HomeMy Public PortalAbout5636 MCCULLOCH AVE_Building__ WORKERS'COMPENSATION DECLARATION 1-01T ✓ I ��• I"70 ULlf 0/'31/0 ' /+��� k1l7/JJ 0
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I Fee� 'y affirm that I have a certificate of consent to self
in'sure,"ar a certificate of Workers'Compensation Insurance APPLICATION FOR BUILDING PERMIT
or a certified copy thereof(Sec L C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY•
Pglicy No. Com
❑ Certified copy is hereby furnishe FOR APPLI ANT T IL N BUILDING
;,ADDRESS _�y C Lel,4-
Ce
Certif'ed c py is filed with the county building inspec- BUILDIN
tion ep tment. ADDRESS G�
DateAlkl Applicant CITY Vi
G� ZIP / M LOCALITY
T ICATE OF EXEMPTION FROM WORKERS' ?O X G NO.OF BLDGS :NEAREST
COMPENSATION INSURANCE SIZE OF LO�y NOW ON LOT`�- ":CROSS ST.
(This section need not be completed if the permit is for one ASSESSOR
hundred dollars($100)or less.) TRACT BLOCK LOT N ' MAP BOOK PAGE PARCEL
TEL. USE ONE MAP -y
I certify that in the performance of the work for which this OWN fi NO. NO. O ! }
permit is issued, I shall not employ any person in any manner f; SPECIAL !�
so as to become subject to the Workers'Compensation Laws. ADDRESS1 CONDITIONS OQ�
Date Applicant
CITY X/Ap Al, ZIP,?
NOTICE TO APPLICANT: If, after making this Certificate of ARCHITE TEL. 22 (/fa DISTRICT GR UP TYPE FIRE PROCE ED BY
ENGINEE d � n'7/NL.rcLJ •�7� CONST. ZONE
Exemption, you should become subject to the Workers' 1
Compensation provisions of the Labor Code, you must forth-
�j� X
withcomplyith such provisions or this prmit shall be ADDRESS �', TE �� ti/ OV
deemed revoked. STATISTICAL CLASSIFI TION APT. CONDO.
CONTRACTO ,NO.�7o R 5 a-L
LICENSED CONTRACTORS DECLARATION LIC, CLASS NO. _DWELL. UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO.4-5reci`7
(commencing with Section 7000)of Division 3 of the Business and +/J� LIC SEWER MAP
Professions Code, and myMli ! 1 force and effect. CITY /+ ^''l CLASS OVALIDATION
SQ.FT NO.OF NO.OF CHECKBK. pG.License Num er ic.Class ( SIZE STORIES FAMILIES ONE
Contractor Date ! / DESCRIPTION OF WORK NEW VAL ION 2702.1 A
$ l 3;zg--
❑I am exempt under Sec. IV&4 f s^ ADD ❑,' 00-
# 1
0 0 0 0 0
ALTER ❑''
B.&P.C. for this r NI REPAIR ❑;: $
Date: USE OF /� 1 - 75-525
EXISTIN!�2G BLDG,5� EMOL ❑';
Signature APPLICANT /' TEL. FINAL o o 7 5 `5 2 5 r=,
O N ER- LDER DECLARATION
(PRINT) ,01A NO. �/ DATE
I hereby affirm t t I exempt from the Contractor's License " 1 2 -87 Law for the foll wi reason (Section 7031.5, Business and ADDRESS 3 FIN 0
Professions Code): PRESENT
❑ BUILDING
I, as owner of the property, or my employees with . ADDRESS
wages as their sole compensation,will do the work and 6 5 4 G A
the structure is not intended or offered for sale(Section LOCALITY
7044, Business and Professions Code). MOVING TEL. ® 0 0 0 o j 3
❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO. 1 0443. 1 4
with licensed contractors to construct the project (Sec-
tion 7044, Business and Professions Code). ADDRESS o 0 4 4 3 1 4
EQUI
RE
CONSTRUCTION LENDING AGENCY SET BARCKD TOTAL SETBACK FROM T.YARD HWY PROP. LINE WIDTH Q 2,2 Q i-S 7
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.
d Lender's Name DZI
P.C. Fee$ �If / Permit Fee LDMA RefA—,, -
10
- Lender's Address /,
r I certify that I have read this application and state that the Issuance Fee (.J LDMA P/C
above inform n is correct. I agree to comply with all County Investigation Fee �`� S
ordinances d State' s relating to building construction, Total Fee , LDMA Per
and hereby uth ize presentatives of this County t en er
upon the ove men oned property for inspectio rpo s.
a
o $ SEE REVERSE FOR EXPLANATORY LANGUAGE
Si nature o ppiicant or Agent Dat 0