HomeMy Public PortalAbout6209-6211 GOLDEN WEST AVE_Building__ WQRKERS"COMPENSATION DECLARATION
Ft � certificate
eself
�A O �1#*I L-D I SG PERMIT " "
j, ins ors certificate of Insurance,
L' or-a'ceftifted copy'thereof•(Sec 3800, Lab C ) ' '
COUNTY OF LOS.ANGELES BUILDING,A213 S FETY
Policy Nd Company
- ,
BUILDI
❑ NGCrtified,copy is'hereby furnished PP ANTTOILL'IN,�eADDRE
CeFrtified
copy is with The county building inspec-
tion
BUILDING L� _ ' •7�l�
hon department 1 j• ADDRESS ° i
Date s:` ')s • "Applicant- a CITY_ _c•Ii�CZIP, ��`., LOCALITY -
CERTIFICATE OF EXEMPTION FROM WORKERS", �4 `h' > ' NO,.OF`BLDGS- --'•. - NEAREST, -kv
COMPENSATION'INSURANCE' SIZE OF LOT NOW ON LOT CROSS,ST_
(This section Geed-not be completed if the•permit'is.for one rrA D - - - - ASSESSOR -
hundred dollars ($100)or.,less ) TRACT BLOCK LOT NO MAP BOOK'' t tet• PAGE PARCEL
' I TEL USE ZONE MAP-
0 '1,5.3
�
I,cerhfy•that m the performance of the work for-which,this - WNER _ - NO' ' ¢ — / •-NO t,�
permitp issued, I sliall not employ any person rn ariy'manner • ,� SPECIAL - -- - - •--: - -- d
so as to bec me subject'to the Workers" amp ❑tion Laws ADDRESS J CONDITIONS O
ldpr", .�.�r ,'`s i,l t CIT _ e(.(-�IP- 9�7d._r•� ' t .... ,_,.
Do e 'APP.lica'nt' �. 1 _
NOTICE TO' PPLICANT '9f;-after'makmg' thi's Certificate of ARCHITECT TEL DISTRICT GROUP_ TYPE; r FIRE _PROCE SED BY
Exemption; ,you should become subject To' the Workers' ENGINEER. NO ye- 7C d y I C
i , 7 CONST, : ZONE- W
Compensation provisions•of.the Labor Code; you must forth- ADDRESS $ CEJ `__ _ - �. i: d.
with comply with;-such provisions or this.permit shall be _ _ X _ N
deemed revoked ,, TEL" STATISTICAL CLASSIFICATION APT NDO Z
'n•i ., CONTRACTOR Y` NO yy //
LICENSED.CONTRACTORS DECLARATION,,, -- - - - LIC CLASS NO LDWELL UNITS '
I hereby cffirm,that I am licensed under provisions of Chapter 9 ADDRESS (i-c•f,NO �y SEWER MAP
(commencing w!! Section 7000)of Division 3 of the Business and LIC-
Professtons Code;and'my license is in'full force and-effect CITY ' _, cr /� CLASS ^' VALIDATION'
SQ FT it pit NO OF NO OF - CHECK
License�Number Lic Class' SIZE (/9 STORIES t FAMILIES ONE t 'J,
VALUATION
r `:,; ,. t `. DESCRIPTION OF WORK'- lu lal- tX/ %r y NEW � $
-
Contractor Date ADD' ❑
❑ I am exempt under Sec -t/.� - - - . 3 8$ A
b, , ALTER ❑ ` , �• k
8&P C for this reason USE OF REPAIR, ❑ $/ 0160 V # -
_ - _Date ] DEMOL ❑ _
EXISTING BLDG �f�i-J. _
Signature ` " - '"" APPLICANT r - '- TEL - FINAL _ ° 5 4 b 9 8
PRINT)--_-- i ( L ✓L`3 NO "'�/
• - OWNER-BUILDER DECLARATION _ DATE � .•�� - �. .� •,.,
�4
•1 hereby offirm.that I am exempt from the Contractor's License °~° 5 4'(x'9 8 LF-
S
.Law for the following reason (Section 7031 5, Business and ADDRESS FINA "' 1 ] A
Professions Code) _- ,<M T - -. _-.. r gY ` - 0- - 6
❑ . - - BUILDING' - - _ y`. 1 i # o 0 0 ° 2 3
I, as owner of the property_ or'my employees wrth ADDRESS ' ':
wages as tFieir sole compensation,will do the work and -41,
the structure is not intended or offered for sale(Section LOCALITY L_` +! .. f'1% 2 4.7,0 0
7044, Business arid Profes%ions Code)- MOVING - TEL
Io =
- CONTRACTOR NO - - y 2-4 7.0 0
, as owner of prop�tty, am exclusrvelycontracting
with licensed tractors to construct;the project (Sec- f 0'U 2 1 -86
y _ F
tion 7044, Business andeP ofessions,CodADDRESSFROM EXIST
e) -
-' CONSTRUCTION L LADING AGENCY r__ SETOBACKD _ "YARD HWY TOTAPSETBAROP NE WIDTH `ti ' 15, 2 4 4-7,•6-A
I hereby affirm that there is a coltructiori lending agency for FRONT it \ ''`i ':' r~4 ' `` r,,-
The performance of the work for which this permit is issued P L - - - - -. - ' � *°� a $� rS`--=':�- # ° o o.°_o_ .
(Sec 3097,'Civ-C•) M SIDE
PL N ° 94a95
Lender's NameLDMA Ref
$ - - P C Fee$ t7.. •- Perinit-Fee^ - CJI _ A _J, ° o.9 4 3,_9 V -
le- der's Address _ i
r I certify that I have read this,application and state that the -. Y _ Issuance Fee �V t�/ O' LDMA P/C# - 40 4 2 7j8 6-
above
_above information is correct I agree to comply with all County Inveshgahon'Fee � t
S ordinances and State laws relating to building_construction, Total Fee 9 {{ LDMA Perm # -•• -• - - Y
u and hereby a'uthori'ze representatives of This County to enter y �,V,.
m upon t e above-mentioned roperty for inspection purposes * ,
l�yv I SEE REVERSE FOR EXPLANATORY LANGUAGE T '
-� Signature of Applicant or Agent- -'/-Date
' ,1