARD HWY TOTAL SETBACK FROM EXIST 0 77550 CONSTRUCTION LENDING AGENCY K PROP LINE WIDTH I hereby affirm that there is a construction lending agency for , ° 0 7 75,5 c=t the performance of the work for which this permit is issued (Sec 3097, Civ C ) 0 7.23-87 Lender's NameLender's Address SO / S' .eG S a 0D Permit Fee �) I certify that I have read this application and state that the Issuance Fee above information is correct I agree to comply with all County Investigation FeeS-6 g ordinances and State laws relating to building construction, Total Fee ] d and hereby authorize representatives of this County to enter 1 - t A upon�qove-mentionecl property for inspectionpu poses a /1 ZS SEE REVERSE FOR EXPLANATORY LANGUAGE Signator of Applcan rte'nt D ®s 4 WORKERS' COMPENSATION DECLARATION insure,oraafcertif carte of Worke s' Compensatioa certificate of n Int to self nsurance, A P P L I CAT I O N,-`FOR BUILDING PERMIT or a certified cop thereof (Sec 3800, Lab C ) /�� !)�-��G COUNTY OF LOS ANGELES t BUILDING AND SAFETY P❑olicy� Company Certified copy is hereby furnished - FOR APPLICANT TO FILL IN BUILDING �7J��f ADDRESS Certified copy is filed with the co my build ng i spec- BUILDING tion department ADDRESS /+ Date -Applicant CITY ` ZIP 7 LOCALITY L 1 CERTIFICATE OF EXEMPTI FROM ORKER ' NO OF BLDGS NEAREST COMPENSATION SURANCE SIZE OF LOT �{NOW ON LOT CROSS ST V (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 OWNER C S �� LOg X70 N L r3/ Z NE MAP ? I certify that in the performance of the work for which this NO x- permit is issued, I shall not employ any person in any manner �� S' SPECIAL so as to become subject to the Workers'Compensation Laws ADDRES 7+� CONDITIONS Date Applicant CITY C. ,. ZIP 7 0 NOTICE`TO APPLICANT If, after making this Certificate of ARCHITECT OR TEL_ DISTRICT GROUP TYPE FIRE PROCESSED BY Q Exemption,, you should become subject to the Workers' ENGINEER NO �j� R CONST / ZONE V Compensation provisions of the Labor Code, you must forth- ADDRESS �!I ° 11// W with comply-with such.provisions or this permit shall be 0-1 deemed revoked r TEL TISTICAL CLASSIFICATION APT NDO N CONTRACTOR � NO Z LICENSED CONTRACTORS DECLARATION LIC F CLASS NO� DWELL UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS�O �� NO J (commencing with Section 7000)of Division 3 of the Business and LIC SEWER MAP Profess ians`Code, andm license is in full force and effect CITY CLASS BK l//`7 VALIDATION � �� SQ FT NO OF NO OF CHECK License Number, Lc Class_ y SIZE PG STORIES FAMILIES ONE G �� ❑ VALUATION Contractor Date r r DESCRIPTION OF WORK NEW ADD ❑ $ I am exempt under Sec [:]� ALTER B 8P C for this reaso REPAIR ❑ $ at USE OF DEMOL EXISTING BLDG ❑ Si nature APPLICANT t TEL / � p' FINA g NEO-BU R D CLARATION PRINT I` { NO 7�� DATEL I hereby affirK that I am exempt from the Contractor's License ` 2 6 A Law for the following reason (Section 7031 5, Business and ADDRESS - FIN Professions Code) PRESENT B ,Q +1 o s o e 61,1 BUILDING tt j, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and :1 o * 60,50 the structure is not intended or offered for sale(Section LOCALITY 7044, Business and Professions Code) - MOVING TEL a o*0 6 Q 5 0 x: I, as owner of the property, am exclusively contracting CONTRACTOR NO C I� with licensed contractors to construct the project (Sec- ADDRESS lT—� r 0 6;� O'i 8 7 tion 7044, Business and Professions Code) l/ J REQUIRED TOTAL SETBACK CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP LINE WIDTH / / / ,I U L I hereby affirm that there is a construction lending agency for FRONT C� M 7 the performance of the work for which this permit s issued P L Z (Sec 3097, Civ C ) SIDE PL Lender's Name 50,60 -/� /9 LDMA Ref # Lender's Address P C Fee$ Permit Fee J V tv(�/ I certify that I have read this application and state that the ' Issuance Fee S LDMA P/C# loo. a above information is correct I agree to comply with all County Investigation Fee r 0 ordinances and�Sv, laws relating to building construction, TotalFee .t LDMA Perm # and her by au hze representatives of this County to enterth ab antsoned property for inspe7-Aw n purposes a SEE REVERSE FOR EXPLANATORY LANGUAGE Si at a of Applicant or Agent Date ,