HomeMy Public PortalAbout5632 1/2 MCCULLOCH AVE_Building__ WORKERS'COMPENSATION•DECLARMION UN t 7, 2 "' �7
liu re, affirm that I.have.r certificate of consent to self P m I CAT I � � R B U I L D I N� PERM'T
iruure, or a certificSte of Workers'Co ensation Insurance, E�
or a certified copy thereof(Sec. 3 b. C.) COUNTY OF LOS ANGELES BUILDING AMID SAFETY
Policy No. Company NZ a
Certified copy is hereby furnis ed. FOR APPLICANT TO FILL IN ', BUILDING
=521
Certified'copy is filed with the county building inspec- 5ADDRESS
p 1 2 t
tLJ tion, epart ent. • Com. (� /_o
Date �' 7Applicant �" r ZIP LOCALITY
ERTIFICATE OF EXEMPTION FROM WORKERS' `' r NO.OF BLDGS. NEAREST
COMPENSATION INSURANCE, T IQ JY 6 7• NOW ON LOT —�" CROSS ST._ .
(This section need not be completed if the permit'is for one BLOCK LOT NO/J'
O Q�'� ASSESSOR..
hundred dollars($100)or less.) MAF BOOK PAGE PARCEL
� ` TEL. USE NE MAP
- rp7 NO.
I certify that,in the performance of the work for which this NO.
permit.is'issued,I shall not employ any person in any manner �/ SPECIAL
so as to become subject to the Workers'CorripensationLaws. .(/� 7 ! � CONDITIONSDate Applicant ' .�.A14.. . ZIP �T TEL DISTRICT GROUP TYPE. FIRE PRO ED B f
NOTICE TO.,APPLICANT: If; after making this Certificate of ENGINEE '-7L)� �G�'�! O.�j /3d (�
Exemption, you should become subject to the Workers' CONST../ Z E
ull
Compensation provisions-of the Labor Code, you must forth- ADDRESS L.t/L C�% ��`' �� {/ 3.
With comply with such provisions or this permit shall be - fH
deemed-revoked. CONTRA L+xJ TEL' STATISTICAL CLASSIFIUQ�TION APT. O.
i1'wo. at/. U y
LICENSED CONTRACTORS DECLARATION LI¢¢,,����� uu gyp- CLASS NO. DWELL. UNI'TSIJ—
I hereby affirm'.that I am licensed under provisions of Chapter 9 ADDRESS����� NO�'r'T7 O i
(commencing with Section 7000)of Division 3 of the Business andLIC. SEWER MAP
Professions Code,a d m license' ' fu -force and effect. ' CITY CLASS BK. F PG.fU VALIDATION
SQ;F7./ NO.OF NO.OF CHECK Q,7 A .
License Numb r Lic.Class SIZE STORIES I FAMILIES ONE
f
NEWVALUATIO� # 0-a o a '2.3
Contracto �� Date / DESCRIPTION OF WORK - " a
ElI am exempt under Sec. ADD ❑`; $ ® �, o,(� i a V.
ALTER ❑ o 0 6 U v.
B.BP.C. for this reason _ _ EPAIR-•. $ -
❑:..
Date: USE OF
EXISTING BLDG. 7b JL-Qj7MQ EMOL ❑ .0. 220-87
Sigriature APPLICANTTEL. FINAL
OWNER-BUILDER DECLARATION PRINT QN NO. �) 3 DATE
.I hereby affirm that I am exempt from the Contractor's License 5-
Low for the following reason(Section 7031.5, Business and ADDRESS l`� J "�+h FIN
y,
Professions Code): PRE ENT BY
❑ x BUILDING
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 2 7 0 2 0 A '
7044, Business and Professions Code). MOVING TEL.
`
I, as owner of the property, am exclusively contracting CONTRACTOR NO. # 0 0.0 o a
with licensed contractors:to construct the proiect"(Sec- ADDRESS
tion 7044, Business and Professions Code). 7 2 2'5' ,
REQUIRED. TOTAL SETBACK FRO I
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH
I hereby affirm that there is a construction lending agency for FRONT a a 72a2 5 X0
the performance of the work for which this-permit is issued P.L. -
(Sec. 3097, Civ. C.). SIDE o5 12 =•8.7•
P.L.
Q Lender's Name
3 LDMA Ref. #
Lender's Address y P.C.Fee$ Permit Fee' " /
@ I certify That I ave.read this application and state.that the Issuance Fee e� kLD !P/C#
z above in or on i correct. I agree to comply with all County Investigation Fee
ordinances a laws relating to building constr ction, Total Fee S LDMA Perm. #
and here b tho ize representatives of this County enter
upon the ve- a Toned property for inspectio rpos s.
p SEE REVERSE FOR EXPLANATORY LANGUAGE
not of Applicant or Agent Dat -