HomeMy Public PortalAbout5528 MCCULLOCH AVE_Building__ 1
WORKERS'COMPENSATION DECLARATION
ofFiof conent to sf
iwog�r'0'certtif catte of Worke s''ificate Compensation-insurance, APPLICATION FOR BUILDING PERMIT
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 BUILDING �cCt„ f(o` e-
ADDRESS a SoZ
❑ Certified copy is filed with the county building inspec- [ADDRESS
LDING p G �oG/
tion department. S a CS Date Applicant Y ; 2 ZIP f7 d LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' 2 NO OF BLDGS. NEAREST COMPENSATION INSURANCE OFF/LOT A � f NOW ON LOT CROSS ST. -1 t1QS � �r-C-u ff0 C. vI
(This section need not be completed if the permit is for one TRACT"' r • �►�r BLOCK LOT NO.d5—
_plicant
ASSESSOR
hundred dollars ($100)or less.) MAP BOOK PAGE PARCEL
TEL. USE ZONE MAP /� y
I certify that in the performance of the work for which this
OWNER L•WO w YL 5�rt o NO. � (/JI//\J NOn
permit is issued, I shall not employ any person in y manner `� a SPECIAL
so as to become subject t he Worker' amp tion Lows. ADDRESS �7T� -�-�cct f�� CONDITIONS U
/ CITY Sa,s., C e 6rf�f ZIP 9(-1ARCHITECT OR TEL.NOTICE TO APP ICANT: If, after mo in this Certificate of //•• DISTRICT GROUP TYPE FIRE PROCESSED BYENGINEER t�T• AiT�LG t`�VtG NO. --� /� CONST. ZONEExemption, you should become subject to the Workers' JCompensation provisions of the Lbor Code, you must forth- ADDRESS 3 1 1E. MOf--( Art- cutC-with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICA710N CONDO.deemed revoked. CONTRACTOR q /1e NO..W
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. 9-1 DWELL. UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS Se-t9'!a ea.S -,vim NO.
(commencing with Section 7000)of Division 3 of the Business and LIC SEWER MAP
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.Clash SIZE ZS TORIES FAMILIES 1 ONE
VALUATION d d
Contractor Date DESCRIPTION OF WORK G�%a -1+ t ca r NEW
❑I am exempt under Sec. C>.�Q.�4G� '� �(��e�-+�! ADD � 9 "�� �097.6 A \
ALTER ,
a a a a e,1
B.&P.C. for this reason REPAIR $
Date: USE OF j.�C � i DEMOL ❑ 'I o 0 7�'
EXISTING BLDG.
Signature APPLICANT TEL FINAL o 0 0 '] 0 Q
OW ER- U DER TI
D CLAR O (PRINT)Cr. ra- i to V t L�1 NO. r-146 o l9 DATE 7
1 herebyaffirm that I am exempt from the Contractor's License -710 .r0,24-88
Law fothe following reason(Section 7031.5, Business and ADDRESS ( E. Ma MY Ale �-e4-A CZ 4 FINA
Professions Code): PRESENT BY ;
BUILDING t
Ok 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 3
7044, Business and Professions Code). MOVING TEL. '
❑ I,as owner of the property,am exclusively contracting CONTRACTOR NO.
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY SETT BACK YARD HWY TOTAPROP.ACK FROM
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 LDMA Ref. p
E Lender's Address P.C.Fee$ Permit Fee c 5
I certifythat I have read this application and state that the Issuance Fee c
LDMA P/C#above iformation is correct. I agree to comply with all County Investigation Fee
ordinances and State laws relating to building construction, Total Fee (1 LDMA Perm.k
3 and hereby authorize representatives of this County to enter
upon th bove-m ned property for inspection purposes.
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c SEE REVERSE FOR EXPLANATORY LANGUAGE
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Signafurve of Ap of Kre D to
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