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HomeMy Public PortalAbout6120 GOLDEN WEST AVE_Building__ /K _ WORKERS' COMPENSATION DECLARATION insure, c raa cevtif catte W �of orke s' Compensation Insurance, APPLICATION, .FOR BUILDING PERMIT or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF.LOS ANGELES BUILDING AND SAFETY Policy No. Company ^ BUILDING❑ OC)Certified copy is hereby furnished.. FOR APPLICANT TO FILL IN ADDRESS O ❑ Certified copy is filed with the county building inspec- BUILDING / tt tion department. ADDRESS tp t of r76AJ`��S k :• C -780 �7L/ / Date Applicant CITY' �yl'Pl-� G 1 i f ZIP „! j LOCALITY J-I�� C CERTIFICATE OF EXEMPTION FROM WORKERS' NO. OF BLDGS. NEAREST SIZE OF LOT '�¢ x 1 Fa NOW ON LOT CROSS ST. COMPENSATION INSURANCE ASSESSOR (This section need not be completed if the permit is for one TRACT BLOCK I LOT NO. MAP BOOK PAGE PARCEL hundred dollars ($100) or less.) TEL. OWNER Lr"C-m'!L NO.-285' 6 USE ZON MAP I certify that in the performance 'of the work for which this SOCIAL permit is issued, 1 shall not employ any person in any manner ADDRESS S�}rY1r �" n CONDITIONS so as to become subject to the Worke s' Compensation Laws. 0 !s /( r CITY• ZIP Date `�U �Z��QDF plicani 1 " ARCHITECT OR TEL. DISTRICT GROUP- TYPE FIRE PROCESSED BY O NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. CONST. E U Exem tion, ou should become subject to the Workers' .Compensation provisions of the Labor.Code, you must forth- ADDRESS 5 N with comply with such .provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION AP-r. CONDO. deemed revoked. CONTRACTOR NO. Z LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. SEWER MAP (commencing with Section 7000)of Division 3 of the Business LIC. and Professions Code,and my license-is in full force and effect. CITY CLASS BK PG VALIDATION SQ. FT. NO. OF NO. OF CHECK License Number Lic. Class SIZE /�3st STORIES FAMILIES ONE VALUATION �y Contractor Date DESCRIPTION OF WORK 2 S�p�� i� faD• NEW ❑ \ � _(& _ ADD 'yJLS�,I( �r� ❑I am exempt under Sec. F!3 �X15;-r//V = 1 QED 5&W+Nd• ALTER ❑ , ��• B.&P.C. for.this reason FA M1 Ly /LQG✓H W LAV A,DR REPAIR ❑ a USE OF � . Date: EXISTINGBLDG. Jr-/1V�LE 1FA"14-)" DEMOL ❑ / C Signature APPLICANT TEL. FINAL OWNER-BUILDER DECLARATION • (PRINT) 'L . FM!r- SrH!i H NO. ��$`P6_ DATE I hereby affirm that I am exempt from the Contractor's License t `10, Law for the following reason (Section 7031.5, Business and ADDRESS &J'2 @ 6o c,2>z-A, h�a 7_ernp.r CIT FINAL ro essions Code): PRESENT By BUILDING `' 1 'a I, as owner of the property, or my employees with ADDRESS �n��j(� —,•-;t-r +� wages as their sole compensation,will do the work and -/ Y �at sr Lam° °``.4 LOCALITY . the structure is not intended or offered for sale(Section ► i sT��l:_ 7044, Business and Professions Code.) MOVING TEL. �� CONTRACTOR NO. ❑ I, as owner of the property, am exclusively contracting' ,. OF (1 p i Ary 161`® � ' with licensed contractors to construct the project (Sec- �� ADDRESS t'. +a •�� tion 7044, Business and Professions.Code.) �••��•�.K 1611 5121 REQUIRED TOTAL SETBACK FROM EXIST. Pm'IT' . CONSTRUCTION LENDING AGENCY SET BACK . YARD HWY PROP. LINE WIDTH i_ t4. �jL �(;; I hereby affirm that there is a construction lending agency for FRONT_ K(q the performance of the work for which this permit is issued P.`L. (Sec. 3097, Civ.'C.). SIDE _ P.L. tilt!'—00 Lender's Name. L"' LDMA Ref. # 4 1 Am i i. ' P.C: Fee$ Permit Fee i�� Lender's Address , o 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 i 9.2 LDMA Perm. # a and hereby authorize representatives of this County to enter upon the a a e-mej4ioned pro erty for inspection purposes. `SLI D-R AVO_yyr2Z1 IPA, SEE REVERSE FOR EXPLANATORY LANGUAGE 'T-Signature of Applicant or Ager.t Date ' WORKERS' COMPENSATION DECLARATION + htsrAy affirm that I have a certificate of consent to self insure, or a c,rtificate of Workers' Compensation Insurance, APPLICATION FOR BUILDING PE RMIT a or o,certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy'No. Company Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING ADDRESS Certified copy is filed with the county building inspec- BUILDING tion department. ADDRESS Date Applicant CITY ZIP 0 LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. NEAREST COMPENSATION INSURANCE SIZE OF LOT X Z NOW ON LOT CROSS ST. (This section need not be completed if the permit is for one ASSESSOR hundred dollars($100)or less.) TRACT > BLOCK LOT NO. /ry MAP BOOK PAGE PARCEL OWNER �rl I NOlt.o 5� � S USkNCTE �gP �'jj_�I certify that in the performance of the work for which this �vpermit is issued, I shall not employ any erson in any manner IAL so as to become subject to the Work Co pq- t Laws. ADDRESS DITIONS Date Applicant �� CITY ZIP U NOTICE TO APPLICANT: If, after making*this'Certificate of ARCHITECT OR N/� O�TEL. DISTRICT GR UP TYPE FIRE PROC D BY O eNO. CONST. / Z0!$E U Exemption, you should become subject to the Workers' ^�+ /}�v( �� tv/ Compensation provisions of the Labor Code, you must forth- ADDRESS V j� �� �� J lJ W with comply with such provisions or this permit shall beTEL. ��f/�,�, �sy 0.' deemed revoked. CONTRACTOR , W�J NO.`7 "�J v STATISTICAL CLASSIFI ATION APT. CO Z LICENSED CONTRACTORS DECLARATION LIC CLASS NO. DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS I, NO.57-* SEWER MAP (commencing with Section 7000)of Division 3 of the Business and LIC {--� Professions Code, and my license,is in full force and effect. CITY t C. CLASS BK L PG " /-7 VALIDATION SO. FT. / INC.OF /) INC. OF CHECK License Number Lic.Class SIZE (p STORIES FAMILIES ONE VALUATION 1 Contractor Date DESCRIPTION OF WORK 9 so NEW ❑ $ ;29.1 Q 4 A- ,(9apD V I am exempt under Sec. ' �' N��rQ4 I 4L7ER ❑ # 0004; 23 B.&P.C. for this reason !L REPAIR ❑ $ J a 5 4.1.2 5 Date: USE OF DEMOL ❑ EXISTING BLDG. (e a o 5 412 5'5) Signature APPLICANT TE - FINAL OWNER-BUILDER DECLARATION PRINT G AJJ N DATE 03, 03-88 I hereby affirm that I am exempt from the Contractor's License ADDRESS Q FINAL Law for the following reason (Section 7031.5, Business and Professions Code): PRE5ENT BY BUILDING 1, I, as owner of the property, or my employees with ADDRESS \ wages as their sole compensation,will do the work and Q a 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. `` O with licensed contractors to construct the project'(Sec-. ADDRESS tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY SETBACK YARD HWY TOTA SET ACK WIDTH 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. (Sec. 3097, Civ. C.). SIDE Lender's Name P.L. 2 9 9 3.3 A LDMA Ref, q Lender's Address P.C. Fee$ ` # 1 � t ° Permit Fee o 0.0 0 0 I certify that I have read this application and state that the Issuance Fee S kLDA P/C# I o 64725 above information is correct. I agree to comply with all County Investigation Fee 0 ordinances and State laws relating to building construction, o o = Total Fee LDMA Perm. p 6 4 Z.2 5 U R and hereby authorize representatives of this County to enter upon t�abov property for inspection purposes. .a 0b2't 8,8 �- SEE REVERSE FOR EXPLANATORY LANGUAGE y I ti Signature of Applicant or Agent Date i WORK ERS'COMPENSATION DECLi RATION A APPLICATION FOR BUILDING PERMIT I herebf affirm that I have a certificate df consent to self insurep or a certificate of Workers' Compensation nsurance, ' or a certified copy thereof (Sec. 3800, Lab. COUNTY OF LOS ANGELES , BUILDING AND SAFETY Policy Nd!���0�D�' Company BUILDING ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS ❑ Certified copy is filed with the county building inspec- BUILDING /f ��� � L4_/ J� tign department. ADDRESS fs t[��%/ CITY �i • -, ZIP LOCALITY Da pplica, NO. OF BLDGS. NEAREST CER FICATE OF EXEMPTION FROM WORK SIZE OF LOT NOW ON LOT CROSS ST. COMPENSATION INSURANCE ASSESSOR '(This section need not be completed if the permit is for one TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL hundred dollars ($100) or less.) TEL. d OWNER m 44� j J' NO, Zk3 USE ZONE- MAP I certify that in the performance of the work for which this yam, N0. }} permit is issued, I shall not employ any person in'any manner ADDRESS ��A'`C7"'Z e4 �� SPECIALCONDITIONS Q so as to become subject to the Workers' Compensation Laws. U CITY ZIP Date Applicant ARCHITECT OW/ TEL. (, tY NOTICE TO APPLICANT: If, after makingthis Certificate of ENGINEER //i I N` d�f NO. 7n� L3�d DISTRICT GROUP TYPE FIRE PROCESSED BY CONST. ZONE (.J Exemption, you should become subject to the Workers' ��-}} w Compensation provisions of.the Labor Code, you must forth- ADDRESS �� ci,4 //f /-T c, L�� `� v d 'with comply with such provisions or this permit shall be TEL. N p y p p � c f. STATISTICAL CLASSIFICATION APT. CONDO. Z deemed revoked. CONTRACTOR�C�C� _ � .-! ! /s �a.� — C. � �j CLASS NO.�DWELL. UNITS LICENSED CONTRACTORS DECLARATION NO ZZ [© I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS O - ��i� SEWER MAP (commencing with Section 7000)of Division 3 of the Business LIC. ��. and Professions Code,and my license is in full force and effect. CITY CLASS�L P`1 7 BK PG VALIDATION T J SQ. FT. NO. OF NO. OF CHECK License Number/- • Lica Class �"' ,L SIZE STORIES FAMILIES ONE GVALUATION � ,N Contractoe`` -�- / � 6 O DESCRIPTION�O/F WORK ADD ❑ $NEW D �����A��� ❑I am exempt under Sec. ' �` � > , ALTER ❑ B.&P.C. for this reason REPAIR ❑ $ te: USE OF EXISTING BLDG. DEMOL ❑ Signature APPLICANT i {. /J -7 (�96—e26 FINAL WNER-BUI R DECLARATION. (PRINT). ,LOl2 G1 6� !� J DATE 1 I hereby affirm that I am exempt from the Contractor's ense ADDRESS f�� -� �t ` �C 'a Law for the following reason (Section 7031.5, Business and FINAL ACCT Professions Code): - IPRESENT By BUILDING �3; 7 44326 44' " e ❑ I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and LOCALITY 1 ITEMS the structure is not intended or offered for sale(Section TOTAL T 4 7044, Business and Professions Code.) MOVING TEL. �� -yam IOTAL. 488� �B I, as owner of the property, arrt exclusively contracting CONTRACTOR NO. CHECK' +':� with licensed contractors to construct the project (Sec- ' *83.+1t ADDRESS tion 7044, Business and Professions Code.) �pCHANGE CONSTRUCTION zj{ij 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 the performance of the work for which this permit is issued P.L. 0130J_I3ft0 t 2/31/92 (Sec. 3097, Civ. C.). SIDE j5270 q ' Lender's Name. AM °20 nn � // G/ LDMA Ref. # Lender's Address P.C. Fee$ `J. 1 Permit Fee l � / a 0 1 certify that I have read this application and state that the Issuance Fee 7� LDMA P/C# above information is correct. I agree to comply with all County Investigation FeeyA 0 ordinances and State laws relating to building construction, Total Fee 0U LDMA Perm. # a and hereby authorize representatives of this County to enter upo a above-mentione r i ection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature Applicant or Age ate