HomeMy Public PortalAbout5634 1/2 MCCULLOCH AVE_Building__ UAB _ l �� ,r l 3� P,//,WORKERS'COMPENSATION DECLARATION
I hereby d'cer that I,havecertificate of consent to self A P P L I CI T ® FOR BUILDING PERMIT �
•� in'suce, or atificate of Worr kers'Compensation Insurance,
or a Certified copy thereof(Sec. 3 Lab. C.)
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Comp ny-'M 1 _
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING r"�� 2 e �L!
ADDRESS e�
5KCertified copy is filed with The county building inspec- BUILDING LLO
do epa�!ment. ADDRESS a �
Date a I Applicant �1.�`&—°—� CITY ��A-C; 7V ZIP LOCALITY
ERT ICATE OF EXEMPTION FROM WORKERS' �/ NO.OF BL GS. NEAREST
COMPENSATION INSURANCE SIZE OF LOT 06 X�71 NOW ON LOT CROSS ST.
(This section need not be completed if the permit is for one pp,gg� ASSESSOR
hundred dollars($100)or less.) TRACT BLOCK LOA& J MAP BOOK PAGE PARCEL
TEL. USE ZONE MAP
I certify that in the performance of the work for which this - OWNER NO. NO. }
permit is issued, I shall not employ any person in any manner —7 "� SPECIAL 9L
so as to become subject to the Workers'Compensation Laws. ADDRESS /eJ �.3 CONDITIONS 0
Date Applicant CITY r✓�o►'� _ Z V get
ARCHITECT L• DISTRICT GR UP TYPE FIRE P ESSED BY O
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER O. 30h0�' CONST. ZONE
Exemption, you should become subject to the Workers' �j ,j
Compensation provisions of the Labor Code, you must forth- , ADDRESS / S �3 f/ J
with comply with such provisions or this permit shall be TEL. ;STATISTICAL CLAS F TION APT. IrIDO.
deemed revoked. ' CONTRACT NO.
LICENSED CONTRACTORS DECLARATION LIC �/ CLASS NO. DWELL. UNIT
I hereby affirm that I am licensed under provisions of Chapter 9 [ADRESS �j NOLO 1F' } SEWER MAP
(commencing with Section 7000)of Division 3 of the Business and LIC. 4
Professions Code, nd y license i in full force and effect. U AJ CLASS BK VALIDATION
FT.% i5' NO.OF NO.OF CHECK
License Number Lic.Class O STORIES FAMILIES ONEy VALUATIO _Contractor DateL7 3O RIPTION OF WORK GLt/ A D $ j� ajl uV �'6 5 4 5 A
6 ✓ G
I am exempt under Sec. ALTER �} , # o o a o 2 3
8.8P.C. for this reason REPAIR ❑ : ; I - 713,37
USE OF // !��
EXISTING BLDG. / JGr�yc
D EMOL ❑';'
Signature APPLICANT /fEL. 0 0 7 3 3 7 T
g N FIN
OWNE - LDER DE� ON PRINT NO. DA
I hereby affirm that I am exempt f om the Contractor's License ?� (� YL yf,��N� 0220-87
Law for the following reason (Section 7031.5, Business and ADDRESS FI ry
Professions Code): PRESENT iiBy
❑ 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
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). P-7023 REQUIRED TOTAL SETBACK FROM A
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH # 0 0 0 0 0 1
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 I o 8 4 9 7 5
g P.L.
Lender's Name 2 ` LDMA Ref. # a ° 8 4 9 7 5
P.C.Fee$ I Permit Fee 0 rj 1 2 -87
Lender's Address
I certify that I have read this application and state that the Issuance Fee IC SD LDMA P/C#
z above inform n is correct. I agree to comply with all County Investigation Fee ,y� 9
ordinances a ws relating to building construction, Total Fee / / ��'� LDMA Perm.#
and hereb a orize presentatives of this County t ent
upon the b v -men oned property for inspectio rr�pos
p SEE REVERSE FOR EXPLANATORY LANGUAGE
ignatur Applicant or Agent Dat