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HomeMy Public PortalAbout5801 GOLDEN WEST AVE_Building__ 4 WORKERS' COMPENSATION DECLARATION JI _ f hereby affirm that I have a certificate of consent urSelf - -APPLICATION FOR "U I L D I N G PERMIT ,,' insure, or a certificate of Workers'Compen on insurance, o - rCertified cop� of (Sec p8 a00 Lob' 00, COUNTY OF LOS ANGELE� BUILDING AND SAFETY ✓ died copy is hereby f Wished --FOR APPLICANT TO FILL IN BUILDING ADDRESS copy is filed with the county building inspec- BUILDING �( !,• , department ADDRESS "�{/ W LOCALITY f NEAREST '/ 6 Date Applicant CITY -ZIP CROSS ST N CERTIFICATE OF EXEMPTION FROM WORKERS' O OF BLDGS ASSESSOR SIZE OF LOT SB ) NOW ON LOT Z�" MAP.BOOIs PAGE PARCEL COMPENSATION INSURANCE ' (This section'need not be completed,if the•'permit is for one ON MAP �J hundred dollars ($100)or less ),. TRACT BLOCK LOT NO NO y } OWNER NO� f SPECIAL d I certify tkat in the performance of'the"work for which this CONDITIONS. Q TRICT GROUP TYPE FIRE P ESSED (� " permit is issued, I shall not employ any person in any manner CONST ZONE. so as to'become subject to the Workers'Compensation Laws ADDRESS f} % Date Applicant CITY ZIP STATISTICAL C SIF CATION• APT CONDO NOTICE TO-APPLICANT If, after�makmg this Certificate of'•` ARCHITE T R • ., TEL - ENGINE /kti NO CL W CLASS NO DWELL UNITS Exemption, you_should become-'subject to .the Workers y Compensation provisions of the Labor Code, you must forth- q RESS SEWER Z with 'comply _with such provisions or this permit shall be ` 7 C NO 57 �3 D'D / 1 VALIDATION deemed revoked ,,, TEL BK LICENSED CONTRACTORS DECLARATION, LIC7 I hereby affirm that I am^licensed und'er,provisions of Chapter 9. A 5 NO(/ _7 - VALUATION (commencing with Section 7000)of Division 3 ofthe Business and LIC j� j Ey-O Professions Code,'and my license is in full force,and effect CITY CLASS!� ✓ $ �® f SQ FT NO OF NO OF CHECK Lacer umber °�!/ � j� Lic Class Z J SIZE, 3 STORIES FAMILIES ONE $ Contra Date. a7 $ Z DESCRIPTION OF WORK NEW ❑ - ADD- ❑ I m exempt from the licensing requirements as I am a licensed architect or a registered professional engineer, ALTER ❑ FINAL �?7 acting in my, professional capacity (Section 7051, I „ Q L Business and Professions Code) USE OF REPAIR ❑ DATE EXISTING BLDG DEMOL ❑ FINAL Lic or Reg No Date APPLICAN TEL, BY j OWNER'-BUILDER DECLARATION (PRINT-I © �� 4,909 d� I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031 5, Business and ADDRESS Professions Code) PRESENT - - - ' BUILDING I, as owner of the property, or my employees with ADDRESS wages as their•solecompensation,will do the work and the structure is not intended or offered for,sale(Section LOCALITY _ '" '' � ' ' •� _ , 7044, Business and Professions Code) MOVING TEL a'3'3 a 8 A I, as owner of the property, am exclusively contracting-' CONTRACTOR NO with licensed contractors to construct the project (Sec, ADDRESS # o 0 0 0 0 tion 7044, Business and Professions Code) 2:°ao 7,0 Q REQUIRED TOTAL SETBACK FROM, EXIST CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP LINE WIDTH I hereby affirm that there is a construction lending agency for FRONT Q, Q Q the performance of the work for which this permit is issued P L ' ' . (Sec 3097, Civ C ) SIDE - - 0 3„1 8; 82 PL _ . Lender's Name P C Fee$ Permit Fee / -V `•� .. Lender's Address > I certify that I have read this application and state that the Issuance Fee aabove information is correct I agree,to comply with all County Investigation,Fee - F ordinances and State laws relating to building construction, _ Total Fee and hereby authorize representatives of this County to enter U upon the above m boned proper or inspection p pos ' ° SEE REVERSE FOR EXPLANATORY'LANGUAGE" Signature of Applicant or Agent Do - ®S