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Home My Public Portal About5321 WELLAND AVE_Building__ A :. A ( II CAYM R UILDING P ET - u _ COUNTY OF LOS ANGELES BUILDONG AND SAFETY WORKER'S co�ol�ENsATa®N DECLARATION - :FOR APPLICANT-TO FILL IN BUILDING ADDRESS I-hereby affirm that-1 have a Certificate'of consent to self Insure, BUILDING ADDRESS C R -C.i4..st3 or a certificate of ft Insurance,or a certified PITY ZIP ereof(Sec.3800,Lab.C.) ' , / \ LOCALITY Poli O�, �� COmpany49QZ Qe,) L�Irirdtal:: SIZE O LOT NO.'OF BLDGS.NOW ON LOT t ❑.Certified copy is hereby furnished.. CROSS ST._hed.• '` '� i. ' ,• , 7Id ied copy is•filed with the ty,bu,` Ing Inspection TRACT BLOCK LOT NO. USE ZONE MAP NO. tme�nt.CDatIiCant ASSESSOR MAP BOOK PAGE PARCEL' .2'7 7 PP SPECIALCONDITIONS . � OWNER-' TEL NO. � � -CERTIFICATE O�E3ttE111PTION tFRO W RICERS'' YES NO IMSU E �' WITHIN 1000 FT OF SCHOOL? ADDRESS (This section need.not be completed If the peimt Is for one hundred �' G� :• DISTRICT .-GROUP TYPE CONST."FIRE ZONE PROCESSED BY', dollais($100)or less.) CITY zip. I certify"that in the performance of the woiii for'which this permit `oo I �J A V� 91 �� /� 3. ,Is•'issued, I Shall not employ any person In any manner so as to ARCHITECT OR ENGINEER TEL NO. become subject to the Mrkers'Compensation Laws.' STATISTICAL C I T ,N CONDO Date Applicant ADDRESS CLAS NO. U NOTICE TO 'APPLICANT=;If', after making this Certificate of REQUIRED TOTAL SETBACK FROM 'EXIST Exemption, you sfiould';beoome Subject t0'the; Workers' INTRACTOR TEL.NO. g�ggCK " 'YARD. HWY, PROP LINE WIDTH Compensation provisions of the Labor Code,.you must forthwith l`ej `. I R' a '� b- / FRONT, comply with such,provistons or this permit shall'be deemed'revoked. ADDRESS LIC NO, C P.Ll �0 per.' LICENSED CONTRACTORS DEC LARATION CI r LIC.CLASS SIDE t I CD hereby affirm that I-am licensed under:provisidns.of Chapter 9 C �' C- SEWER MAP CA (commencing with Section 7000)of,Division 3 of the Business and• SO.FT.SIZE... NO:OF STORES: NO.OF FAMILIES fr Professions.Code and m license is In full force and effect. ' ' NEW, BK, PG j~j ; ; y/y DESCRIPTION-OF WORK - VALUATION License NumtieT/y/A Lia Class G �� ADD I❑ I ,,✓ 6� '�,.r�i r �' , Contractor Date �Z'G-�� - ALTER. ❑ I I , 3304 ;,y 1 a g- ry I C E REPAIR ❑ i r; ry ❑ I am exempt under Sec. �' .w ai`t=� , .&RC.forthisreason - DEMOL1.' LDiw►P/C p € t '' -`` USE OF EXISTING BLDG. Data-.'' -URM. ❑ tI�i lI "�. •t-�"i;..�-+.)-F,L is a Y 1 Signature LI T( Arn r: _TEL.NO. LDMA Perm# �"K 1,•as'owner'of the property, or my emplbyees with wages as �� ' their sole compensation,Will do the work and the.structure Is ADDRESS _ �, _ hot intended or offered for sale (Section 7044, Business and FBIALDATE Professions COd@:) WILLTHEAPPLICANTORPUTUREBUILDINGOCCUPANTHANDLEAHAZARDOUSMATERIAL - ❑ I, ".Owner Of the property, em'exClusively Contracting with :OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR.GREATER THAN g 'THE AMOUNTS SPEC IED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE?,. FINAL BY' j' •T'q :• 5'"`° licensed contractors to construct the project.(Section 7044, Y� ND i• }_;.;. L�,�x = 3 ti Business and.Professions Code:) { c>';•l; •.t -}.7:. WILL THE INTENDED USE OF.THE BUILDING VY THE APPLICANT OR FUTURE BUILDING ' ; r"r-:1-0- CONSTRUCTION LENDING AGENCY \ OCCUPANT REQUIREA PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH ' COAST AIR QUALITY MANAGEMENT DISTRICT ISCAOMD)SEE PERMITTING CHECKLIST �'•';.: ','�^ ji� FOR GUIDELINES. Y`4_: .. hereby affirm that there is a-construction•lending agency for YES❑,'" ND ;; ". the performance of the work for which this permit is issued(See. OM rN. 5' :a" _b. 1 HAVE READ E HAZARDO � IALS,INFORMATION GUIDE AND THE SCAiTKAD r•'� � ' i"t"I T,i't •• - r� 30117,CIV.C.I+ PERMITTING KLISL I UN MY,REQUIREMENTS UNDER THE-LOS ANGELES ?I 7/92 . Lenders Name cHAQzuwR MATER N co ONS22DIN0THRORMTFROM�SCAQMD. r ft—R. :, -;, . LendbesAddress :1 . ... _ v,.:J: _ atQi , _ ; a' I certify that 1 have d this application and state that the above P.C.FEEPERMIT FEE . r information-ls_CO I-agree:to,comply-with-all-county�r: -= .-- ---- - - - - ----.— --------- -, ---------- ----- ordinances nd Sta reiating to building construction,and hereby a crize re nta' of this County to enter upon ISSUANCE FEE" 13 th ab on rope for inspection purposes. �; r; :l 1-•n ., Sw:: 1"• 7/ ��1 Z• INVESTIGATION FEE TOTAL FEE'. �nj r;=' F'; NJ SEE REVERSE FOR EXPLANATORY-LANGUAGE fir_ _•zN WVORKERS'COMPENSATION DECLARATION 4 hereb �tiffirm that I have a certificate of consent to.self •insure, or a certificate of Workers'Compensation Insurance, APPLICATION FOR BUILDING P E RM I T orya�cer :e t*42rVin. ec. 3800, ab:C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy iTo. any Certified copy is hereby furnished. BUILDING FOR APPLICANT TO FILL•IN ADDRESS Q ING Certified copy is filed with the county bBUILD uilding inspec- ADDRESS Y tion ep tment. . ZIP Date , Applicant CITY NO.OF BI s. LOCALITY .G..m . NEARE ERTI ICATE OF EXEMPTION-FROM WORKERS' SIZE OF LOT NOW ON LOT CROSS 3T. COMPENSATIOWINSURANCE I �y� ASSESSOR (This section need not be completed if the permit is.for one TRACT •�,r BLOCK LOT NO. MAP BOOK PAGE PARCEL hundred dollars ($100)or less.) . . •TEL• USE-ZONE MAP OWNE NO• i NO. �7 7 I certify that in the performance of-the work for which this SPECIAL permit is issued, I shallnot employ cny.person in any manner ADDRESS �` CONDITIONSCL so as to become subject to the Workers'Compensation Laws. I O CITY ZIP Date Applicant RCHITECT OR TEL im NOTICE TO APPLICANT: If, after making this Certificate of i ENGINEER NO. � r DISTRICT GROUP TYPE FIRE. PROCESSED BY Q Exemption, you should become subject to the Workers' I CONST. ZONE Compensation provisions•of the Labor.Code, you must forth- ADDRESS •-3 wiih comply with such provisions or this permit shall be TEL Z STATISTICAL CLASSIFICATION APT. CONDO. deemed revoked. CONTRACTOR NO.1 /��, _ LICENSED CONTRACTORS DECLARATION : . i g �-� LIC. ;s CLASS P40. 420 UNITS I hereby affirm that I am licensed under proyisions of Chapter.9 ADDRESS tl G NO.L4_7_ ) ' (commencing with Section 7000)of Division 3 of-the Business LIC. SEWER MAP and Professions Code,and my license is in full force and effect. I CITY CLASS • BK NVALIDATION SQ. FFirNO. OF NO. OF CHECK License umber Lic. Class SIZE STORIES FAMILIES ONE ' VALUATIONContractor r tl `ilC'-- J Date DESCRIPTION OF WORK n NEW �y ADD ❑ ► ❑I am exempt under Sec. 1 B,BP.C. for this reason ALTER ❑ $�fJ/SOOD-� USE OF REPAIR.❑ Date: EXISTING BLDG. NMOL ❑ Signature. APPLICANT INT)' •, Y; 1 FI AL OWNER -BUILDER DECLARATION _ NO; DATE L—Z(o�Q I hereby affirm that I am exempt from the Contractor's License I „ ,. * "' ADDRESS' ��' !• s0/ /1 .�ptl//�' Law for the following reason'(Section 7031.5, Business and I FINAL Professions Code): ,� PRESENT By . , � ,, ❑ I, as owner of theproperty, or m employees with BUILDING ht:., Yt Work-and # . wages as their sole compensation;will do the ork�and \ LOCALITY I the structure is not•intended or offered for sale(section /p•—j/ 7044, Business and Professions Code.) 1 MOVING TEL. Poo. 1 CONTRACTOR NO. :,.s•_LJr �: -r•'.'s:. ❑ I,as owner of the'property,am exclusively contracting ti•:�-.�.,�C� •t�� .';;�•�-� with licensed contractors to construct the project (Sec- I ADDRESS 1 �^ " t e Zc"' tion 7044, Business and Professions Code.) 1I:iL REQUIRED TOTAL SETBACK FROM EXIST, !•� +�?;'•_� CONSTRUCTION LENDING AGENCY I SET BACK. YARD HWY PROP. LINE WIDTH �'p� I hereby affirm that there is a construction lending agency for FRONTi �j�� p t the performance of the work for which this permit,is issued I P.L. (Sec. 3097, Civ. C.). SIDE. Lenders Name _ LDMA Ref.# P.C. Fee$ �� // Permit Fee �W 16, �(�I> _U�.1 5/f.Z: ' Lender's Address 1 certify that I have read this application and state that the �d / Issuance Fee Al 7S LDMA P/C# , 1. (�s above information is correct. I agree-to comply with all County Investigation Fee ordinances and State lows relating to building construction, Total Fee / R 4(-• LDMA Perm. # and hereby authorize IS Ives of this County to enter upon the a o perty or inspection pur ose . SEE REVERSE FOR EXPLANATORY LANGUAGE :gn re Ocite