HomeMy Public PortalAbout5241 MCCLINTOCK AVE_Building__ WORKERS'COMPENSATION DECLARATION
siar,eby oaEcer that I have r certificate of consent to self APPLICATION FOR 'BUILDING PERMIT IuI
insdre, or a certificate of Workers'Compensation Insurance,
or 4certified copy thereof(Sec. 3800, Lab. C.)// ����'^ COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No.,�9o1�Company C, -• ,COO,
• BUILDING
Pol
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS .la�/
Certified copy is filed with the county building inspec- BUILDING /. n
oN tion department. ADDRESS JJ 1 1 W i V LOCALITY
11 �,( / y�J�`����,�J,�/(' NEAREST
Date I' Applicant 1'IA 1 G Ac co kk CO cITY � � 9 zip 9117120 CROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. ASSESSOR
COMPENSATION INSURANCE 'SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL
(This section need not be completed if the permit is for one USE ZONE MAP
hundred dollars($100)or less.) TRACT BLOCK LOT NO. NO.
Cl-t 15 Ca(!-l5 TEL. —/ SPECIAL }
I certify that in the performance of the work for which this OWNER In NO.� / CONDITIONS CL
DISTRICT GROUP TYPE FIRE PROCESS ED BY O
permit is issued, I shall not employ any person in any manner ADDRESS '(�C��0.J II.V /� n CONST. ZO E u
so as to become subject to the Workers'Compensation Laws. )�J y� �• /� � y ,o 3 3
CITY {"i N V zip 1V r�'v(/ „ v O
Date Applicant STATISTICAL CLASSIFICATION APT. CONDO. tm
NOTICE TO APPLICANT: If, after makingthis Certificate of ARCHITECT OR TEL.
ENGINEER NO. CLASS NO. �/ DWELL.UNITS LUExemption, you should become subject to the Workers' a.
Compensation provisions of the Labor Code, you must forth- ADDRESS SEWER MAP U3
with comply with such provisions or this permit shall be IV1Ar1L 11L�Ffltr� TEL VALIDATION
deemed revoked. CONTRACTOR , - NO.-Ialt9-be Z� BK. PG,
LICENSED CONTRACTORS DECLARATION y LIC.
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS 254$E, d V�}t•0 NO. bJp o40) VALUATION
(commencing with Section 7000)of Division 3 of the Business and p p� LIC. 2 �^ co
Professions Code,and
my license is in full force and effect. CITY '' •� T CLASS C— J 1$ a- V-001 ,
�4 -) Lic.Class C--) SIQZE� c—ISTORIES o0FAMILILIESOA)e c0 EK
License Number .
Contractor IL1W2IF M�.(�PN`'Pbate 4L.30-412L DESCRIPTION OF WORK 5C—L6G NEW ❑ $
OVC iG?��5 ' 1_1 5 FELT ADD ❑:
ALTER
I am exempt under Sec. G� a
B.BP.C. for this reason +F �1 5' 9 17G60� REPAIR ❑ DA EL
/+' /a/ A?
Date: I USEOIF BLDG. DEMOL ❑ FINAL
EXISignature I APPLICANT 7 TEL. �^ y _ -
OWNER-BUILDER DECLARATION PRINT NO.3SOL� v
I hereby affirm that I am exempt from the Contractor's License ADDRESS� � �� IIJ�OC� VE
Law for the following reason (Section 7031.5, Business and - i
Professions Code): PRESENT
I, as owner of the property, y employees BUILDING
p p y, or m em to ees with ADDRESS
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section
LOCALITY 33-117 =+ °U-
7044, Business and Professions Code). MOVING TEL. a ';-'=•_
I,as owner of the property,am exclusively contracting CONTRACTOR NO.I
with licensed contractors to construct the project (Sec- ;I•I s "EI-2 o 00
'tion 7044, Business and Professions Code). ADDRESS -
REQUIRED TOTAL SETBACK FROM EXIST. !:Hrt i'. ,?,_sib
CONSTRUCTION LENDING AGENCY SET BACKYARD HWY PROP. LINE WIDTH _
I hereby affirm that there is a construction lending agency for FRONT CHANGE
the performance of the work for which this permit is issued P.L.
tSec. 3097, Civ. C.). [investigation
IDE
0
.L.
Lender's Name
Lender's Address .Fee$ Permit Fee C/ �,. i,�� i i'-i d I
N'�li
rI certify that I have read this application and state that the Issuance Fee a9�
above information is correct. I agree to comply with all County Fee 1
ordinances and State laws relating to building construction, Q-a
Total Fee
and hereby authorize representatives of this County to enter
upon the-above-mentioned prope ty for'nspection purposes. '
SEE REVERSE FOR EXPLANATORY LANGUAGE ®s
D b eAAv//tu�asSJlua1
Signature of Applicant or Agent Date