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HomeMy Public PortalAbout5632 MCCULLOCH AVE_Building__ WORKERS'COMPENSATION'DECLARATION i r, su reby affirm that I have r certificate of consent to self j ® P P L ���I®N ® ® RAMMING P E RM i T , insure, or a certificate of Workers'Compensation Insurance, �® or a er i ed copy thereof(Sec. 3800, Lob. C.) i• �f I COUNTY OF LOS ANGELES BUILDING ARID SAFETY PoYicy No. ��Company /l�L- BUILDING Certified copy is hereby furnished. FOR APPLICA T' ILL ., ) AbDRESs Certified'c6py is filed with the county'building inspec- BUILDING tion eport ent. /J1 I ADDRES C� .�•y��' /� Date 1 Applican �i�C CITY LpCALITY / ����/• L� ERTIFI A OF EXEMPTION FROM WORKERS' I NO.OF BLD f NEAREST .. C MPENSATION INSURANCE '- SIZE OF LOT NOW ON LOT ` CROSS ST. (This section•need not be completed if the per . or one ASSESSOR = hundred dollars ($100)or less.) TRACT BLOCK LOT NO. MAP BOOK = PAGE PARCEL TEL. ?? USE NE MAP �n certify that in the perforM. irkers'.Compensation the work for which-this OWNER - " (�' NO." ""'�J Np• oG permit is issued, I shall notany person in any manner I �U77 SPECIALso as to become'subject Laws. ADDRESS e 7 �` ,r ) 5 CONDITIONS 0 Date Applicant CITY C vL �'� - ZIP.. C.. / U/.. � 29 NOTICE TO LICANT: If, after makingthis Certificate of ARCHITECT TEL. DISTRICT- -, GR P TYPE FIRE P•ROC SED BY O ENGINEER /�yJ NO. Exempyo , you should become subject to'the Workers' °6r�� CONST ZONE t Co sation provisions of the Labor Code; you must forth- gDDRESS '! `0IL with comply with such provisions or this permit shall be y TEL. STATISTICAL C FI TION APT. 100�t` deemed revoked. u�%( NO. / ^' CONTRACTOR -� LICENSED CONTRACTORS DECLARATION 7 LIC, ? CLASS NO. DWELL. UNITS / hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS >, L 0�S NO. SEWER P. (commencing with Section 7000)of Division 3 of the Business and LIG ---� Professions Code, and my license is in full force and effect. CITY /`�L '��" CLASS �� I BK p, "VALIDATION SQ.FT., NO.OF / NO.OF CHECK Licgnse Number Lic.Class i SIZE STORIES ! FAMILIES NEW i ALUATION CgntracfaL���' Date DESCRIPTION OF WORK E] ADD 0d � • , I am exempt under SeS. ALTER B.BP.C. for this re t� !' REPAIR. USE OF C�r� Date: EXISTING BLDG. // DEMOL h; APPLICANT. TEL. Signature / �" S�)? FINAL WNER-BUI R DECLARATION ,�77 PRINT fir O/J NO. DATE .l hereby,affi that I am empt from the Contractor's L�i cense ` -tet/ ADDRESS � C '� 1—la- - Law fort following eason (Section 7031.5, Busi�ss and � r FIN • ' •I ,' •' " �•(�7 4,G-A. , Professio s Code): ' PRESENT By L } 0 0 0 0,0* 1' I, as owner of the propertmr' y employees with ADDRESS �- wages as their sole comps.sEtion;will do the work and s ° o the structure is not intended or offered for sale(Section LOCALITY qS• �' �� ( 6 Q•5 0 7044, Business an Professions Code). ;MOVING TEL CONTRACTOR NO. /J 5' L ° ° ° 6 0.5 0 0 I, as owner a property,am exclusively contracting d� with lice d contractors to construct the project-"(Sec- ADDRESS D () �j 2 6 i$�] tion 7 , Business and Professions Code). REQUIRED TOTAL SETBACK FROM CONSTRUCTION LENDING-AGENCY SET BACK YARD HWY PROP. LINE WIDTH I her y affirm that there is a construction lending agency for FRONT the erformance of the work for which this permit is issued P.L. (Sec. 3097, Civ. C.). SIDE 3 . P.L. Q Lender's Name i - LDMA Ref. # Lender's Address P.C.Fee$ Permit Fee ox1 I certify that I have read this application and state that the Issuance Fee !D LDMA P/C# above information is correct. I agree to comply with all County .Investigation Fee ordinance nd S}at s relating to building construction, Total Fee LDMA Perm. # J and her fu rize presentatives of this County to enter upon abo a-me one property for inspection urposes i !� OY �� SEE REVERSE FOR EXPLANATORY LANGUAGE Signa tur Applicant or Agent Dat •©� i WORKERS'COMPENSATION DECLARATION ,✓ L� '307 APPLICATION FO BUILDING PERMIT ' affirm that I have a certificate of consent to self +il•t'sure, ��a certificate df Workers'Compensation Insuionce, ,or if certified copy thereof(Sec. 38 (tab. C.) COUNTY OF LOS ANGELES BUILDING-AND SAFETY, Policy IVo. Compo ❑ Certified copy is hereby furnished. _• FOR APPLICA T TO LL IN BUILDING �— _ ADDRESS � rCj � -2. � �Certif' d copy is filed with the county building inspec- [ADDRESSILDING �^/ _ �� tto epar enf. (P Date Applicant /l 1--+��—� TY �� c 7� ZIPERTIF TE OF-EXEMPTION FROM•WORKERS' E OF LOT�� 267`S-/ NOW ON LOTS NEARESST. COMPENSATION INSURANCECROSS(This section need not be completed if the permit is for'one ASSESSORhundred dollars($100)or less.) ACT BLOCK LOT N Map BOOK PAGE PARCEL �JjTEL. USE ONE MAP j�j�I certify that in the performance of the work for which this WNER NO. NO. /V - 7 permit,is issued, I shall not employ any person in any manner � - /17� SPECIAL d so as to become'subject to the Workers-Compensation Laws. [ADDRESS ESS /��, �Lf CONDITIONS O Date Applicant G. j 'V L/� ... .-ZIP .. V OG NOTICE TO APPLICANT:'If, after makingthis Certificate of ITECT 7 L. Z DISTRICT G OUP TYPE FIRE• PROCESSED BY O' NEER 7� 3a� F Exerriptiori, you should become subject to,the Workers' CONST. ZONE V Compensation provisions of'the Labor Code, you must forth- ESS ' r �`!�� _ ;d with comply with such provisions or this permit shall be y deemed revoked. , TEL. �! STATISTICAL CLASSIF C TION APT. CONDO. RACT �1 �'�. NO. Y LICENSED CONTRACTORS DECLARATION - 7 _' r-" LIC: '/�//�� CLASS NO. �' DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 o�3) NO.17 `�-7� SEWER MAP (commencing with Section.7000)of Division3 of the Business and LIC. •�Professions Code;and my license.is full force and'6ffeclf D/v• CLASS' l� BK PG.1�� VALIDATION ' SQ,FT. NO.OF NO.OF CHECK License Number .1 C.Class SIZE / V STORIES �FAMILIES ONE VALUATION Contractor Date DESCRIPTION OF WORK CO S NEW ADD $ Al) -2z 6 5 4 4 A ❑ I am exempt under Sec. ALTER ❑ , 0 0 0 o 2.3 B.&P.C. for this r son REPAIR ❑ $ + Date: USE OF Oeyf OL ❑ ( ° 7 1 3.37 EXISTING BLDG. �y,-- r'� Signature - APPLIC NTT C %/T/�-� a ' NO. 7 3241 FINAL _ ° ° 7.1 3,3 7 OW BUILDER DECLARATION _ DATE -I hereby affirm that ram exempt from the Contractor's License �]� /LYLr U�2 0—8 7 Low for the following reason (Section 7031.5, Business and ADDRESSc T Professions Code)': PRESENT B ', ❑ BUILDING I,as owner of the property, or my employees with ADDRESS S wages as their sole compensation,will do the work and 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 CONTRACTOR NO. with licensed contractors to construct the project (Sec- ADDRESS ;0-7.0 2 2 A tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY REQUIRED YARD HWY TOTAL SETBACK FROM I # 0 0 0 a o 1 SET BACK 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: ° 8.4 9.7 5 (Sec. 3097, Civ. C.). SIDE ' 'a P.L. ' .o'a8.49.756 e Lender's Name q LDMA Ref.# Lender's Addre °°. P:C.Fee$ ­713,3 Permit Feer 3•/,o (� al 2-8 7 : - ss - f J� 5 I certify.that I hav read this application and state that the Issuance Fee + LDMA P/C = above information correct I agree to comply with all County Investigation Fee ' ordinances and e, s elating to building construction, Total Fee % �� LDMA Perm:# and hereby out tz _Pr senfatives of this County to ter . upon the above en ion �pr erty for inspection pu ses. p D ��� SEE REVERSE FOR EXPLANATORY LANGUAGE Signatur$of Apy>6nt or Agent ater Q t ,