HomeMy Public PortalAbout6247 GOLDEN WEST AVE_Building__ 'WORKERS' COMPENSATION DECLAI AT]Of F
:I hdreby aft�rM that I have a cert#ficate of conseht to se If APPLICATION FOR BUILDING PERMIT
Irg4re„or a ceHtficate of Workers Comppnsatlon Insurance,
dr q certified the reof{Sec . C ) COUNTY OF LOS ANGELES *: BUILDING AND.SAPE'TY
P�o11 NA' '>( 1 Company
�LJ'�/Eerttffed 'copy-is herebBUILDING
y."J FflR APPLICANT TO FILL IN 6w,?,1/7
LkX, Certified cdpy Is filed with a uRty Ildl - A�o
Ming
Datetl n depditnibnt.
Appllcdnt �{Y ZIP LOCAUTY
NO. OF
CERT1F1cATE OF ON FROM 5 ZE OF LOT 7 r I NOW ON tOT s
COMPEENSATION iNSURANa a t
(This section need not be com leted If the perrttlt Is for one TRACT BLOCY LOT NO. - ASSESSOR
MSP BOOKJ^ .�7 PAGE��� PARCEL
hundred dollars (;j00) or ivas.� J ,i � G
I certl that In the vl
NO-0) Z ,
fy, h pakformance of the work for which this. ) f ,�/ p
permit Is I>s}ued, I alialt not employ any person In any manner
ADDRESS�l G_. I/I br/0O. SPECK
so as To.become subject to tie Workers;Compensatlon Laws ZIP �' 1O3NDn1OKS
O
CITY
Date Applicant ARCH fIECT _ I TEL �7 `� p / DISTRICT GROU RE PR0�35�BY O
NOTICE TQ. 4fPLICANT: if, after maklnq•this.Certlfltate of a4GiNEER c C. C��I _N0�1S J]�/��.�b OOfSt ZONE
Exemption,, you shoold ,become sub ect to -the,
o -the Wrkers' L y
Cc mpensdtlon provisions,of the Labor C666,'you mus?oforth- ($ ADDRESS �7(C
..with comply With such provisions or.thlk permit shall be � TEL STATISTICAL CLASSIFICATION APT. COfJDO.
deemed revoked.; CONTRACTOR tsfvr.1NG , Z
-LICENSED.CONTRACTORS DECLARATION ___ _�J �{l �j I ( CASS NO. 4� UNITS
IharebyafflrmtFKtIamllcensed'underprovIsIansofChcspter9 ���r + NO.
� IEW
(commencing-with Section 700Q)of Division 3 of the Busings ` �j( �- SEWER MAP
and frq{"Ioro.Co� and my Ilcgrne Is In full force effecT. 7� "^' �� CIA SS `� gK PG. 4
�1 ATFOH
/Q SQ. ET NO. OF NO. OF CHECK :I
LltenseNumber, /(] ' llc,Ckrss _ STORIES FAM ONE
,,� r s- DESCRIPTION OF WORK (4ti VALl1AT10N �� L�
- ConfracforNK�"� q'•'!-+ 10�date CO ( � L� a�000.� � �'�'��
I am exempt under Sec ADD
ALTEP L� , '1)TAL1?Q7.L
B.BP.C..for this reason $
1 - 1 K i
pats: iL
JSE OF REPAIk 0 _ a 117.!7 n�
EXISTING BLDG. DEAAOL 4
. Signature , APPLE - � d ''RNAL
OWNER-BUILDER DECLARAT1dN /�/ DATE ' �tv� {i'
I hereby affirm that I am exempt from the Contractors License �/ �;Vml v l �� s (,7 l
Law for the following reason (5ectlon 7031.5, "mess and v 1 `� 1 FINAL
Professions Code): BUI NG r y f f s-'. + ,. k�-f �cX c✓ 1
El I, as owner of the,prop",,or my efnployees wlih ADDkESS
wages as their sole cortmpensatIan,will cio the work and ti . )
f *.�AiRL
the structure Is not Intended(x offered for sale(Section LOG41ffY ��"I1�-
7041, Buslnesi and Profewlons Code.). NG . E
NO.
I, as owner of the property, a'-exclusively contracting
with licensed corlfractora to.construct the project (Sec-
tion 7044, Buxlnesw and Profoulons Code.)
ul;�w TOADDRESS FROM + .'' '—� `? 1 T'�'�a.
CONSTRUCTION LENDING AGENCY YARD HyM tir
I hereby affirm that there Is a tanstructlon lending agency for FRONT. � -r
the performance of the work.for which this permit Is Issued P.L
(Sec. 3D97, Ov, C_). Sim. -
P.L :
Lenclei s Nome p
LDMA Ref. I
P.0 Fes f permit Fee
Lenders Address ,
o I certify �af� .e read this applleatlon-and state that the litudnce LDMA P/C+r
above Inform on Is corn I agree to comply.with all County. nveetlgattdn Fee
ordlnan d Stat 1 relating to building construction, Total Fee �/ LDMA Perm. 1�
and her uthorl rb esentatives of thls.County to enter
upon th ve-m tlon property for'InspecIllorn�purposses.
�L �9 a- /�� Sk R/VEM POR E04 AHATORY LAO#GUAGG
---------111---..--"�- ----���— `r.
pnature of Applkant or Agent Date -
APPLICATION FOR BUILDING PERMIT
l�
COUNTY OF LOS ANGELES BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN
I hereby affirm;that I have a oe tfflae a of consent to'&W hv%^-
or a.cer llcate of Workers' Comparmwon hourence,Or a
copy thereof �IG.) �CopyPolicy OF •, NO.OF BL-D0.4 IOW ON LOT Certtw coshed. `7 lA�,rk NEAREST CAoBs ST.
❑ CerttfTed Copy le,f9ed with the �hrepection lrrmTBLOCK LOT No'
USE ZONEMAP
t ASSESSOR MAP PARE PARCEL
APd , SPECLAL o
Cotmort9
CERTIF TE OF EXEMPTION FROM WORKERS' Ta �� ? YES No
COMPENSATION INSURANCE FT OF
ADDRESS .
(This section need roter
ebe completed If the pmft Is for one hundred ftp DISTRICT oROUP CONST. PROCESSED BY
dolfar>� ($100) or iasis)
I certify that n the performance of the Wock for which this pemnft (� �O
I8 Leeued, I shell not employ any person In Arty mannrjr so as b AR(HfTECT El- f TEL NO
sub to the Vkrkera' tion Law& SVTTOTIGAL CLASSIFICNION APT CONDO -
De Appfloant 7 gg CLh49 Na D5NE1L UMTS
NOTXE TO APPLr–WF. tf, after 'makhp this Certfflcate -o( REOUIRED TUU L SETBACK FROM EXIST
Exampbon, you should bacome subject to the VlbrkerS' .SET BACK )ARD HWY PROP LI•E WIDTH
Compensation provlailcm of the Labor Code, you must kc&wlth ,', FRONT
comply with ouch provlelon8 or this Permit shall be deemed revoked.. PL
LICENSED CONTRACTORS DECLARATION P�
I hereby affirm that I am Licensed underprovfsbro of Chapter 9 t 1A 7 SEWER MAP
(oomrngnctip wRfr Section 7000)of Division 3 of the Bum qndFT No. of FA.M LIE
E��am
In furl end ffect
NEW eK PoLk:.C DEscR%,noN OF WORT( ADD ❑ �fI&ILQFON
Date ALTER ❑
cc
❑ I am exempt under Seo. REPAIR ❑ 0
BAP.C.for this reason DEMOL ❑ LDW PSC f W
Deter USE OF EX19T1N0 URM ❑ a
S♦XiHtura APPLr-WT(PFV TI - TEL NO. LDMA,Porm 1
Q l as owner of thA property, or my enployom wfth wages ao O ACCT.i
USole compermation, wnl do the work and the structure Ie ADDRESS FOiAL DATE0 3307 117.90
not Intended or offered for eels (Section 7044, Businees and
Professions Code.) wtL THE APPL".Hr OR FUTU745 B■Tyra CCCLlFN1TEL�rnLe A Us7�wq��n EL
El 1, �s owner of the property, am exDluslvety cotta V with �A,,pl,fis�CO"`�^ ,ON ? FINAL BY _ 1 ITEMS
Acenead contraaofB to coosi uct,the project (Section 7044, YES❑ MO❑ , K i` TOTAL 11 9�
&mbiess and Rofecabne Code.) --
OC L »-E N-rao®use of THF ewu+o THE LbCCFr.PPL��, FW T erSOUTo - . 17.90
.OCCURWT FEGI.FE A PETtlfi FOR COFldTRUGTION OR IIOOFIG�p11 FF1OY ll-E SOUTH
CONSTRUCTION LENDING AGENCY �T AIR ou.&LrrY LLMAGIE @rT DlsmaCT(SOMW)�P�7+c1 CHECKLIST FOO
ram .Ka G
I hereby affirm that there W a conetructbn lendnp apency for . YES El 11O,�I,y� .W'/—73
Cb the performance of the work fqr which this permit Is Issued(Sec. ' FEADi µ� � zf
HE 6kZAFPDUB
9097, Ctv.C.) CHECKLIST UN W�CILWEeurs TFE ANGELES COUNTY
W �I �- �
7a b
L6ndere Name �m A FROHEE / o pODOO-0001 w4y/15/91p
Lenders AddreSe c0ow OR err 7 1 1�111:i0
0
I Certify that.1 have read this application and State umder penally
of perjury that the above Information Is oorracL I aWee to Gonply PLG FEE PERMT FEE
with all oourrty ordktencee and State Iff" reiaUnp to bundling
conahuction, and hereby autfnrtxe repra&antatfves of thls County ISSUA;•lCE FEE iJ
to enter upon the above-mentioned property for Inspection purpoeee.
o NVESTKIOTION FEE TOF,L FEE ^
SEE REVERSE FOR EXPLANATORY LANGUAGE