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HomeMy Public PortalAbout4819 GOLDEN WEST AVE_Building__ WORKERS COMPENSATION DECLARATION _ I:hereby affirm that I'have a certificate of consent to self insure, or a certificate of Workers'Compensation Insurance, APPLICATION FOR O U I L D I N G .•PERMIT • or a certified'copy thereof (Sec. 3800;-Lab. (f.) eCZ � f am j� �/J J /( COUNTY OF LOS ANGELES BUILDING AND S T Policy No. 'C •Pany /Gi �T�✓t _- _.... Certified copy is hereby furnished. . FOR APPLICANT BUILDING DDRESS Certified 'copy is filed with the'couhty buildirig inspec- BUILDING- _ A tion department. ADDRESS y Dote Applicant.E-2) 7CITY _ ZIP LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' N . OF BLDGS. - NEAREST.~ - /! COMPENSATION INSURANCE SIZE OF LOT OW ON LOT CROSS ST. (This section need not be if.the',permit is for one - ASSESSOR hundred dollars ($100)or,less.,) TRACT BLOCK LOT NO. � MAP BOOTEL: K PAG/E PARCEL P OWNER NO.�� OlJ� SE NE �t*✓.' I certify thaf in the erformance of the for which this U �I NO -IL permit is issued,1 shall not employ any person in any manner 7 c• I-e SPECIAL, - 0 so alto become subject to the Workers Compensation Laws. ADDRESS /✓ CONDITIONS CITY ZIP. _ .. O Date" Applc iant ARCHITECT OR TEL. NOTICE'TO APPLICANT: If after'making this Certificate of ENGINEER NO. DISTRICT, G UP TYPE FIRE PR CE ED BY Exemption you.should become,subject to `the Workers' S CONST., ZONE 'W Compensation provisions of:the Labor Code,.you must forth- ADDRESS - y with-comply, withsuch provisions or this permit,shall be - - - - - T' - CLASSIFICATION PT EL. /,[ STATISTICAL CLASSIFI ON A C DO. Z deemed revoked. CONTRACTOR N . LICENSED CONTRACTORS DECLARATION /��j /� // LIC. p CLASS NO. DWELL. UNITS I hereby affirm that I am licensed,under-provisions of Chapter 9 ADDRESS /<lf r X50 �/ Ei NO.Z�O-Jz (Commenting with'Section 7000)of Division 3 of the Business and LIC: Professions Code, and my license is in full force and'"effect. CITY CLASS ZCZ/ - VALIDATION " SEWER MAP ' SQ. FT. NO.OF NO.,OF ._ _ CHECK BK. PG. License Number , 2'' Lic:Class- Z c'Z SIZE STORIES / FAMILIES ONE ,� DESCRIPTION OF WORKaEW Contractor VALUATION ate ADD $ am exempt under Sec. �' �O�`"� El , ALTER B.&P.C. for this reason / REPAIR $_ - __: Date: .. _. USE OF „� DEMOL EXISTING BLDG. �5! ^C� APPLICANT -^ ,/ `N L. Signature _.. (PRINT).J _ C�r i� O. Z�j'. FINAL � _ o OWNER-BUILDER DECLARATION DAT - - �.3 8 Z 8 I.hereby affirm.that I am exempt from-the Contractor's License A Law for the following reason {Section 7031.5, Business and ADDRESS �r�b ® `� �` FINA # ° •'"• •'• 1 Professions Code): PRESENT. - ; BUILDING I' • • 60,50' _ I,'as owner of the property, or my employees with ADDRESS Q $L'Lfl (@A( By wages as their sole compensation,wilLdo the work and _ the structure is not intended or offered for sale(Section LOCALITY , • • 0 c� 7044;Business-and.Professions Code): MOVING TEL. 6 0,�5 . 1, as owner of the property, am exclusively contracting CONTRACTOR NO. 1,2 o 0 86 with licensed contractors to construct the project (Sec-. ADDRESS tion 7044, Business and Professions Code). REQUIRED TOTAL SETBACK FROM EXIST. YARD HWY - - .-" "CONSTRUCTION LENDING AGENCY- - SET BACK PROP. LINE WIDTH. I hereby affirm that there is a construction lending agency for FRONT the performance of-the--work for which this permit is issued P.L. - : (Sec. 3097 Civ. C.). n , SIDE o Lender's Name LDMA Ref. # m P.C. Fee$. Permit-Fee.. rW - Lender's Address y ' I certify.that-I.have read this..application and.state that the Issuance Fee- w� LDMA P/C# above information is correct. I agree to comply with all County Investigation Fee /] m ordinances and State laws relating to building construction, -Total Fee -- �` LDMA`Perml# u and hereby authorize representatives of this County to enter m' upon t ove-mention property for inspection purposes: Q_ i SEE REVERSE FOR EXPLANATORY LANGUAGE ' - --- Signa:7 Applicant or Agent - - Date -- - -' - ©