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Home My Public Portal About6030 GOLDEN WEST AVE_Building__ 3fv WORKERS' COMPENSATION DECLARATION (o(93 O J 603,;2, '1•r O ^��+Fj)pr herd!j ffirm that I have a certificate of consent to self )z !o sure, br a certificate of Workers' Compensation Insurance, APPLICATION FOR BUILDING P E RM I T `or•8 certified c'apy,thereof ©c. 3800, Lab. C.) _ COUNTY OF LOS ANGELES +a BUILDING AND SAFETY Poli y No Company -� • 1G El Certified copy is hereby furnished. -�/ FOR APPLICA T TO FILL IN ADDRESS O D Certified copy is filed with the county building inspec- BUILDING , ©� � t tion department. ADDRESS a� CITY' •%'W'' ZIP LOCALITY Date Applicant.C�GGcC� G�-,ry. NO. OF BLDGS. NEAREST s CERTIFICATE OF EXEMPTION FROM WORKERS' 44�- SIZE OF LOT /6,K JCP/ NOW ON LOT % CROSS ST. COMPENSATION INSURANCE ASSESSOR r; �5 �• _ ,k JW (This section need not be completed if the permit is for one TRACT BLOCK LOT NO. � MAP BOOK PAGE tJZ P RCEL It hundred dollars ($100) or less.) / Y'9A, j. . {3 Y; % TEL. OWNER V(; ;t/f i Z NO.f� fj28 55t9 USE ONE OP, I certify that in the performance of the work for which this q permit is issued, I shall not employ any person in any manner ADDRESS J( ✓7 fj/%►/_ �: )8 (�. l�� SPECT I J•� CONDITIONS so as to become subject to the Workers' Compensation Laws. 7t _71bL O CITY / r ✓ �/f ZIP I U Date Applicant ARCHITECT R 7EL. DISTRICT GROUP TYPE FIRE OCESAEB Q NOTICE TO APPLICANT:'If, after making this Certificate of ENGINEER f / k Cf't' 4 C� NO f f •% CONST.' FIRE VExemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- ADDRESS y. � h /"Gi�'�'%1� y�1/ j' lIk Of A�_ � CL with comply with such provisions or this permit shall be TEL STATISTICAL CLASSIFICATION APT.t CO O. N deemed revoked. CONTRACTOR' NO r' Z LICENSED CONTRACTORS DECLARATION , IC. CLASS NO. 6?��JDWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS Sv _ NO. '(commencing with Section 7000)of'Division 3 of the Business (� I SEWER MAP l'C�eQ�-,e 4YI4 9i C x;� and Professions.Code,and my license•is in full force and effect. CITY BK. PG. i^t? t•VALIDATION SQ. F NO. OF NO. OF CHECK _ _ License Number Lic. Class SIZE" STORIES FAMILIES ONE ?_1,7 is `ice°ti VALLITION Contractor bate DESCRIPTION OF WORK NEW ADD ❑ :-. ❑Tani exempt under Sec Yl/ti" , )LI'4i;_ ALTER ❑ � � � B.&P.C. for this reason S / '.-s �;•.,: -;"f REPAIR ❑ it !. 1_l«-°_. Date: USE OF EXISTING BLDG. laae�•e tCcAYi li�/J/a Ra DEMOL ❑ 'r•ff^ii1`•]L rl_11_P Signature APPLICANT TEL. 'FINAL OWNER-BUILDER DECLARATION (PRINT) Gi#i ILS Cialf/ NO: Cd4v I hereby affirm that I am exempt from the Contractor's License •,_ f Law for the following reason (Section 7031.5, Business and ADDRESS %✓�� /�/jf't4r f.1f-� ��• YJt f}�y FINAL r * Pkx EA Professions Code): PRESENT B Ty °1 BUILDING ❑ I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and L �� & �� T the structure isnot intended or offered for sale(Section LOCALITY (/ d 7044, Business and Professions Code.) MOVING TEL. �p '3-7�r )0 , CONTRACTOR NO. ❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions.Code.) REQUIRED TOTAL SETBACK FROM EXIST. Q +v(J t'i 1U CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH j 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. '1= (Sec. 3097, Civ. C.). PIDE Lender's Name �.{�� _ -_- /cam/ �� LDMA Ref. # ,'a-: . P.C. Fee$. as Permit Fee J 3 Lender's Address I certify that I have read this application and state that The . Issuance Fee 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. # a and hereby authorize representatives of this County to enter upon the ove- entioned property for inspection pJurposes. UY SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applica Xqent J—Dat—eay) y 1 . q f�� O �/ J