HomeMy Public PortalAbout6047 GOLDEN WEST AVE_Building__ WORKERS' COMPENSATION DECLARATION !• .
hereby affirm that I'-have a certificate oconsnt,to self I CAT I O N FOR BUILDING PERMIT
insure, or a cert.ficateof Workers , L
or a certified copy''thereof'(Sec'3800_Lab'C )=a' ' _ ,'COUNTY_OF LOS ANGELES , BUILDING AND SAFETY
Policy N7 t004037Company State C:onnY.' Ins
BUILDING
py ' y FOR APPLICANT TO FILL IN ADDRESS
❑, Certified co is hereb .furnished
Certified co is filed with the count buildin ins c- BUILDING
y g ADDRESS 6047 N . Golden West
tion department. ^
Date-4/1 /9 0 Applicant Ly t 1 e ;Ro o f fi n g C o OTv` ZIP91 780 LOCALITY v
NO OF BLDGS NEAREST,
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NOW ON LOT CROSS ST 3 '
COMPENSATION INS0RANCE - ASSESSOR
(This section need not be completed if:the permit" 'is for one ' TRACT' BLOCK LOT NO MAP BOOK r PAGE PARCEL
hundred dollars ($100) or less')-• TEL MAP
OWNER , R t -Boyd NO — NO
O
I certify,that in the performance of the work for which this SPECIAL >
permit is issued, I shal I not employ any person in any manner_ 'ADDRESSH 6 5 6 S u n n s I o' e Drive
CONDITIONS t1
So as to become sublect to the Workers' CompensationLaws r O
} CITY S�n G ZIP , U
Date Applicant - ARCHITECT OR TEL FIRE PROCESSED BY
-
ENGINEER- NO
NOTICE;TO•APPLICANDISTRICT APPLICANT TYPE
T If, after-making this Certificate.of CONST ZONE
` Exemption, you should,become subject to the Workers' U
Compensation provisions of the Labor Code, you must forth- ADDRESSpw
with comply,with•such provisions or this,permit shall be TEL STATISTICAL CLASSIFICATION AP CONDO N
deemed revoked' , e CONTRACTOR NO — Z
LICENSED CONTRACTORS DECLARATION LIC CLASS NO DWELL UNI7S i `
I hereby affirm that I am licensed under provisions-of Chapter 9 ADDRESS -2 9 4 NO
18630
(commencing with Section-7000)of Division 3 of the Business LIC r SEWER MAP
PG
and Professions Code,and my license is in full force and effect CITY'' 'P a s a d•e n a C A CLASS C 9 BK VALIDATION`
= SQ FT NO OF NO OF CHECK
License Number ' 1.8 6 3 0 3%- Lic Class C 3 9 SIZE -23, STORIES FAMILIES ONE ,
L t 1 e R o o f Z n DESCRIPTION OF WORK, NEW
❑ VALUATION
,Contractor y �ote 3 31 91 A
F'lber lss shin -les- tAi ADD . ❑ $3 000 pop. '
❑I dm exempt under Sec a - _ -
.ALTER ❑ _
B•8P C,for this reason UL R21 REPAIR $
Date USE OF '
EXISTING BLDG R n DEMOL F-1
Signatur APPLICANT TEL FINAL
WNER- ILDE 'DEC ION` (PRINT),L' t le Roofing Co NO 7 9'2•-51 7'1 '
DATES m
I hereby,affirm that I exempt fro a Contractor's•License ADDRESS2 9 4 8 E . Walnut S t . P a s a d e n a'` y}/
LavJ,for,the•follow reason(Section 7031 5, Business and FINA VU � 1
Professions Code) i - PRESENT-, � , • • , , • • •• i �"<sy
❑ I, as owner of the property, or myremployees with ADDRESS t u ACCT.4
wages as their sole compensation,will do the work and- `� �n CC
the structure is not intended or offered for sale(Section LOCALITY y , .3, 59.2
7044, Business and Professions Code ) MOVING TEL 1-ITEi'!S
❑ I, as owner of the property„am exclusively contracting
CONTRACTOR NO
with licensed contractors to construct the project (Sec- ADDRESS n TI-�T� 5925
o
tion 7044, Business and Professions Code ) = r rc
REQUIRED TOTAL SETBACK FROM', EXIST `' a CHECK t7•'�;-t
'CONSTRUCTION LENDING.AGENCY SETBACK -'YARD HWY PROP LINE WIDTH`
I hereby affirm that there is a constructton lending agency for FRONT
'the performance of the work for which this permit'is issued P L'
(Sec 3097, Civ C ) %SIDE
Lender's Name �. P L :t - - t� d'0001 10t/20/i�r.9�,
? LDMA Ref # - v rJ�0 1 Fri 1 3 0 i7
PC Fee$ Permit Fee ,
Lender's Address - - �
' I certify that I have read this application'and state that,the issuance Fee 10 5'0 LD MA PSC#
above information is correct I agree to comply with all County Investigation Fee 5 9 .2 5
ordinances ond•State laws lating•to building construction,. Total Fee LDMA Perm #
a - and ereby authorrep entahves of This County to enter
' up a abov e o property for inspection*pu-rposes
1 /B 9 SEE REVERSE FOR EXPLANATORY LANGUAGE
Sig ature of� ant o Agent Date
'r