HomeMy Public PortalAbout6249 GOLDEN WEST AVE_Building__ 4 iNOR//KF125' COMPENSATION DECLARATION
17 here;. a cor that I have i certificate ns consent To self AP P L I CAT I N F Q R S U I L D I N G PERMIT,
Insure,or a certificate of Workers' Compensation Insurance,
or a certffled copy thereof (sec 3800 La ) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Polity No. Company. BUILDING
ElCartlfid
eFopy Is hereby fumlahed.. - FOR APPLICANT TO FILL IN ADDRESS a�9
Certlfted copy Is filed with county bullding aspeo- �� 0(� _
tion department.
Doted Applicant 11y ZIP QTY
CERTIFICA ON FROM WORKERS, S OF LOT I�7/I NOW ON LOTOFBLDG& NEAREST _
CROSS ST.
connPt NSATION INSURANCBc
LE
(th
is iectlon�n&ot4 nrtl
not be copleted If the perrhlt Is for one TRACT BLOCK T-NO. MAp PAGE Da f PARCEL 4911
hundred dollars (;100) or leas.) _ v NO �6LdE
I certify
that In-the performance of The work for which this �-~I
. permit Is Issued, 1 shall not Bmploy any perabn jn any mpriner ADDRESS fin/ SPEC7A1
so a;,to becom f 0 /`�•"� COf Dfrl "
Q jublect To:the Workers'CompeniaTlon Laws. �7 L .. �
CITY' ZIP I /7 V'
Date Apfsl(cant ARCH TEL 0
`4 / Di GROUP RRE BY O
NOTICE TO APP�I.(`ANfT: ff, after making this.Certificate of BdGINffR NO. o a'�1�0T ZQNE G
Exemption, you.should ;become subloo to.tht Workers' QQ r(
Compensation provlslorn•of The.Labor Code, you must,forth- ADDRESS> t � � � �� 3 V
with .comply with such provisions or thlq'permit shall be TFL < STA11STICAL CLASSIRCATK)N APT. CONGO.
deemed revoked. '. O�NTR4CTOR C(IJI 1 L No. } _ —
UC1 N$FD CONTRACTORS DECLARATION ADDRESS _ art' LIC CLASS NO. UNhS f
I hereby affirm that l am llcor under provisions of Chapter 9 G '
LSC. SEWER MAP
w
•(cQmmencing with Section 7000)of Division3 of the Bvslne '
and lsrofesslons COanynd my license is In fullforce effect. NO CLASS BK PG 'VALIDATION
Lrcense Numbbr �" �I` Llc: ClPas STORIES FAM LI ONE
t VALUATION
Contractor � —I•`rINL- bate DESMPTKSNOFWORK' I ��..
. . , ; .�'BB(J.
0 I am exempt under Sec: ' Ac r
ALTER IQIIt►? ^CI?.C�7
BAP.C. for.t'hls reaion� RFpA1R LU .
NG BLDG.
OF, 1 I TEFF
Slgnaturo EXISTICANT (JI,cS TEL RN/�l TOTAL j2D- .��7
OWNED-BUILDER DECLARATION Q � NO.
I hereby affirm that I am exempt from the ContradoraLicense +'
Low fat the following reason (Sactloh 7031.5, and . FINAL ' � jL
Professions CodG
Cc-do): - \ -
BUILDING
❑ 1, as owner of the brbpei'ty, or my employees'with �j ADDRESS l ti• i I!
wages as their sole corppensatlon,wIH do the work and LOCALITY O 1 1 J,31;7{
The structure Is not Intended or ofFered'for sale(Sedlon
7044, Business and Professions Code.) TEL �1� -d'
❑ I, as owner of the property,am exclusively contracting CONTRACTOR NO.
-
with Ifcensed contractors to'consfruct the protect (Sec lADDRESS tf f�_1 1 .'+ _ •t
Tion 7044, Buslneas and'Profewl4ns Co¢e.) FRAM
CONSTRUCTION LENDING,AGENCY YTOTAL — 1 11I16I9�
I hereby affirm That there Is a construdlort lending agency for FRONT i�
the performance of the work for which This-permit is Issued. P.L. 6~514 1 AM 9:49
(Sec. 3097, Cly. C.). SIDE
P.L.
Lenders Name : � LDMA Ref. i
Lenders A¢dresa P.C. Fee Permit Fee
I certify th I have read Thla appllcatlon and state that the lasuan Fee LDMA P/C '
above n atlon correct. I ree to comply with all County In Igation Fee
ordln and 5 to laws re Ing To'bulldtr�q corutructlon, Total Fes /,V,/.
� LDMA Perm.
and h auth Ize repr Tatives of this County to enter
. upon a e toned pt �Iorspbdlon�pu7e� :a RlfVMSE rot KPI.ANATOKY LANGUAw
of Applkarftor Agent Datq
APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
WORKE.R'S'COMPENSATION DECLARATION FOR APPLICANT TO FILL IN QS
I hereby aff}rna that I have a ceritflcafe of dorAwrt to W Imre, A
or a certfik2ate of Vk&&8' Compensation Insure Ka %or a oerdfled
orry ZIP
copy 3600, C.) r L.00ALfTY
Poles cOR1 40.OFBLDoa Now ON L.OT NEAtaEST CROSS .❑ CertMSed,00py is hereby furnkh .❑ Carwied copy in filed wnh the ty I IrV haepeotbn PT'NP.
. Bt oC7c LOT 40.
UBE ZlJN E MAP NA
'y
A33E330Fl AARP BOOK PrL3E PAFiCE1
� 9PEClN_COt�IDfTION'3
CERTIFICATE OF EXEMPTION,FROW WORKERS' TEL Na YES 40
COMPENSATION INSURANCE gm
jy MTHN 1000 FT.OF SCI O CC?
(This section dead rant be completed It the permit b for one hundred D19TF}CT GROUP CONST. FIRE�0ff PfAQCE33ED BY
ddlpr9 ($100)or leas))
ZIP— 1 A
I certify that In the partorrhm of the wv" for whlch thb p rrrlft • `p _ 3
Is Iswed, I ct,allnot employ any person,In arty manner cq as to
beoome the V1orfS CT OR ENC3fJEFA TEL NO.
� SVTtBTIC�J_q ASSFlGrTION APT CONDO
Dat Applk3a r I ADDRESS CLASS NO. drVELL LINTS .
N07LETO : K,-after mak ti-de C`wtk:ate d REOUCRED_ TOIAL SETBACK FRCU' EXIST
ExerriPtlon, • you ahould beo roe . subtect t0 the Ykfl,. rs' FM1N
/ 8J f BACs( YTRD Y PROP UNE WOTIi
Compensation prdvWom of the- Labor Code, You hxret for�wfth tW Q- w+ FF00T
GorrOy wtUl doh provWorm or thb permft shall be deemed rewired. P L
;FE.-J—
SDELICENSED CONTRACTORS DECLARATION L
uc/7A wfl
naIhereby affirmthat I em Ik�need urderprovbbna of Chapter 8 SE VER MAP
(cwrrnclnp with Section 7,000)of Dlvialon 3 of the Butelr s end NO.,OF STORES aF FAAiJEB ...---///``
Prdeeai" Code 1 In In full force NEW RK BK Pd , a
Licenee Lic.c w ADD `❑ vauAno�Nro O
Date f v1 AVTER El $ c12►�� (�
REPAIR ❑
Q I am,exempt under Sec $
B.BP.C.for this raaeon DEMOL ❑ PDM, P/C+. ILLI
Date: USE OF EGSTING BLDG - URM ❑
SiRaeture APPLrANT(PFNVT) TF1 NO. UWA PQrm I. 1 Z
❑ I, as owner of the property, or my ernplo ea with weaes as war r
their•eoie compensation, will43o the wbrk,and the More IS ADDRESS rn�.41 .r
not 1pterded or offered for Bale (Section 70aa, Buslri6m and FLNAL°'°E 3 7 117.5
Profeeaiortn Code-) w�THE
APPUGA T OR FUTURE eu.naa ocdnn+++T+wnrE A �r
❑ I,as owner d the property, em e)oduaiYety COfrtreCfirap with as K WCRFE COKMOOCI A r ►w=EQUAL TO ora�THAN THE
�3. 1 ITu 13
A64CWM OPECFED ON TFIE taATHiM19 FRDRWroN OUIDE7 FINAL BY .-
Ilcenead Corrtrpda'e to conetr r the protect (3w5m 7044, YEa❑ No❑ (�,,=, TOTAL 117-90
Buslness and Profeesbm Code.)
wai THE HTENDm ueE CP THE euoLrro ar T rE CA Riru� RAL*o
PANT rECU1 E A PETarr F ,cr OR�FROM T}E 7),T CLEC#: 117.90
CONSTRUCTION LENDING AGENCY Corer��TY'�'�T 01�T(W'°Ao)aE£PwArrMao CHEq"r FQR
rFI.FR _ �A`�
00
I hereby affirm that there Is a corm4uctbn WdVQ aoency for YEs El No El
N the performance o(the work for wtrlch thb permft is leaued(Sec. +�E READ Tri gkL-noou6 S NFoRmxnoN oink iw T-E eC.�a�PErau FFm ■
6097,Cfv.C) aT7CKUST.i UHXFawo rn REQU143JEWM 100 T 0► T�ia�o Fv�oo�is
Ler;iWs Name e��MC F09MeCTKA4OMMA a A_PE1�rr o,, '+" OQ00—pD01 4/15/93
Landers--A,cldreae OR mn" 9224 1. AM 11:Z8
I certlly'thst I haw read this epopation and state under penalty
c perjury that the above Inforniabw Is correct.I spree to oxrOy PC FEE PE}TMT FEE
Oth ell ,ormty ordlnaro and State Tawe mlat to bUfldkap
cormtrucb6rl and hereby authdrtxe remmotaffves of this County 183UANCE FEE r `
to anter upon the eboye-mentioned property for h gpBcbw purpD-a. (O
m N/ESTKaATKIN FEE TOTAL FEE
,
$EE REVERSE FOR EXPLANATORY LANGUAGE