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Home My Public Portal About5323 WELLAND AVE_Building__ WORKERS' COMPENSATION DECLARATION nsum, oraa certificate of Workers' Compensation ty. ffirm that I have a certificate of conseInsuto self rance, APPLICATION FOR BUILDING PERMIT C1S,p�t'fye�l�n thereof (Sec. 3800, b. C.) T+ COUNTY OF LOS ANGELES BUILDING AND SAFETY olicy No. `fry Company BUILDING ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS Q I'Gr ❑ Certified coy is filed with the county building inspec- BUILDING tion spar ment. ADDRESS r CITY ZIP LOCALITY Date pplicant NO. OF BLDGS. ERTIF ATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NOW ON LOT NEAREST CROSS sr. COMPENSATION INSURANCE ASSESSOR (This section need not be completed if the permit is for oneY ACT BLOCK LOT NO. MAP BOOK PAGE PARCEL hundred dollars ($100)or less.) �1 OWNER TEL. USE ZONE MAP /`�7 // 1 7 NO. � �- 1 certify that in the performance of the work for which this � .. SPECIAL >_ permit is issued, I shall not employ any person in any manner ADDRESS l.Mo n.J rYCLCONDITIONS Cl- so so as to become subject to the Workers'Compensation Laws. O CITY ZIP 't I—I'l I U Date Applicant ARCHITECT OR TEL.u, ' ty ENGINEER NO.�1 - DISTRICT GROUP TYPE FIRE PROCESSED BY NOTICE TO APPLICANT: If, after making this Certificate of CONST. ZONE F— Exemption, you should become subject to the Workers' 2 U Compensation provisions of the Labor Code, you must forth- \ ADDRESS , J J a with comply with such provisions or this permit shall be \►� TEL. STATISTICAL CLASSIFICATION APT. CONDO. N `( ` Z deemed revoked. CONTRACTOR NO. LICENSED CONTRACTORS DECLARATION �1 LIC. CLASS NO. e Q DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS \ L NO�_"715 (commencing with Section 7000)of Division 3 of the Business LIC. SEWER MAP and Professions Cg�e..Qn�n lice a in full force a ffect. CITY ft CLASS BK PG VALIDATION G SQ. FT. STORIES NO. OF NO. OF I ONE VALUATION License Num r !!` / Lic. Class SIZE STORIES Z FAMILIES VALUATION Contractor s Date DESCRIPTION OF WORK net,, NEW ADD ❑ $ ► ❑I am exempt under Sec. 'ALTER ❑ �j 1 C ( c' B.&P.C. for this reason Q REPAIR ❑ $ Date: USE OF DEMOL ❑ 1A EXISTING BLDG. t Signature APPLICANT TEL FINAL OWNER-BUILDER DECLARATION (PRINT) O. , I hereby affirm that I am exempt from the Contractor's License DATE Law for the following reason (Section 7031.5, Business and \ ADDRESS LOO I'l. VT FINAL Professions Code): PRESENT By El , or m I, as owner of the property, to with BUILDING Q P P Y Y employees Yees ADDRESSo�✓ wages as their sole compensation,will do the work and pop, - the structure is not intended or offered for sale(Section LOCALITY / )r 7044, Business and Professions Code.) MOVING TEL. O' ❑ 1, as owner of the property, am exclusively contracting CONTRACTOR NO. with licensed contractors to construct the project (Sec- ADDRESS Ad tion 7044, Business and Professions Code.) OMM REQUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH I hereby affirm that there is a construction lending agency for FRONT O the performance of the work for which this permit is issued P.L. (Sec. 3097, Civ. C.). SIDE P.L. Lender's Name, $ �j� .3a DMA Ref. # P.C. Fee$ !7` Permit Fee Lender's Address I certify that I have read this application and state that the �j Issuance Fee a 76 LDMA P/C# 3 above information is correct. I agree to comply with all County Investigation Fee / D ordinances and State la sting to building construction, Total Fee LDMA Perm. # and hereby authori re ntativ of this County to nter upon t ntion roper for inspection pur oses SEE REVERSE FOR EXPLANATORY LANGUAGE Si nature of Lica Age ate / ••WORKERS' COMPENSATION DECLARATION insure.,hereby a certif carte of Workers' Compensat on I have a certificate of coeInsuto ran elf APPLICATION FOR BUILDING PERMIT or �jrtif�ied coy th reof/S�jc. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY PolicyT7"o: "r�� Company ( Vl BUILDING ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS ��J. � <<' C'f�er y-��•L ❑ Certified copy is filed witZthe unty bui ng inspec- BUILDING ,FORI n 1„L/tion department. ADDRESS .J 1/ UDV_ZIP Date u Applicant � CITY NO. OF BLDGS. LOCALITY /i Z CERTIFICATE OF EXEMPTION F OM WO S SIZE OF LOT NOW ON LOT NEAREST CROSS ST. COMPENSATION INSURANCE ASSESSOR (This section need not be completed if the pe rmi i f r one TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL hundred dollars ($100) or less.) OWNER Np USE ZONE MAP /u y-7 I certify that in the performance of The work for which this 7 NO. 7 I 3 / / permit is issued, I shall not employ any person in any manner ADDRESS _ SPECIAL a CONDITIONS O so as to become subject to the Workers'Compensation laws. U CITY ZIP Date Applicant ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY 0 NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. CONST. ZONE Exemption, you should become subject to the Workers' U Compensation provisions of the Labor Code, you must forth- ADDRESS '� - J Iff e-4"C e...i+,,t a with comply with such provisions or this permit shall be ! TEL �I- f' deemed revoked. CONTRACTOR t O. lD-�`f STATISTICAL CLASSIFIC ION APT. CONDO. Z LICENSED CONTRACTORS DECLARATION �c ,' ^ LIC CLASS NO. c' �D�iELI'. U e _ ADDRESS tSS �� O�t'� St— NO. I hereby affirm that I am licensed under provisions of Chapter 9 SEWER MAP (commencing with Section 7000)of Division 3 of the Business LIC. and Professions Code,and my license is in full force and effect. CITY CLASS BK PG VALIDATION �q'� l� SQ. FT. NO.STORIES OF FA OF CHECK License Num{�ber Lic. Cla/s+s, SIZE STORIES FAMILIES ONE Contractor 1, P� Date �V�� J14:k0� NEW ❑ VALUATION DESCRIPTION OF WORK ADD ❑ $ l/ , ❑I am exempt under Sec. 71 IL ALTER ❑ BAP.C. for this re son REPAIR ❑ $ ate: USE OF EXISTING BLDG. DEMOL ❑ Signature APPLICANT TEL.(PRINT) NO. FINAL WN -BUILDER D RA ON DATE I hereby affirm that I am exempt fro the ontr.ctor's License Law for the following reason (Secti n 71 1.5, Business and ADDRESS FINAL Professions Code): PRESENT By 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.) REQUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY SET BACK YARD HWY 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. (Sec. 3097, Civ. C.). SIDE P.L. Lender's Name S P.C. Fee$ Permit Fe e `.3� LDRef. # MA Lender's AddressPoll , I certify that I have read this application and state that the Issuance Fee LDMA P/C# 3 above information is corr t I agree to comply with all County Investig on Fee Z ordinances and State I s relati to building construction, Total Fee LDMA Perm. # n and ereb uthorize r pr sTy �rt, of this County to enter upo above- nti n or inspection purposes. 0 -07 SEE REVERSE FOR EXPLANATORY LANGUAGE i nature of A a gent Date