Loading...
HomeMy Public PortalAbout5528 GOLDEN WEST AVE_Building__ WORKERS'COMPENSATION DECLARATION �- h 'aff am that I certificate,of consent To self insur*e,'or a certificate of Workers' Compensation Insurance, APPLICATION FOR B U V LOJ �N G PERMIT or a•certified'Copy thereof (Sec. 3800, Lob. C.) COUNTY OF LOS ANGELES BUILD5NG AND SAFETY Policy No. Company BUILDING ❑ PY v FOR APPLICANT TO FILL IN ADDRESS S.Jr' Za ro0 en weS Certified co is hereby furnished. ❑. Certified copy is filed with the county building insect- FBUILDING21 /_ / / ) y- /tiondepartment. 2—e teC7! (i(/ LOCALITY. !�/� NARESTDate Applicant ZIP O`� CROSSST.CERTIFICATE OF EXEMPTION FROM WORKERS' NO. OF BLDGS. / ASSESSOR /COMPENSATION INSURANCE O NOW ON LOT ! MAP BOOK AGE PARCEL (This section need not be completed if the permit is for one �+ - USE ZONE MAP hundred dollars ($100)or less.) TRACT, J :� BLOCK LOT NO. ; �i NO. i a TEL.' /�"'� SPECIAL IL I certify that in the performance of the rk r which this OWNER ! NO. z «r CONDITIONS DISTRICT 1�.G UPTYPEFIRE PRO ESSED BYpermit is issued, I shall not employ any p rso many manner ADDRE Gr CONST. ZU so as to eco subject to the er ensation Laws. �, " / d, Date Pelican CITY lr1 ZIP STATISTICAL CLASSIFICATION APT. JC0 DO. V NOTIC O PPLICANT: If, er m ing this Certificate of ARCHITECT OR TE-q'L f Exemption, you should become s bject To the Workers' ENGINEER Al V h NOT `�7Doc� CLASS NO. T' t DWELL.'UNITS4LU CL Compensation provisions of the Labor Code, you must forth- ADDRESS 2.5 L Jke % e .✓ SUr il+ SEWER MAP with comply with such provisions or this permit shall be TEL. y VALIDATION deemed revoked. CONTRACTOR ��{� -�U�j NO. BK. PG,I(� LICENSED CONTRACTORS DECLARATION LIC. I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. VALUATION (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 $ SQ. FT�A�� INC. OF NO. OF / CHECK License Number Lic.Class SIZE IJV STORIES FAMILIES ONE $ Contractor Date DESCRIPTION OF WORK NEW I am exempt under Sec. s� ��`.�� .g e4v_ ADD ❑ 2 6 9 a 9 A /�� ALTER ❑ FINAL Q B.&P.C. for this reason G .ro �>Q(% REPAIR ❑ DATU"V/ # a o 0 0 2 3 Date: USE OF DEMOL ❑ EXISTING BLDG. B 1A 0 614 4 Signature APPLICANT i TEL OWNER-BUILDER DECLARATION PRINT NO. - 1,061.4430- 1 hereby affirm that I am exempt from the Contractor's License e Law for the following reason (Section 7031.5, Business and ADDRESS Ov►-L�' O 5 0 T-8 7 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 LOCALITY 7 44, Business and Professions Code). MOVING TEL. z 7 6 a 5 A I as owner of the property, am exclusively contracting CONTRACTOR NO. # 0 0 0 ®.o with licensed contractors to construct The project (Sec- ADDRESS 1,2 5 9.2 5 tion 7044, Business and Professions Code). REQUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH 1 a = ,2 5 9,2 5 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. O a 1 7�8 7 (Sec. 3097, Civ. C.). SIDE FD P.L. Q Lender's Name_ o AA b Lender's Address P.C. Fee$ L/ Permit Fee 71 I certify that I have read this application and state that the Issuance Fee < above informat' n is orrect. I agree to comply with.all County Investigation Fee 9 ordinances a St laws relating to building construction, Total Fee .157 u and hereby Tho resentatives of this County to enter . m up a ove- oned property for inspection yurpfses. 7 SEE REVERSE FOR EXPLANATORY LANGUAGE n Sign ure of Applicant or Agent LD to - es e I-•WORKERS' COMPENSATION DECLARATION IL I hereby affirm that I have certificate of consent to self APPLICATION FOR BUILDING PERMIT in ure, or a certificate of Workers' Compensation Insurance, of a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company ❑ Certified copy is hereby furnished. . FOR APPLICANT TO FILL IN ADDRESS ss;Z8 ❑ Certified copy is filed with the county building inspec- BUILDING SS c tion department. ADDRESS J q G/1 Date Applicant CITY Gt ZIP 1n po LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' NO. OF BLDGS. NEAREST COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS ST. I ILe (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. USE ONE MAP I certify that in the performance of the work for which this OWNER o pp(1-�. NO.7.85'224O' �/a/� No. permit is issued, I shall not employ an person in any manner ADDRESS O�D�p ^(�v�G�,s (Y I SPECIAL 11» CONDITIONS so as to be a subject to the Work s'Compensation Laws. U CITY ��bfcP� ZIP Date Applicant ARCHITECT OR TEL. NOTICE T AP LICANT: If, aft m king this Certificate of ENGINEER NO. DISTRICT GROUP TYPE FIRE PROCESSED 8Y O Exemption, you should become s ject to the Workers' /' CONST. ZONE V Compensation provisions of the Labor Code, you must forth- ADDRESS t(/� L?-, L> with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION APT. CONDO. fn deemed revoked. CONTRACTOR 0 NO. Z LICENSED CONTRACTORS DECLARATION LIC, CLASS NO. 7-1 DWELL. UNITS — I hereby affirm that I orn-licensed under'provisions of Chapter 9 ADDRESS NO. (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. CITY CLASS BK PG VALIDATION SQ. FT. NO.OF NO. OF CHECK License Number Lic.Class SIZE STORIES FAMILIES ONE VALUATION DESCRIPTION OF WORK NEW Contractor Date ADD s 45��.�, ❑ I am exempt under Sec. RQS�0T(� L2F t'1 Y1fS ❑ 0010.ALTER 2 8 25.4 A B.BP.C. for this reason REPAIR E] : USE OF # 0 0 0,0 '23 Date: EXISTING BLDG. DEMOL ❑ © o57.35 Signature APPLICANT TEL. FINAL OWNER-BUILDER DECLARATION PRINT NO. DATF5' � o o a 5 7,3 5,= . 1 hereby affirm that I am exempt from the Contractor's License Low for the following reason (Section 7031.5, Business and ADDRESS FIN Professions Code): PRESENT B �.'� 02 $'7 BUILDING I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and he structure is not intended or offered for sale(Section LOCALITY 0/1 044, Business and Professions Code). MOVING TEL. I, as owner of the property, am exclusively contracting CONTRACTOR NO. with licensed contractors to construct the project (Sec- ADDRESS o tion 7044, Business and Professions Code). #g$ 6 REQUIRED TOTAL SETBACK FRO tAlbi. CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH ( o 0 7 a O O I hereby affirm that there is a construction lending agency for FRONT o the performance of the work for which this permit is issued P.L. (Sec. 3097, Civ. C.). SIDE o o o 7 8 Q,O v /L J P.L. Lender's Name r�' LDMA Ref. # ( 1.30-87 P.C. Fee$ s Permit Fee Lender's Address `_ ' oI certify that I ho v read this application and state that the . Issuance Fee J LDMA P/C p above informatio s correct. I agree to comply with all County Investigation Fee n� 0 ordinances an ate relating to building construction, Total Fee V LDMA Perm. 4 o and he t oriz repr sentatives of this County to enter upon e o -m tione property for inspection purp ses. 3Q a SEE REVERSE FOR EXPLANATORY LANGUAGE Sign ure V Applicant or Agent Dilate WORKERS'COMPENSATION DECLARATION I her*y offirr7i that I have a certificate of consent to self insure, or a certificate of Workers' Compensation Insurance, APPLICATION FOR BUILDING PERMIT or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAF TY Policy No. Company Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING ADDRESS _1 L Certified copy is filed with the county building inspec- BUILDING 55a tion department. ADDRESS CA 6o pa ties r y Date Applicant CITY 1ti k- Ct ZIP OO 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 GE PARCEL TEL. USE Z NE MAF I certify that in the performance of the work for which this OWNER NO.� NO. —M permit is issued, I shall not employ any p rso in any manner g0(� V SPECIAL so as to beco a subject to the Workers' o ation Laws. ADDRESS �a-S ✓16 S CONDITIONS U Date Applicant Y l ZIP_9 L"77L NOT IC T APP (CANT: If, a r maing this Certificate of ARCHITECT OR TEL. DISTRICT GROUP I TYPE FIRE PROCE SED BY O �� I Exemption, you should become subject to the Workers' ENGINEER NO. CONST. ZONE 3 W Compensation provisions of the Labor Code, you must forth- ADDRESS t with comply with such provisions or this permit shall be Cf- deemed revoked. TEL. STATISTICAL CLASSIFICATION APT. CON z CONTRACTOR UIJI�'�e.✓1--- NO. LICENSED CONTRACTORS DECLARATION LIC, CLASS NO. 1,23 DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. (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. CITY CLASS BK VALIDATION SQ. FT. NO.OF NO. OF CHECK License Number Lic.Class SIZE STORIES FAMILIES ONE VALUATION Contractor Date DESCRIPTION OF WORK NEW ADD O s 1 am exempt under Sec. ^ ' D ALTER 0 , 8.8P.C. for this reason REPAIR Q $ 7 7 2 A Date: USE OF DEMOL # o o ® • 0 1 EXISTING BLDG. Signature APPLICANT TEL. FINAL ) c ® 6 Q 5 0 OWNER-BUILDER DECLARATION PRINT NO. DATE 1 hereby affirm that I am exempt from the Contractor's License o 0':* 6 0.5 0 5 Law for the following reason (Section 7031.5, Business and ADDRESS FINAL Professions Code): PRESENT By 0 6.0 4t 8 7 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 LOCALITY 4, Business and Professions Code). MOVING TEL. ` 8 I, as owner of the property, am exclusively contracting CONTRACTOR NO. with licensed contractors to construct the project (Sec- ADDRESS $� tion 7044, Business and Professions Code). REQUIRED TOTAL SETBACK F �/r CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH �/ ( S, 0 I hereby affirm that there is a construction lending agency for FRONT the performance of the work for which this permit is issued P.L. (Sec. 3097, Civ. C.). SIDE P.L. Lender's Name m P.C. Fee$ Permit Fee LDMA Ref. # Lender's Address I certify that I have read this application and state that the Issuance Fee �L� LD P/C# abe correct. I agree to comply with all County Investigation Fee 0 ore laws relating to building construction, Total Fee t�vr� LDMA Perm. # N ane representatives of this County toe er ntioned property for inspection rp ses. SEE REVERSE FOR EXPLANATORY LANGUAGE ure of Applicant or Agent ate