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HomeMy Public PortalAbout5525 GOLDEN WEST AVE_Building__ WORKERS' COMPENSATION DECLARATION firm thainsure, ora afcertif carte of Workers' Compensatioa certificate of n eInsuran ent to lf APPLICATION _FOR BUILDING PERMIT or a certified copy thereof ec. 3800, Lab. C.) !A ��//,�,� AA II COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No©Y' alotnk Company e c w4 O Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING ADDRESS ,s! Fj Certified copy is filed with the county building inspec- BUILDING tion department. ADDRESS Date Applicant CITY 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 EL. USE ZONE MAP I certify that in the performance of the work for which this OWNER O NO, permit is issued, I shall not employ any person in any manner SPECIAL i ' so as to become subject to the Workers'Compensation Laws. ADDRES L9P CONDITIONS U Date Applicant CITY 2-2IP ARCHITECT OR TEL. 0 NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. DISTRICT GROUP' TYPE FIRE PROCESSED BY Exemption, you should become ,subject to the Workers' CONST. ZONE U Compensation provisions of the Labor Code, you must forth- ADDRESS Ltl with comply ,with such provisions or this permit shall be EL. STATISTICAL CLASSIFICATION APT. CONDO, fn deemed revoked. CONTRACTO NO Z LICENSED CONTRACTORS DECLARATION LCLASS NO. DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRE ' Q NpIC.� (commencing with Section 7000)of Division 3 of the Business and LIC SEWER MAP Professions Code, and my license is in full force and effect. CITYZ CLASS -C BK PG VALIDATION SO. FT. NO. OF NO. OF CHECK License Number � Lic.Classes SIZE STORIES FAMILIES ONE fes, ��r �S Q VALUATION Controctor.�J� /MJ w-/G►O !�J U DESCRIPTION OF WORK 0��l7 A D O s ?/ r� I am exempt under Sec. S� O U(/(1 , ALTER B.BP.C. for this tea n REPAIR $ Dai USE OF EXISTING BLDG. g!55�9 42)6_ DEMOL Signature 2 APPLICANT TEL FINAL OWNER-BUILDER DECLARATIO PRINT O J DATEZ I hereby off irm that I am exempt from the Contractor's License pa-1 . ! 1 , Law for the following reason (Section 7031.5, Business and ADDRES �-�L_ 1�7:F1 � � FIN Professions Code): PRESENT B aBUILDING I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and ;28851 A the structure is not intended or offered for sale(Section LOCALITY 7044, Business and Professions Code). MOVING TEL. # o o,0 0 0 1 I, as owner of the property, am exclusively contracting CONTRACTOR NO. with licensed contractors to construct the project (Sec- o o = tion 7044, Business and Professions Code). ADDRESS CONSTRUCTION LENDING AGENCY SETT BACKK YARD HWY TOTAL ET ACK FRum WIDTH C O 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 P.L. . Lender's Name LDMA Ref. # P.C.fee$ Permit Fee Lender's Address g I certify that I have read this application and state that the Issuance Fee i LDMA P/C# above information is correct. I agree to comply with all County Investigation Fee 0 ordinances and State laws relating to building construction, Total Fee LDMA Perm. # R and her b uthorize re tives of this County to enter m upon ove-me perty for inspection purpo s. SSEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Appiko 'or Agen Date `F WORKERS'COMPENSATION DECLARATION f I hJ4�4 'affi!m that 1-1nave a certificate of consent to self p,p L I C�►T-I O N .FOR BUILDING pERMIT c insu ,'; a certificate of Workers' Compensation Insurance, or a certified copy thereof (Sec. 3800, Lab. C. COUNTY OF LOS ANGELES, BUILDING AND SAFET Policy No. �___Company CertifiW.>copy is hereby furnished. .:FOR.APPLICANT TO.FILL IN BUILDING ADDRESS Certified copy is filed with the county building inspec- BUILDING tion department. ADDRESS jc� _ TDate Applicont CITY WoiG 't.,� ..•ZIP LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' f4O..OF4LDGS. NEAREST COMPENSATION INSURANCE SIZE OF LOT D liQ '�." NOW'ON LOT l CROSS ST. (This section need not be completed if the permit is for one ASSESSOR GE PARCEL hundred dollars ($100)or less.) TRACT`'///3 / BLOCK"12:,✓ 7T LOT NO. lS MAP BOOK -TEC , MA I certify that'in the performance of the work for which this OWNER.,� p it T I"C!/ l NO._JJ USE ZONE P NO. permit is issued, I shall not employ any person in any manner ADDRESS �j .,, ►^�G.'91� � SPECIAL ' so as to become subject to the Workers'Compen on Laws. / 6, CONDITIONS 0. CITY /1/+t�CL'lii�� ZIP �J�� U Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY 0 ENGINEER W e-+^ NO. CONST. ZONE V Exemption, you should become subject to the Workers' - Compensation provisions of•the Labor Code, you must forth- ADDRESS � W. with comply with such provisions or this permit shall be 0L TEL STATISTICAL CLASSIFICATION APT. NDO. � deemed revoked. CONTRACTOR w is�� NOZI _ LICENSED CONTRACTORS DECLARATION LIC, CLASS NO. . DWELL. UNITS — I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. SEWER MAP (commencing with Section 7000)of Division 3 of the Business and LIC. �"' Professions Code, and my license is in full force and effect. CITY CLASS BK G PGJ L/ Ow6ATIOW 3 SQ. FT. c+ NO. OF NO. OF CHECK License Number Lic.Class SIZE 14 J STORIES FAMILIES / ONE I - 55a4 5 VA DATION Contractor Date DESCRIPTION OF WORK NEW Q o o 5 5 8,4 5 c=, ADD p ; ® I201a87 I am exempt under Sec. —"' "�3y� c^'c^' Q U." A-vt 4e. ALTER a B.&P.C. for this reason ' If?­— REPAIR $ L, U Date: USE OF 40 ❑ EXISTING BLDG. DEMOL Signature APPLICANT TEL. FINAL OWNER-BUILDER DECLARATION (PRINT) NO. DATE z 9 0 2 5 I hereby affirm that I am exempt from the Contractor's License rry J # 0 0 0 0 Law for the following reason (Section 7031.5, Business and ADDRESS FINAL Professions Code): PRESENT By BUILDING ' I, as owner of the property, or my employees with ADDRESS 0 7= c� wages as their sole compensation,will do the work and O 2 23,-8 8 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- ' tion 7044, Business and Professions Code). ADDRESS 29026 A REQUIRED TOTAL SETBACK FR "' k 1� a ' CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH a . hereby affirm that there is a construction lending agency for FRONT 4�#±0 o o 0,0 the performance of the work for which this permit is issued P.L. e, • 1 (Sec. 3097, Civ. C.). SIDE I o 7 6 a 7 5 , P.L. Lender's Name � _ o - 76 &750' LDMA Ref #. P.C. Fee$ `/�J Permit fee Y 't 2,23,-88 Lender's Address J _ ' 3 '. g I certify that I have read this application and state that the Issuance Fee LDMA PSC,# above information is correct. I agree to comply with all County Investigation Fee 0 ordinances and State laws relating to building construction, Totaf.Fee LDMA Perm. # o and hereby authorize representatives of this County to enter upon the above-mentioned operty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date 1