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Home My Public Portal About4959 MCCLINTOCK AVE_Building__ WORKERS'COMPENSATION DECLARATION I insure,hereby aafcertificate of Workers' Compensat on Insuran elf APPLICATION F R BUILDING PERMIT jl jl or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company BUILDING C Certified copy is hereby furnished. r FOR APPLICANT TO FILL IN ADDRESS y JAt M�.,J ❑ Certified copy is filed with the county building inspec- BUILDING �,� tion department. ADDRESS ii ^� Date Applicant CITY -cc:in e ZIP ` 1 o LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' 1 i t NO.OF BLDGS. NEAREST COMPENSATION INSURANCE SIZE OF LOT —1 d 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. MAP BOOK PAGE PARCEL �/ll O. OWNER MAP I certify that in the performance of the work for which this , Q USE ZONE NO. permit is Issued, I shall not employ any person in any manner �+ SPECIAL so as to become subject to the W kers'Co ns 'on aws. ADDRESS 1 '7 CONDITIONS U Date L —�" Applicant CITY C� Le C ZIP NOTICE TO APPLICANT: If, after making this Certificate ARCHITECT OR TEL. DISTRICT G UP TYPE FIRE PROCESSED BY O ENGINEER NO. / 'r CONS . ZONE I" Exemption, you should become subject to the Workers' `� Compensation provisions of the Labor Code, you must forth- ADDRESS vL with comply with such provisions or this permit shall be EL. STATISTICAL CTS17APT. N deemed revoked. CONTRACTOR �J _/ Z LICENSED CONTRACTORS DECLARATION LIC, CLASS NO. (/l DWELL. UNITS — I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. SEWER P (commencing with Section 7000)of Division 3 of the Business and LIC. I Professions Code, and my license is in full force and effect. CITY CLASS BK PG ail VALIDATION SQ.FT U7JNO.OF NO.OF CHECK License Number Lic.Class SIZE STORIES FAMILIES ONE VALUATION Contractor Date DESCRIPTION OF WORK tr O NEWADD ❑ $ I am exempt under Sec. Ge'v---I ` 0 ❑ � �� .r�` ��;�/� 4� ALTER B.BP.C. for this reason { v 1�� CQQelrG.0 a/�r— REPAIR ❑ $ Date: USE OF DEMOL EXISTING BLDG. tt� .T^ �c77F� /��D ❑ Signature APPLICANT NVAMEW ` - WNoL. —[T8��7 FINAL OWNER-BUILDER DECLARATION ��yy �q ,��/� DATE I hereby affirm that I am exempt from the Contractor's License ADDRESS `t—I J 1 1 s -s--V �' FI 0 1 9 0 A Law for the following reason (Section 7031.5, Business and Professions Code): PRESENT 'l # 0 0 0 0 0 1 BUILDING I, as owner of the property, or my employees with ADDRESS I o 0 2 8 5 O wages as their sole compensation,will do the work and the structure is not intended or offered for sale(Section LOCALITY = 7044, Business and Professions Code). MOVING TEL. o o o 2 8 5 0 5 ❑ I,as owner of the property,am exclusively contracting CONTRACTOR NO. with licensed contractors to construct the project (Sec- o7.1 4-88 tion 7044, Business and Professions Code). ADDRESS CONSTRUCTION LENDING AGENCY SET BACK YARD HWY TOTAPREOTP ACtKEF 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 P.L. Lender's Name OLDMA Ref. # Lender's Address P.C. Fee$ Permit Fee L I certify that I have read this application and state that the Issuance Fee L LDMA P/C# above information is correct. I agree to comply with all County Investigation Fee ? ordinances and State laws relating to building construction, Total Fee s S LDMA Perm.# Ohereby authorize representatives of this County to enter � u o th abov - nti ed p petty for inspection purposes. g SEE REVERSE FOR EXPLANATORY LANGUAGE o ' Signature of Applicant or Age Date APPLICATION FOR CJI-LDING -PERMIT �" • ,'� ' �' COUNTY OF LOS ANGELES =a BUILDING AND SAFETY �' •• ��, BUILDING ADDRESS ' `5WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN , BUILDING ADDRESS �G�\, C� ,` „ C 1 L hereby affirm that I have a certificate of consent to self insure, V IC or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec.9800.Lab.C.) CITY��, �� ZIP y� LOCALITY , PQIIQy NO. Company SIZE OF LOT NO.OF BLDG .NOW ON LOT 6 NEAREST CR ST ❑ Certified copy is hereby furnished. � ❑ Certified co is filed with the county building inspection TRACT BLACK LOT NO. � � USE ZONE MAP NO. department. i Date Applicant ASSESSOR MAP oOK �� PARCEL ,...� SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' NN(� 4NpRZ" TE N� �i�l$-.'2.375 //�\ YES NO COMPENSATION INSURANCE WITHIN 1000 FT.OF SCHOOL? his section need not be completed If the ADDRESS (T p_ permit is for one hundred (� m C L'•'(��, �v � DISTRICT '"GROUP TYPE CONST.' FIRE ZON PROCE D BY dollars($100)or less.) CITY . • ZIP Q % I certify that in the performance of the work for which this permit TCM �c Cts —L 1 R. / 3 : �• Is issued, I shall not employ any person in any manner so.as t0 ARCHITECT R.ENGINEER TEL NO. o become subject to the Workers'Compensation Laws. 6 V—E_EG 4ZA V NT'l : q 3g-343b STATISTICAL CLASSIF CATION AppC NDO' Data Applicant ADDRESSCLASS NO. DWELL UNITS PO X ' SNNTX MAa6A•F_RA 1345 3, • NOTICE TO APPLICANT. If, after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST Exemption, -you •should, become subject to the Workers' CONTRACTOR -TEL'NO. SETBACK YARD HWY PROP LINE WIDTH Compehsation provisions of the Labor Code,you must forthwith FRONT comply with such'provlsibns or this permit shall be deemed revoked. ADDRESS LIC.NO. PL -� per' LICENSED CONTRACTORS DECLARATION clTv LIC.ewSIDE. PL ''-T O I hereby,affirm that I am licensed,under provisions of Chapter 9SEWER MAP ��uLl r � �o`�v (commencing With Section 7000)of Division 3 of the Business and' SO.FT.SIZE NO.OF STORES NO.OF'FAMILIES a 7 � NEW El BK PG Professions Code,and my license is in full force and effect. C DESCRIPTION OF WORK ADD VAL noN I TTI_IM,_ LU License Number Lic.Class Op" w_a J p a QpK� ,r.e._„, „ � Contractor Date ALTER ❑ ' TOTAL 5 ❑ I am exempt under Sec. RIY\E R�m` FNAF% L (�O REPAIR ❑ !!%F� DO(y• eL0 (HECK 527.21 ❑ CHARGER��( B.&P.C.for this reason � DEMOL A• LDM ,P/C# - - Date. USE OF EXISTING BLDG. .URM ❑ Signature ' ; , {7Q 0- OIJ 7/26,110 APPLICANT(PRINT) n TEL NO. LDMA Perm# I ❑ 1,as owrier of the roe ID 1 PtRDNZ20 Ligcg'-a l5 `;' Z property;rty, or mq employees with wages as OI AM 23%" their sole compensation,will do the work and the structure Is ADDRESS /� • l F. f `�' not Intended or offered for sale (Section 7044, Business and CL S (ACCI 11 ikoc•c - e 2• lC Ql FINAL ATE _ c c . rofessions Code.) G 3,i 1 r} '' s(• 1� WILLTHEAPPLICANTOR FUTURE BUILDING OCCUPANTHANDLEA HAZARDOUS MATERIAL I, as owner Of the ro art , 8m'exCIUSIVeI contractin Wlth OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN ti r lk P P Y Y g THE AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY > = i 1 E I:; ensed contractors to construct the project.(Section 7044,- _ Business and Professions Code.) YES❑ No❑ ` t „56 WILL THE INTENDED USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING _ •i ' CONSTRUCTION LENDING AGENCY C°oAsuTP"A"I'A ouuirvAPERMIT FOR MANAGEMENT DISTRICT CONSTRUCTION SEE PERMITTING CHEc°icL1�sTK 6135.56 FOR GUIDELINES. q,f I hereby affirm that there is a construction lending agency for YES❑• NO❑ ;� #Yci CSE �i ICI r the performance of the work for which this permit Is Issued(Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD 176 ' 9097,CIV.C.). - PERMITTING CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES HAUSTiTLELSRTOR PUGH O40 CONCERNING Lenders Name HAZARDOUS MATER AREPRTINGAND FOR AERMIT M THE SCAOMD. �-7 9/9i'i ' Lenders Address �� ! �� 001131343001l (��!}r :}�y; 'ILOMERORAGENr .� R S 1'•Ii 1 is•I+' C2 1 certify that I have read this application and state that the above P.C.FEE PERMIT FEE information is correct. I agree to comply with all county ordinances and State laws relating to building construction,and heft authorize re tative3 of this County to enter upon ' ISSUANCE FEE th a tion rty for inspection purposes.AA �:r r., . : ,:' '; , OD E( a INVESTIGATIONTEE TOTAL FEE `D6"B sz \v SEE REVERSE FOR EXPLANATORYLANGUAGE y8J ti WORKERS.COMPENSATION DECLARATION rm that4,*have a certificate of coent to self in6,a hereby aff�certificate of Workers' Compensat on Insurance, APPLICATION FOR BUILDING PERMIT or a<e'rtified copy thereof (Sec.•3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company ElBUILDING -yam Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS ❑ Certified copy is filed with the county building inspec- BUILDING 11 q 5q �Ccf t tion department. ADDRESS �•_,1� 1 1 p !•� Date Applicant CITY 1 Gam+ ZIP 1� p v LOCALITY ' NO. OF BLDGS, NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT 0 X ( 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 p (}� 2ZO '�I� ($100)or less.) V.� (� -�I�tX�3 OP I certify that in the performance of the work for which thiOWNER NO, USE ZONE s SPECIAL >- permit is issued, I shall not employ any person in any manner ADDRESS S .tib CONDITIONS a_ so as to become subject to the Workers'Compensation Laws. O CITY ZIP U Date Applicant ARCHITECT OR TEL. W NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER roor.6 NO DISTRICT GROUP TYPE FIRECONSTZONE PROCESSED BY O Exemption, you should become subject to the Workers `�p 3 I./ S Compensation provisions of the Labor Code, you must forth-- ADDRESS 0 - V - a with comply with such provisions or this STATISTICAL CLASSIFICATION APT. CONDO. N P Y P permit shall be No � � Z deemed revoked. CONTRACTOR �C:�� W�e 1' 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 Q� STORIES FAMILIES ONE VALUATION Contractor Date DESCRIPTION OF WORK 9-C NEW ❑ $ 4-0 El1 am exempt under Sec. cayc. /�Gd y D ► 8.8P.C. for this reason =�JJL �� y�- _ ALTER ❑ USE OF �C REPAIR ❑ $ Date: EXISTING BLDG. DEEMOL Signature APP(NT OWNER-BUILDER DECLARATION ❑ FINALP I ) 0 rJD Z�NO. 4b X - Q DATE 1 hereby affirm that I am exempt from the Contractor's License / ti��r� Law for the following reason (Section 7031.5, Business and ADDRESS liCtS� MCC \ FINAL Professions Code): PRESENT BY �• r �'i a BUILDING I, as owner of the property, or my employees with ADDRESS Dk wages as their sole compensation;will do-the work and the structure is not intended or offered for sale(Section LOCALITY pool 7044, Business and Professions Code.) MOVING TEL. -� ❑ 1, as owner of the property,am exclusively contracting CONTRACTOR NO. — ,L1f�L with licensed contractors to construct the project (Sec- ADDRESS - . tion 7044, Business and Professions Code. 1�■t v REQUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH -CHANGE hI hereby affirm that there is a construction lending agency for FRONT te performance of the work for which this permit is issued P.L. (Sec. 3097, Civ. C.). SIDE P.L. (Lf {+�f�e i =� :/9 Lender's Name _ LDMA Ref.# 647- . i j r;yam P.C. Fee$ Permit Fee � Lender's Address I certify that I have read this application and state that the Issuance Fee ' 6� LDMA P/C# 3 above information is correct. I agree to comply with all County Investigation Fee p� 3 ordinances and State laws relating to building construction, I Total Fee s �d LDMA Perm. # a r by authorize representatives of this County to enter z u o above-mentioned property for ins ction purposes. •(' ! SEE REVERSE FOR EXPLANATORY LANGUAGE Sign u of pplicant or Agent