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Home My Public Portal About5232 MCCLINTOCK AVE_Building__ WORKERS'COMPENSATION DECLARATION j hereby affirm that I,havecertificate of consent to Self ; APPLICATION F O R �B U I L D I N G P E RM I T insure, or a certificate of Worr kers'Compensation Insurance, or a certified copy thereof (Sec. 3800, Lb . c.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company BUILDING Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS a 3 Cert i— is filed wi county building inspec- BUILDING L I on departmen��t, ADDRESSsaz Z r� Date• Z -Applican� CITY ice. [ IP LOCALITY CE TIFI ATE'OF EXEMPTION FROM WORKERS' NO.OF BLDGS. NEAREST COMPENSATION INSURANCE SIZE OF LOT 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 TEL.q q f/ 111 USE ONE MAP I certify that'in the performance of the work for which this OWNER OC NO. -1 r1 NO. permit is Issued, I shall not employ any person in any manner �`_ SPECIAL so as to become subject to the Workers'Compensation Laws. ADDRESS —� CONDITIONS V CITY ZIP Date Applicant NOTICE TO APPLICANT: If, after making'this Certificate of ARCHITECT OR TEL. DISTRICT G UP TYPE FIRE PROCE ED BY O Exemption, you should become subject to the Workers' ENGINEER NO. G, /� CONST. Z E V Compensation provisions of the Labbr Code, you must forth- ADDRESS `SL V �� V LU with comply with such provisions or this permit shall be TE. �+� L� STATISTICAL CLASSIFICATION APT. CO Z deemed revoked. CONTRACTOR NO. LICENSED CONTRACTORS DECLARATION LIC Y z U3s� CLASS NO. 2 DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS ""' NO. SEWER7MAP (commencing with Section 7000)of Division 3 of the Business and LIC. Professions Code, and my license is in full force and effect. CITY L L CLASS BK PG VALIDATION SQ. FT. SNO.TO IE FA OF CHECK License mber C W )) Lic.ClassS� l 512E STORIES FAMILIES ONE VALUATION N ❑ Contr $ I am exempt under Sec. DD 1:1 ALTER ❑ B.BP.C. for this reason REPAIR $ Date: USE OF DEMOL ❑ g 9 0 9.3 A EXISTING BLDG. Signature APPLICANT TEL. FINAL4_ #,13 0 o e;o 1 OWNER-BUILDER DECLARATION PRINT NO. DATE d/ I herebyaffirm that I am exempt from the Contractor's License ADDRESS FINA �1 0 1 06''1 3 Law for the following reason (Section 7031.5, Business and Professions Code): PRESENT By - 0 1 0 6?1 3 5 1:1 BUILDING I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and . o3,02.-88 the structure is not intended or offered for sale(Section LOCALITY 7044, Business and Professions Code). MOVING TEL. I, as owner of the property, am exclusively contracting rADDRE R NO. with licensed contractors to construct the project (Sec- tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY YARD HWY TOTAL SETBACK AL NE WIDTH I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). Lender's NameLDMA Ref. II Permit FeeLenders Address J�I certify that I have read this application and state that the IssuanceFee ,(/ DMA P/C# 01111.above information is correct. I agree to comply with all County n Fee ordinances and State laws relating to building construction, Total Fee LDMA Perm..# ' and hereby authorize representatives of this County to enter qpon theabove-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE , Signature of Applicant or Agent Dche WORKERS'COMPENSATION DECLARATION insGre oi'fa ctgrrttificatethatlof Worke se Compenofon insurance,olf APPLICATION FO" _U I L D I N G PERMIT a c t c hereof(Sec. 3800, Lab. P c��-1 hereof Company COUNTY OF LOS ANGELES v. BUILDING AND SAFETY ❑ Certified copy is hereby fur shed. FOR APPLICANT TO FILL IN BUILDINGADDRESS /�/�� lc''L' 13 Certified copy is filed with the county building inspec- BUILDING gg-''y�•�SAA — tion department. ADDRESS a �Y�cI�G/L'! G ✓T<: LOCALITY /��r,�� r L� Date—i�3 kdUO !J Applicant N CITY ~�G/Ll i �� ZIP CROSS NEARE5T. CERTIFICATE OF EXEMPTIOFROM WORKERS'• NO.OF BLDGS. ASSESSOR } , COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK PAGE I PARCEL (This section need not be completed if the permit is for one USE ON6 MAP /� / TRACT BLOCK LOT NO. / NO. i7C C/C% hundred dollars($100)or less.) _ �• q TEL. //rl SPECIAL AL I certify that in the performance of the work for which this OWNS !2&_ rL(.�� NO. ` I CONDITIONS 0 t /� _ �} G (STRICT GROUP ITYPE FIRE P SED BY V permit is issued, I shall not employ any person in any manner ADDRESSg Okt ��/GC�w� � (f�Gf� 6rI9�z CONS �� G,Ix so as to become subject to the Workers'Compensation Laws. r CITY %L l9� iG 7 ZIP Date Applicant STATISTIC ALCIASSIFICATION� APT. CONDO. W NOTICE TO APPLICANf: If, after makingthis Certificate of ARCHITECT OR• ,//) !� TEL. 2 G� Exemption, you should become subject to the Workers' ENGINEER /7�/U,�ry�E�k� LD NO.3✓�'(.�s� CLASS NO._�` DWELL. UNITS Compensation provisions of the Labor Code, you must forth- ADDRES&� O A2"5 i W, o J_-z,0 ej� SEWER MAP a with comply with such provisions or this permit shall be TEL ,' // —� deemed revoked. CONTRACTOR 9yAf 0 •7 r NO.� 6; Bim- PG// � VALIDATION LICENSED CONTRACTORS DECLARATION G n LIO.C. I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS 3� C' /7tLG '%4 N ! VALUATION (commencing with Section 7000)of Division 3 of the Business and , B LIC. E� Professions Code, and my license is in full force and effect. CITY(�1-•e dVL?J9 /9 G'4+ CLASS $ /_S 00 ii L SQ. FT. NO.OF NO.OF CHECK License NumberA!CL-74 3 Lic.Class_ SIZE 0.5 STORIES NO ONE Contra or,•� A "?&IC W. Date�'��'� {� DESCRIPTION OF WORK&05 0 NEW ❑ ❑ I am exempt from the licensing requirements as I am a ADD licensed architect or a registered professional engineer ALTER ❑ FINAL J) s acting in my professional capacity (Section 7051, REPAIR ❑ DATE r Business and Professions Code). USE OF ` FINAL EXISTING BLDG. 7�i NYI ' DEMOL ❑ Lic.or Reg.No. _Date APPLICANT TEL. By 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 � J Professions Code): PRESENT BUILDING ❑ 1, as owner of the property, or my employees with ADDRESS ` wages as their sole compensation,will dd the work and LOCALITY the structure is not intended or offered for sale(Section 7044, Business and Professions Code). MOVING TEL. t ❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO. with licensed contractors to construct the project (Sec- ADDRESS `2 2 a.7 0, tion 7044, Business and Professions Code). REQUIRED TOTAL SETBACK FROM EXIST, 0 0 o a o 1 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. 2 0 1 5 1.0 0 (Sec. 3097, Civ. C.). SIDE P.L. a o 1 5 1.p r Lender's Name 9,23-80 ,2 3_8 0 _ Lender's Address P.C. Fee$ Permit Fee ��` 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, Total Fee entatives of this County to enter 9 and hereby authorize repres upq he oILyme'nT.ioned property for inspection purposes. �— � SEE REVERSE FOR EXPLANATORY LANGUAGE L� Signa re of Applicant or Agent Dote ®s