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Home My Public Portal About4964 MCCLINTOCK AVE_Building__ , WORKERS'COMPENSATION DECLARATION C/ ' hereby affirm that I have a certificate of consent to self APPLICATION FOR BUILDING PERMIT insure, or a certificate of Workers'Compenstion Insurance, or a 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 ADDRESS G Certified copy is filed with the county building inspec- BUILDING / tion department. ADDRESS t7 //1f LOCALITY �• NEAREST Date Applicant CITY ZIP CROSS ST. CERTIFICATE OF EXEMPTION FROM WORKERS' OF BLDGS. ASSESSOR COMPENSATION INSURANCE SIZE OF LOT OW ON LOT MAP BOOK PAGE PARCEL (This section need not be completed if the permit is for one y / USE ZON §PE hundred dollars ($100)or less.) TRACT BLOCK LOT NO.TEL. �I+ IAL ��eaf/v i I certify that in the performance of the work for which this OWNER NO. DITIONS permit is issued, I shall not employ any person in any manner , �S DISTRICT GROUP TYPE FIRE PROCESSED BY ADDRESS CONST. V r ' �I( a so as to became subject to the Workers'Compensation Laws V/ ZONE 13 Date__2 —Z—sl Applicant * CITY ZIP STATISTICAL CLASSIFICATION I APT. CONDO. V NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL. DWELL. UNITS � Exemption, you should become subject to the Workers' ENGINEER NO. CLASS NO. 03 N Compensation provisions of the Labor Code, you must forth- with comply with such provisions or this permit shall be ADDRESS SEWER/MAP _ deemed revoked. CONTRACTOR TE ��+ �'�/ BK. �7 PG, VALIDATION LICENSED CONTRACTORS DECLARATION t/ LIC. ✓ 1 hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS iLy VALUATION (commencing with Section 7000)of Division 3 of the Business and LIC. Professions Code, and my license is in full force and effect. CITY CLASS G 121 $ SQ. FT. NO.OF NO.OF CHECK License Number 2 03g Lic.Class X SIZE STORIES FAMILIES ONE ,I�( L , d NEW $ Contractor r rL I C1�C�,��FI /X/L Date��—'3� DESCRIPTION OF WORK I am exempt from the lic requirements as I am a � _ ADD licensed architect or a registered professional engineer !� ALTER FINAL acting in my professional capacity (Section 7051, DATE REPAIR Business and Professions Code). USE OF DEMOL FINAL EXISTING BLDG. By Lic.or Reg. No. _Date APPLICANT TEL. OWNER-BUILDER DECLARATION (PRINT) NO. I hereby affirm that I am exempt from the Contractor's License / Law for the following reason (Section 7031.5,'Business and ADDRESS Professions Code): PRESENT ❑ BUILDING I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and ' LOCALITY the structure is not intended or offered for sale(Section 7044, Business and Professions Code). MOVING TEL. I 0 1 7.0A I, as owner of the property, am exclusively contracting CONTRACTOR NO. , with licensed contractors to construct the project (Sec- ADDRESS 0 0 0 0 0 1 tion 7044, Business and Professions Code). I REQUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH j 0 - 31.00 1 hereby affirm that there is a construction lending agency for FRONT the performance of the work for which this permit is issued P L a d 0 3 1.!� (Sec. 3097, Civ. C.). SIDE Lender's Name P.L. 07.01 -81 � P.C. Fee$ Permit Fee Lender's Address L I certify that I have read this application and state that the Issuance Fee above information is correct. I agree to comply with all County Investigation Fee ordinances and-State laws relating to building construction, Q L7 3 Total Fee i �� and hereby authorize representatives of this County to enter ��EE99 = upon the a o e-me t) edper for inspection purposes. ` /— / SEE REVERSE FOR EXPLANATORY LANGUAGE I�� R Signature of —a�3i-/— III ®s g pplicant oI Agent Date WORKEkf 'COMPENSATION DECLARATION '7 T t� affirm thdt I have-0 certificate of consent to self �� ® R U e L D I N G PERMIT , •ins or a certificbte of Workers'Com ensation Insurance, r d�- r_tifie�d�c�opy th f(Sec. 3800, Lab. C.) P �N y� Compan i�vy� COUIINTY OF LOS Afi�GELES BUILDING AND SAFETY Certified copy is hereby furnished. ' FOR APPLICANT TO FILL IN � : ADDRESS Certified copy is filed with the county building nspec- BUILDING �� tion department. ADDRESS Q� LOCALIT �i C Cori [/ NEAREST Datq ��3/—8/Applicant ��J � S CITY IP r CROSS ST. 4Owp CERTIFICATE OF EXEMPTION FROM WORKERS' O.OF BL GS. ASSESSOR COMPENSATION INSURANCE SIZE OF LOT d Gb NOW ON LOT MAP BOOK PAGE PARCEL (This section need not be completed if the permit is for one USE ZONE MAP hundred dollars($100)or less.) TRACT BLOCK LOT NO. NO. + TEL. �/ SPECIAL I certify that in the performance of the work for which this OWNER NO. s-•O� CONDITIONS IJP+b permit is issued, I shall not employ any person in any manner DISTRICT GROUP TYPE FI PROCESSED BY so as to become subject to the Workers'Compensation Laws. ADDRESS 7 J Gs �I oc' CONST._ ` ZONE C! Date Applicant CITYr ` ZIP -� STATISTICAL CLASSIFICATION 3 APT. CON NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL.�jy1S,-Wf- ENGINEER �J N 77 CLASS NO. All UNITS LU Exemption, you should become subject to the Workers' y Compensation provisions of the Labor Code, you must forth- ADDRESS Lir SEWER MAP with comply with such provisions or this permit shall be TEL /➢ /1 deemed revoked. CONTRACTOR e ,N /•�� BK. (T PG, VALIDATION LICENSED CONTRACTORS DECLARATION LICO, Q I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS Cj N . q �sni? VALUATION (commencing with Section 7000)of Division 3 of the Business and �� LIC. Professions Code, and my license is in full force and effect. CITY CLASS $ ® 0 9 8 7 A �/ SQ. FT NO.OF NO.OF CHECK License Number 7S9 Lic.Class SK � STORIES FAMILIES ONE $ -� J D/'(h # 0 0 0 0 2 3 -�_ 3�r�y DESCRIPTION OF W NEW • �J v I o Contractor/� 9 ��YlS Date 39207 i ADD ❑ ..., ,. I am exempt under Sec. ALTER DANA_L? ��r 0 0 3 9 2 0 7 B.BP.C. for this reason REPAIR ❑� J Date: USE OF DEMOL ❑ " FIN I 0 v 1 -8 4 EXISTING BLDG. By Signature APPLIPR NT �� TEL OWNER-BUILDER DECLARATION �/ 21 0 2 6 A I hereby affirm that I am exempt from the Contractor's License T O� �� d �� Law for the following reason (Section 7031.5, Business and ADDRESS ,. .> Professions Code): PRESENT # o 00025 ❑ BUILDING I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and004 ° 2 0 6 5 5 the structure is not intended or offered for sale(Section LOCALITY 7044, Business and Professions Code). MOVING TEL. v. o a 2 0(1 5 5;-' I, as owner of the property, am exclusively contracting CONTRACTOR NO. with licensed contractors to construct the project (Sec- ADDRESS 11.07-84 tion 7044, Business and Professions Code). REQUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH D 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. JSec. 3097, Civ. C.). SIDE c �r P.L. G 1 0 2 7 A Lender's NameO # 0 0 0 0 0 1 Lender's Address / P.C.Fee$ !W2107 Permit Fee r r I certify that I have read this application and state that the pC f0 l Issuance Fee 10 Su I ° 7 1 4,7 5 above information is correct. I agree to comply with all County Investigation Fee ordinances and State laws relating to building construction, Total Fee , 57 ° - 7 1 4,7 5 and hereby authorize re resentatives of this County to enter upon the above-me a arty for inspection purposes. 11. 07-84 oLS+3/-$y SEE REVERSE FOR EXPLANATORY LANGUAGE as Signature of plica gent Date