HomeMy Public PortalAbout4817 GOLDEN WEST AVE_Building__ WORKERS'COMPENSATION DECLARATION
insure,oraafcertif cafirm thatte of Worke s'tCompensat on Insuranceent to , APPLICATION FOR B U-I L D I N G- PERMIT
or a certified copy thereof (Sec. 3800, Lob. C.�) �] COUNTY OF LOS ANGELES BUILDING AND SAFETY
Poi ,
ft-) ?�J e 3-3,4 Company Ahl7 i•61 f '21P�^��C
ElCertifiedCertified copy is hereby furnished. - FOR APPLICANT TO FILL IN BUILDING ry/� /�` e�
�( 2
Certified copy is filed with the county building inspec- BUILDING ��""
tion department. ^ ADDRESS ;� 6 /E�i�r-L �' `��y •`
Date Applicant /1✓'� y
CITY � C[' ZIP LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. NEAREST
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT �' CROSS ST.
(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
TEL. f USE ZO�E MAP '
OWNER [ C NO. iOrG�3
I certify that in the performance, of the work for which this �
permit is issued, I shall not employ any person in any manner pp�� SPECIAL CL
so as to become subject to the Workers'Compensation Laws. ADDRESS 47,7S LJ�( &'e/-e"j, 1"�' CONDITIONS O
f V
CITY i/ �' F ZIP
Date—:, Applicant ARCHITECT OR TEL
NOTICE TO APPLICANT: If, after making this Certificate of DISTRICT GROUP TYPE FIRE PROCESSED BY H
ENGINEER NO.
Exemption, you,should .become subject to the Workers' CONST. ZONE
LU
Compensation provisions of the Labor Code,.you must forth- ADDRESS ` �. - -L
with comply, with such provisions or,this permit shall be t TEL. z
a , C NDO.
deemed revoked. STATISTICAL CLASSIFICATION APT.
CONTRACTOR� - ��' ,ti,NO.
LICENSED CONTRACTORS DECLARATION LIC, 7 __� CLASS NO. DWELL. UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS( O,j�o-X NO. -� 1��
(commencing with Section 7000)of Division 3 of the Business and 1 v LIC. SEWER MAP gg r}
Professions Code, and my license is in,full force and effect. CITY' ;_,"&W1/1, / CLASS ILS BK - PG Iii 0 VALIDATION "
per/ SQ. FT./2., NO.OF NO.OF / CHECK
License Number� ' w - ' Lit.Class C,4?-C SIZE STORIES I FAMILIES 4 ONE VALUATION
.DESCRIPTION OF WORK NEW. ❑
Contractor��� �CY//y.//,c I�yJ Date �';-70-2? �i •-
[ i�G'r ftp O /. �1 Z / ADD ❑❑
❑ I am exempt under Sec. ALTER
/ 4
B.&P.C. for this reason /� °�' f`✓ REPAIR ❑ $ 3 8 7;9 A
Date: USE OF EXISTING BLDG. �S j _ Q DEMOL # • a o a e 1
Signature APPLICANT aJ� TEL. 9 FINAL �A
OWNER-BUILDER DECLARATION PRINT)- V ti NO.Ci, ��Z DATE � ) ° - 60.50,
I
60,JcQ-
I herebyaffirm that I am exempt from.the Contractor's License r
p ADDRESS t�� b� (� /
Law for the following reason (Section 7031.5, Business and � �-/ B N r a a o (}Q 5�Q 3:-Professions Code): PRESENT
BUILDING 01,20-86
F1 1, as owner of the property, or my employees with ADDRESS Sc� COAI
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section LOCALITY
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- ADDRESS
tion 7044, Business and Professions Code).
REQUIRED TOTAL SETBACK FROM EXIST.
CONSTRUCTION LENDING AGENCY SET BACK YARD HNY PROP. LINE WIDTH
I hereby affirm that there is a construction lending agency for FRONT
-the performance of the work for which this permit is issued P.L.
(Sec. 3097, Civ. C.). SIDE
Lender's Name I
o /�/� LDMA Ref. #
Lender's Address P.C. Fee$ Permit Fee V v
I certify that I have read this application and state that the Issuance Fee LDMA P/C 1t
above information is correct. I agree to comply with all County Investigation Fee
ordinances and State laws relating to building construction, Total-Fee c J LDMA Perm:#
d and her authorize representatives of this County to enter
upon t'e a ove-mentioned.property for inspection purposes.
f��-- SEE REVERSE FOR EXPLANATORY LANGUAGE
Signatur of Applicant or Agent Date