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HomeMy Public PortalAbout5939 GOLDEN WEST AVE_Building__ L WORKERS' COMPENSATION DECLARATION � APPLICATION FOR BUILDING PERMIT ® I hereby affirm that I have a certificate of consent to self insure, or a certificate of Workers'Compenstion Insurance, or a certified copy thereof (Sec. 3800, Lab. COUNTY OF LOS ANGELES BUILDING AND SAFETY 40 44 Policy Noa3_7-2az Company BUILDING fj Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS l Certified copy is filed with the county buil ing inspec- BUILDING ,--t �tion department. ADDRESS y �-- li 'caj S ) LOCALITY 7 ' O �- e NEAREST p Date Applicant CITY E C t� ZIP CROSS ST. CERTIFICATE OF EXEMPTION FROM WORKERS' OF BLDGS. ASSESSOR COMPENSATION INSURANCE SIZE OF LOT OW ON LOT MAP BOOK PAGE PARCEL (This section need not be completed if the permit is for one USE ZONE EMAPhundred dollars ($1100)or less.) TRACT BLOCK LOT NO'TEL.I certify that in the performance of the work for which this OWNER 7, NO. S O permit is issued, I shall not employ any person'in any manner < DISTRICT GROUP TYPE FIRE PROCESSED BY V so as to become subject to the Workers'Compensation Laws. ADDRESS ' 3CONST,_ ZONE Date Applicant CITY ZIP STATISTICAL CLASSIFICATION �f? APT. CONDO. NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL. `: Ly ENGINEER NO. CLASS NO. DWELL. UNITS 0. Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- ADDRESS r SEWER MAP g with comply with such provisions or this permit shall be deemed revoked. CONTRAC OR p NO. BK. PG, VALIDATION LICENSED CONTRACTORS DECLARATION r- LIC. I hereby affirm that I am licensed under provisions of Chapter 9. ADDRESS e NO. VALUATION fl (commencing with Section 7000)of Division 3 of the Business and LIC. Professions Code, and my license is in full force and effect. CITY L` CLASS $ �® t2 SQ. FT. O. OF NO. OF CHECK License.Number Lic.Class J SIZE STORIES FAMILIES ONE Contractor . `Y ) e Date 7" l DESCRIPTION OF WORK NEW $ I am exempt fro the licensing requirements as Lom a Egr+to _ i ADD licensed architect or a registered professional engineer ALTER FINAL/ acting in my professional capacity (Section 7051, 6A�' /c1 REPAIR DATE Business'and Professions Code). USE OF �,,�. DEMOL E] FINAL EXISTING BLDG. By Lic. or Reg O No. Date APPLICANT TEL. OWNER-BUILDER DECLARATION (PRINT)c� Q v A1451, N .( - Z' I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and ADDRESS/ e 6C., lu e-/ ,0— 4 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 7044, Business and Professions Code). MOVING TEL. 1, as owner of the property, am exclusively contracting CONTRACTOR NO., 2 �I 0 b A With licensed contractors to construct the project(Sec- ADDRESS # 0 0 0 0 8 9 tion 7044, Business and Professions Code). . REQUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH 0 0 0 0 0 0 0 z I hereby affirm that there is a construction lending agency for FRONT the performance of the work for which this permit is issued' P.1. 0'7,2 O_ 1 (Sec. 3097, Civ. C.). SIDE P.I. Lender's Name P.C:Fee$ Permit Fee Lender's Address w I certify that I have read this application and state that the 14 ssuance e Qabove information is correct. I agree to comply with all County Investigation Fee o ordinances and State laws relating to building construction, Total Fee and hereby outhonz representatives of this County to enter a u m he above-me toned propertl for inspection purposes. a , 1 � / SEE REVERSE FOR EXPLANATORY LANGUAGE Sign"'.1.711170,; pp in or Agent Date - ©s