HomeMy Public PortalAbout5526 MCCULLOCH AVE_Building__ ,_.. APPLICATION FOR BUILDING PERMIT
F KAPPIYC"ANT TO FILL IN (Print or type only)-
BUILDING COUNTY OF LOS ANGELES
ADDRESS L" DEPARTMENT OF COUNTY ENGINEER
CITY zIPaI ' BUILDING AND SAFETY DIVISION
NO.OF B DGS. BUILDING
SIZE OF LOT Y40 U NOW ON LOT ADDRESS
u
TRACT BLOCK I LOT NO. LOCALITY v r i.•
/ �J NOL t^ ��V NEAREST
OWNER % CROSS ST.
p � ASSESSOR
ADDRESS k r MAP BOOK PAGE PARCEL
y DISTRICT GROUP TYPE FIRE P C SS D BY
CITY ' C' ` ZIP �` ,� V � CONST ZONE
ARC ITECT OR TEL.
LV• v -�
ENGINEER NO.
STATISTICAL CLASSIFICATION SEWER MAP
ADDRESS CLASS NO. �DWELL.UNITS 'r B ®ffPG
CONTRACTOR
TEL US ZONEFNO
AP
LIC. ) /� .ADDRESS NO. N.� ] PECIAL
LIC. ONDITIONS
CITY CLASS
ROAD DEPARTMENT APPROVAL REQUIRED YES❑ NO
CONSTRUCTION LENDER
NAME AND BRANCH BLDG.SETBACK FROM G+ (STREET)
FRONT PROP.LINE OF
ADDRESS CITYHIGHWAY + _
YARD TOTAL SETBACK FROM TYPE OF EXISTING SQ. FT., NO. OF NO. OF CHECK . FRONT PROP. LINE HIGHWAY WIDTH
SIZE STORIES FAMILIES � ONE + ``'/) = �}
l/C/
NEW ❑ r Q
S'CRIPTION OF WORK V
ADD ❑ BLDG.SETBACK FROM
�+ SIDE PROP.LINE OF (STREET) a
/ LTER ❑ _ TOTAL.SETBACK FROM TYPE OF EXISTING I--'
HIGHWAY + YARD V
REPA SIDE PROP. LINE HIGHWAY WIDTH
EXISTING BLDG 6I� esf EMOL C1IL
USE OF + Z
AP PRICAN ) j ` % NO. ' � �••r` / CORNER CUTOFF YES ❑ NO ❑
� IN OPEN SPACE YES ElNO 13BY ISIGNATUR
1-1 dip �' t-� IN COASTAL PERMIT ZONE YES NO El
VALUATION,
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION "AM � EE Q'
ANDWITH
STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITN ALL ORDINANCES AND LAWS REGULATING BUILDING CON-
STRUCTION. I CERTIFY THAT IN DOING THE WORK AUTHORIZED
HEREBY I WILL NOT EMPLOY ANY PERSON IN VIOLATION OF THE
LABOR CODE OF THE ST/1TE OF -CALIFORNIA IN RELATING TO
WORKMEN'S COMnETION INS CE.
SIGNATURE
PERMITTE •�
ADDRESS
CI ' NO.� FINAL SJ 71 BY*
TEL.
DATE ,` Q
MAKE CHECKS PAYABLE TO: FEE v FEE /,
HARVEY T. BRANDT, COUNTY ENGINEER //
�• O LLL1>>
PLAN'CHECK VALIDATION CK. M.O. CASH PERMIT VALIDATIO M.O.
56 �� V 4 1 0 6.00 0!k
76AG36A CE0803 S%74 -..-
r / 1 i
n' e6�- 1�vY. PENSATION DECLARATION r i
-s insure-or a certifi affirm alfa have a certificate of consent to self
of Workers' Compensti do Insurance, APPLICATION' FOR BUILDING PERMIT
or a certified copy Yhereof(Sec. 3800, Lab. C.)
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. CompanyBUILDING /
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDREss •��� . v! [s
❑ Certified copy is filed with the county building inspec- BUILDING �'^��`— // G,
tion department. ADDRESS ✓ (9 d' s ..0 y
Dates Applicarr� �� CITY /� I ZIP /AP LOCALITY
CERTI CAT OF EXEMPTION FROM WORKERS' / O.OF BLDGS. NEAREST /
COMPENSATION INSURANCE SIZE OF LOT Y (� aC OW ON LOT CROSS ST.
(This section need not be completed if the permit is for one ASSESSOR
hundred dollars($100)or less.) TRACT BLOCK LOTEL.: MAP BOOK PAGE PARCEL
I certify that in the performance of the work for which this OWNER G{>_� l NOyd���'d USE ONE AP
permit is issued, I shall not employ any person in any manner //�� i SPECIAL
so as to become subject to the Workers'Compensation Laws. ADDRESS O J� �' CONDITIONS U
Date �—/ //��Applicant CITY ZIP //
NOTICE TO APPLICANT: If, offer making this Certificate of ARC ITECT OR TEL. DISTRICT G UP TYPE FIRE PRO MISSED BY O
ENGINEER NO CONST. ZONE V
Exemption, you should become subject to the Workers' n , �� /]
Compensation provisions of the Labor Code, you must forth- ADDRESS A
with comply with such provisions or this permit shall be TEL, STATISTICAL CLASSIFI ATION APT. JPONDO. N
deemed revoked. CONTRACTOR NO. Z
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 and LIC.
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 D STORIES FAMILIES ONE
NEW VALU/�I �0
Contractor Date DESCRIPTION OF WORK ADD C1 $ (</f
21111'am exempt under Sec. ❑ ,
ALTER
B.BP.C. for this reason REPAIR ❑ $
USE OF
Date: D ❑
` EXISTING BLDG. S.
APPLICANT ,/ TEL.
Signature h PRINT GJ ✓�' // NO. - f FINAL
O NE - UILDER C RATI N DATE
I hereby affirm that I am exempt from the Contractor's License /ioAlffX 114 L
Law for the following reason (Section 7031.5, Business and ADDRES 'TT
Professions Code): PRE EN Y
El 1,
27610 A
I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section LOCALITY ® #•0 0 0 0 0.1
7044, Business and Professions Code). MOVING TEL.
I, as owner of the property,am exclusively contracting CONTRACTOR NO. oil 43,6 3 .
with licensed contractors to construct the project (Sec- i 0 1 4 3 6 3
tion 7044, Business and Professions Code). ADDRESS 0
YARD HWY TOTAL SETBACK () 1 1 -87`87
CONSTRUCTION LENDING AGENCY REQUIRED SET BACK PROP. LINE WIDTH
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.
(Sec. 3097, Civ. C.). SIDE
P.L.
Lender's Name
m
LDMA Ref. a
P.C. Fee$ Permit Fee
r Lender's Address /1
I certify that I have read this application and state that the Issuance Fee O t`� ✓ LDMA P/C 0
g above information is correct. I agree to comply with all County Investigation Fee
0 ordinances and State laws relating to building construction, Total Fee LDMA perm. N
N and hereby authorize representatives of this County toe ter
;6upon above- ntioned property for' specti n urp es.
mOf
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent ate