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Home My Public Portal About5113 MCCLINTOCK AVE_Building__ APPLICATION FOR BUILDING PERMIT FOR APPLICANT TO FILL IN (Print or type Only) BUILDING`„"� � -OL COUNTY OF LOS ANGELES ADDRESS VDEPARTMENT OF COUNTY ENGINEER CITY zIP BUILDING AND SAFETY DIVISION 1 NO.OF BLDGS. BUILDING SIZE OF LOTQ1 NOW ON LOT /J ADDRESS G TRACT 3U BLOCK LOT NO.;? LOCALITY el--,6061NEAREST OWNER 1JFt`>tJ' �` T€4 CROSS ST. . 1 ASSESSOR ADDRESS r �+ MAP BOOK PAGE PARCEL DISTRICT rIC- I ROUP TYPE FIRE PROCESSED BY CITY ZIP �� CONST ZONE ARCHITECT �' TEL.! S��ENGINEER �Gl No. STATISTICAL CLASSIFICATION WER MAP ADDRESS R\\ CL ` ` CLASS NO..�DWELL.UNITS EBK`f�PG CONTRACTOR NEL' USE ZONE MAP LIC. NO. y ADDRESS Af Jg&fNO. SPECIAL LIC. CONDITIONS CITY CONSTRUCTION ENDER CLASS ROAD DEPARTMENT APPROVAL REQUIRED YES NO❑ NAME AND BRANCH BLDG.SETBACK FROM FRONT PROP.LINE OF (STREET) ADDRESS CITY c HIGHWAY + YARD TOTAL SETBACK FROM TYPE OF EXISTING Q SQ. FMO I I NO. OF NO. OF CHECK FRONT PROP. LINE HIGHWAY WIDTH 10 SIZE STORIES FAMILIES ONE C DESCRIPTION OF WORK NEW ❑ + p ADD BLDG.SET CKFROM v SIDE PROP.L OF (STREET) ALTER ❑ HIGHWAY + YARD TOTAL SETBACK FROM TYPE OF EXISTING REPAIR❑ SIDE PROP. LINE HIGHWAY WIDTH USE OF + EXISTING BLDG. DEMOL ❑ APPLICATEL CORNER CUTOFF YES NO ❑ (PRINT) N0. Ago BY (SIGNATURE) 1. Aft > IN OPEN SPACE YES ❑ NO ❑ .t J ICOASTAL ZONE YES ❑ NO VALUATION$ AMUR* Q CATEGORICAL EXEMPTION YES❑ ❑ 1 HEREBY ACKNOWLEDGE THAT I HAVE RE D THIS PLICATION ENVIRONMENTAL AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY IMPACT EXEMPTION DECLARATION SIGNED (DAT WITH ALL ORDINANCES AND LAWS REGULATING BUILDING CON- - STRUCTION. 1 CERTIFY THAT IN DOING THE WORK AUTHORIZED IMPACT REPORT PROCESSED (DATE) HEREBY I WILL NOT EMPLOY ANY PERSON IH VIOLATION OF THE _ LABOR CODE OF THE STATE OF CALIFORNIA IN RELATING TO WORKMEN'S COWeENSATION INSUR NCE. n dm f]t^I SIGNATURE OF r P E R M I T T E E A NJL 33 XIEM ((►- P / ADDRESS FINAL a �'`� BY TEL. CITY NO. DATE MAKE (.HE(.KS AYA(3LC: 7'O: FEE $ EE HARVEY T. BRANDT, COUNTY ENGINEER "� PLAN CHECK VALIDATION <:a� M.O. CASH PERMIT VA��DATION' K.� M.O. CASH _ 342 (5'13 ocT 223 D 25204 L o sor-'No)! X23 O 4 4.55 °u 'U 76AG38A CE#803 12772' "- �, �,� 0 4.&NOV b 1 Q 1 1 6.2 5 A01L e WORKERS'COMPEN�ATION DECLARATION . Tk7:!..' ey affirm that I have r certificate of consent to self APPLICATION FOR UILDINC PERNIITinF' e or a•certificate of Workers' Compensation Insurance, or o`certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company ' ADDRESS 5 BUILDING �j �j Certified copy is hereby furnished. FOR APPLICANT TO FILL IN / - � Certified copy i3 filed with the county building inspec- BUILDING C tion department. ADDRESS C {� /�� t7 Date Applicant � CITY L� �4 ZIP LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' J NO.OF BLDGS. 1 NEAREST COMPENSATION INSURANCE SIZE OF LOT I 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 �y TEL. {� USE ZONE MAP I certify that in the performance of the work for which this OWNER �{ NO. l� / MA t r Z permit is issued, I shall not employ ny person in any manner L �-,1 , 61— SPECIALso as to become subject to the or ers'Compensation Laws. ADDRESS E� ( CONDITIONS 0• / ' CITYEEIA X G Cv` ZIP Vr Date �r 7 Applicant NOTICE TO APPLICANT: If, after making•this Certifi ate of ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE CESSED BY O ' ENGINEER NO. CONST. ZONE V: Exemption, you should become subject to the Workers �. Compensation provisions of the Labor Code, you must forth- ADDRESS �. t7 U !"('� LLI with comply with such provisions or this permit shall beTELW, deemed revoked. • STATISTICAL CLASSIFICATION APT. CONDO. N CONTRACTOR NO. � LICENSED CONTRACTORS DECLARATION t ?t LIC. CLASS NO. 1�WELL. 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 and LIC Professions Code,and my license is in full force and effect. CITY CLASS BK PG VALIDATION SQ.FT. f NO.OF NO.OF CHECK License Number Lic.Class SIZE �J STORIES FAMILIES ONE • VALUATION Contractor Date DESCRIPTION OF WORK Taw _, NEW ® ; U ❑ I am exempt under Sec. ADD 101I , % ALTER ❑ B.BP.C. for this reason REPAIR ❑ $ Date: USE OF ci EXISTING BLDG. DEMOL Signature APPLICANT TEL. FINA OWNER-BUILDER DECLARATION PRINT NO. DAT ' I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and ADDRESS FIN Professions Code): PRESENTREESERB BUILDING fi I, as owner of the property, or myemployees with. ADDRESS ' wages as their sole compensation,will do the work and the structure is not intended or offered for sale(Section LOCALITY Q* U•8 2. 7044, Business and Professions Code). MOVING TEL. a 14, }�U ❑ I,as owner of the property,am exclusively contracting CONTRACTOR NO. o with licensed contractors to construct the project (Sec- ADDRESS 0 al 9"88 tion 7044, Business and Professions Code). REQUIRED TOTAL SETBACK FROM 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. (Sec. 3097, Civ. C.). SIDE P.L. Lender's Name 11A, DMA Ref.,N I P.C. Fee$ Permit Fee Lender's Address ^, I certify that I have read this application and state that the Issuance Fee C7, 5� LDMA P/C q above information is correct. I agree to comply with all County Investigation Fee i ordir�an�es and State laws relating to building construction, Total Fee � + p v LOMA Perm. R 3 andJhereby authorize representatives of this County to enter up fi thAe ve-mentioned property for inspection p rp ses. + D { SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applica t or Agent Date