HomeMy Public PortalAbout6059 GOLDEN WEST AVE_Building__ WORKERS'COMPENSATION DECLARATION k �/
insure, or afclertificate� 'thatlof Workershave a 'Colmpenso`trtifcate fonolnsurance, olr ! APPLICATION fOR BUILDING PERMIT
a certified copy thereof (Sec 3800, Lab C ) - /
Policy No - Company- ti _
COUNTY OF LOS ANGELES @ BUILDING AND SAFETY
BUILDING_ /
Cer,tifted co +s•hereb furnished ADDRESS �,�
❑' py y FOR'APPLICANT T FILL IN
Certified copy is`filed with the county building nspec- BUILDING.
tion'department' ADDRESS LOCALITY
NEAREST
Date' Applicant CITY ZIP CROSS ST
,CERTIFICATE OF EXEMPTION FROM WORKERS' N OF BLDGS ASSESSOR
COMPENSATION INSURANCE SIZE OF LOT bj6W ON LOT MAP BOOK PAGE PARCEL
(This•section,nded not be completed if,-the permit is for one USE ZONE MAP
hundred dollars ($100)or less ) r TRACT BLOCK T,NO NO ~
/ ,TEL SPECIAL a
I certify that in the performance of the work for which this, OWNER CONDITIONS O
permit is issued, I shall not employ any person m any manner i DISTRICT GROUP TYPE E PROCESSED BY U
ADDRESS CON E
so 7�to�esuble't. tke Workers'Compensation Laws + �n CITY ZIP STATISTICAL CLAS CATION APT CONDO ~
NOTICE'TO AP LICANT- If,•'after make g this Certificate of ENGINEERARCHITT OR TEL - _ / LU
CLASS NO DWELL UNITS CL
Exemption, you 'should become sublect to the^Workers' &A
Compensation,provisions of-the Labor Code, you must forth- ADDRESS SEWER MAP z_ `
with•comply With such provisions or this-permit shall be , lb4�
,deemed revoked CONTRALTO T O BK/---PG, CZ VALIDATION
LICENSED CONTRACTORS DECLARATION - ��
I hereby affirm that I am licensed under,provisions,of Chapter 9 ' 1 ADDRESS' v0 VALUATION
(commencing with Section 7000)of Division 3 of the Business and LICA
Professions Code, and my
SQ
is in full force and effect CITY CLASS $'
e SQ F NO OF NO OF HECK
License Numbef G 'Lic Class SIZE' �/�, STORIES FAMILIES ONE _
Contract /� Date
DESCRIPTION OF WOR NEW
❑ ADD
I am exempt from the rlicensing req ire ents: I-am a d w
licensed architect or a registered'profes"sional engineer, ` ALTER FINAL t• - -1 ,1 7.�J'�
acting in my professional capacity (Section 7051, DATE �'k REPAIR # o e o 0;2 3
• Business and Professions Code) "� - � E p - FINAL
` - E G BLDG DEMOL ❑ "P
Lic or•Reg' No Date APPLICANT TEL By d'°' 2 0 0 5 4.O O
OWNER-BUILDER DECLARATION PRINT NO' ° 5 U O O c�i
I hereby affirm that I am exempt from the Contractors License
Law for the following reason,(Section 7031 5, Business and ADDRESS r
Professions Code) •. PRESENT
09, 1 -81,
❑ I, as owner of the aro ert y employees BUILDING D�, -
p p y,`.or m em to ees with ADDRESS / f
wages as,their sole cbrnpensotton,will do the work and ,
the structure is not intended or offered for sale(Section' LOCALITY - -
7044, Business,and Professions Code) MOVING - /��� `. 1 1 7,4 A
❑ CONTRACTOR O
I, as owner of the property, am exclusively contracting # o e e o 0 1,
with licensbd contractors to construct the protect (Sec- ADDRESS
tion 7044, Business and.Professions Code)
--CONSTRUCTION LENDING AGENCY • REQUIRED YA7�7P HWY TOTAL SETBACK FROM EXIST• 2 0 3 1 O,Q
- SET BACK PROP LINE � _
I hereby offirm,that there is a construction lending agency-for FRONT - .'O /° 31/ o o �J,1 000
the performance of the work for wH16 this permit is issued P L �'
(Sec 3097, Civ C ), SIDE
PL 0 9. 1 5'-81
Lender's Name v _ _• _ '
P C Fee$ ��/ Permit Fee
Lender's Address
W I certify that Ihave read this application and state that the ssuance Fee �.
aabove information is correct Lagree to comply with-all County Iriveshgation Fee
0 ordmanceseand State laws relating to building construction,
U
and hereb authorize representahves•of this County•to enter Toral'Fee '
< upon t ore-m t neroper or inspection-purposes
a - �j' /� J SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Appli7ant or Agent D / C/'"/