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Home My Public Portal About5325 WELLAND AVE_Building__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR BUILDING PERMIT I hereby,affirm that 1`have a certificate of consent to self• insure, or a,certificate of Workers' Compensation Insurance, or a certified copy th-e;reof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy N 5` o_A�t�y�r�fy&old 6aL� `9 ElCertified copy.is hereby.furnisBUILDING hed... FOR APPLICANT TO FILL IN ADDRESS ,� av�' G% ��-+�-' .e� , Certified.copy is filed h the co ty buil n i'ns ec- BUILDING tion department. ; ADDRESS Date—Applicant CITY ' 1/Lt` . `� ZIP LOCALITY NO.OF BLDGS. NEAREST or CERTIFICATE OF EXEMPTION F OM WORK $' SIZE OF'LOT• NOW ON.LOT CROSS ST. .COMPENSATION INSURANCE ASSESSOR . (This section need not be completed if the:permii-is or one TRACT BLOCK LOT IVO. MAP BOOK PAGE PARCEL hundred-dollars ($100):or less.) n^ II TEL. USE ZONE MAP J OWNER ea Cid, O. NO: I7 ;L-77 I certify that in the performarice'gf..the work for'which this /� permit is issued,.I shall not employ any person in any mariner ' ADDRESS Y-(qx - .4!_ SPECIAL O / CONDITIONS so as to become subject to the Workers'Compensation.Laws. - (r� U 'CITY ZIP -1 L , , a Date Applicant ARCHITECT OR. TEL. DISTRICT` GROUP TYPE FIRE PROCESSED BY O NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. CONST. ZQNE Exemptions you should. become,sub,ject•.to the Workers'. . 1 w Compensation provisions of the Labor.Code,'you must.forth- ADDRESS I j,e - , u n_ with comply with such provisions,or.this permit shall be " • 0��_I f .TEL.%�/�/�_- STATISTICAL CLASSIFI ON .APT CONDO. N deemed revoked., CONTRACTOR LQC TI YY[� Z LICENSED CONTRACTORS DECLARATION 1 _ J 1 - IC. CLASS-NO. DWELL UNI ADDRESS �P6Y'"C- 1 NO. hereby affirm that I am.licensed•under p�ovisions.of Chapter 9 - LIC ) SEWER MAP •' (commencing with'Section 7000);of Division 3 of the Business CITY• CLASS -'L VALIDATION and'Professions Code,and my license is in full 6cle aandd effect.`� BK. PG. 1l7 t Class L --L SI NO. OF NO.IOP CHECK License Number � 7S SIZE STORIES FAMILIES ONE • � � JJ ❑ VALUATION — Contractor Datey' I DESCRIPTION OF WORK NEW ADD D $Elpoll.I-am exempt under Sec. ALTER .❑ B.&P:C, for this re n REPAIR ❑ $ ate: US OF EXISTING BLDG. DEMOL ❑ Signature �� _ APPLICANT TEL. FINAL • ' OW R-BUILDER 94TPN (PRINT). � �Q NO. �-� I hereby affirm that I am exempt fr m t e. ontractor's Lice_nse rr2 QQ DATE Law for the following rea_son'(Se ion 1.5, Business and ADDRES5.1�.7 c D J •. lCc FINAL �•__. Professions Code): PRESENT By ❑ I, as•owneir of the-: BUILDINGproperty, 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.) TEL: , '"- rMOVING +.K ❑ I,as owner of the property,Y,am exclusively contracting CONTRACTOR NO. _ t with.licensed coritractors to construct the-project (Sec- i ADDRESS " tion 7044, Business and.Professions Code.) REQUIRED TOTAL SETBACK FROM ExIST. CONSTRUCTION LENDING AGENCY SET BACK YARD HWY ' PROP. LINE WIDTHr ,.-, I hereby affirm that there is a construction lending agency for FRONT �I�.I (=°-:`"i, = i I� ?P2 the performance of the work for which this permit is issued P.L: (Sec. 3097, Civ. C:). SIDE '`:�_ i 10.'59 P.L. Lender's Name LDMA Ref.# 8 P:C."Fee$ �`��' Permit Fee Lender's Address , ' I certify that I have r ad this application and state that the Issuance Fe; ' LDMA P/C# 2 is Tett.I agree to comply with all County oabove information Investigation Fee ordinanc and Sta I ws relating to building construction, Total Fee LDMA Perm. # q d he y authori a eprese tatives.of this County to enter d e abov t' nedperty for inspection purposes. 0 1 � SEE REVERSE FOR EXPLANATORY LANGUAGE Date Signature of iwnt Agent ' �.1�WOR(CERS' COMPENSATION DECLARATION -?,-hereby affirm that I hbve certificate of consent self in APPLICATION FOR BUILDING PERMIT insure, or a.cartificate of Workers' Compensation insurance, j 6C j�r c ti ;ed c thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY `� Plmmf Company ElCertified copy is hereby furnished. -FOR APPLICANT TO FILL IN ADDRESS BUILDING. VJe ' Certified copy is filed with the county,building inspec-' BUILDING i tion pa ment. ' •e i ADDRESS^ =�YY�.'r CITY' ) . ZIP � LOCALITY . y Date Applicant NO.OF BLDGS. NEAREST RTIFI TE OF EXEMPTION FROM WORKERS" SIZE F LOT NOW ON LOT CROSS ST. Qq r' COMPENSATION INSURANCE �7 2 ASSESSOR ' (This section need not be completed if the permit is for one I: TRACT LI J C,7 BLOCK LOT NO. MAP BOOK 'PAGE, PARCEL hundred dolldrs ($100)or less.) : . TEL USE ZONE MAP n �� OWNER NO. I 'NO. a I certify that in the performance of•the work for which this �A permit is issued, I shall not employ any person in any manner ADDRESS l� �� SPECIAL, CONDITIONS so as to become subject to the Workers'Compensation.Laws. O CITY ZIP 0 Date Afie pplicant ARCHITECT OR TEL DISTRICT GROUP TYPE FIRE' R ESSED BY O NOTICE,TO:APPLICANT: If, after making this,Certificate of ENGINEER. NO. CONST. E ��--- Exemption, you. should become subject to' the. Workers'. . f/ w Compensation provisions of the Labor Code; you must forth- ADDRESS -� li 1 -7 n_ with.comply with such provisions or-this permit shall be TEL. TATISTICAL CLASSIFICATION APT. CONDO., to deemed-revoked. CONTRACTOR NO. Z LICENSED CONTRACTORS DECLARATIO'N' �.. LIC• -�-� CLASS NO'.�DWELL UF41TS� I herebyaffirm.that I am licensed under provisions of Chapter.9 ADDRESS NO. . 1 !/� (commencing with Section 7000)of Division 3 of the Business LIC. \ ` + SEWER MAP I . CITY- . . Kckffi;5; � ' and Professions Code,and my license is in full force and effect. ' ;BK• PG,. VALIDATION SQ:Fi NO.yOF NO,OF CtiECK License NumSer'� 0� / [, ® �Lic; Class SIZE STORIES:s�� '•,FAMIL'IES"+` •�ti �,'ONE �_ .��.. VALUATION Contractor 1• !I !L-)r 9_C2J • Date'- L'( DESCRIPTION,QF WORK `.. Z �C^ ADD ❑ , ❑I am exempt under.Sec. � ALTER . B.&P.C. for this reason ' ❑ $ I�a �CD U REPAIR ❑ Date: DEMOil ❑ SM EXISTING BLDG. ' Signature + APPLICANT TEL FINAL g OWNER-BUILDER DECLARATION (PRINT) DATE Z-Z6-� I hereby affirm that I am exempt from the Coritractor's License Law for the following,reason (Section 7.031.5, Business arid ADDRESS FINAL f' Professions Code):.- I' PRESENT ' B Y BUILDING ❑ I, as owner of the property, or my employees with ADDRESS - ;c ,_� wages as their sole compensation,will do the work and I. I' o?3 4�'I`! :1'• , -r the structure is not intended of offered for-sale(Section LOCALITY , 7044, Business and Professions-Code.) MOVING TEL. F CONTRACTOR' NO. .� `f ,i� r. I,as owner of'the property;am-exclusively contracting 4. .• : , �'. .�„ '�'�•yti- . = with licensed contractors to construct the project (Sec- gN tion 7044,.Business,and Professions Code.) I ADDRESS d� REQUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY SET BACK. 'YARD HWY PROP. LINE WIDTH p��• (l1J �' ' ' - -- r,0 ' hereby affirm that there is a construction lending agency for FRONT V ` "' the performance of the work for which this permit is issued P•L.• J1 �� C� (Sec. 3097, Civ. C.). SIDE, , ti CHECK �52, Lender's Name S P.C. Fee i�011y�9. 3a LDMA Ref.a i•H:j $ NS.+ E ill Permit Fee Lender's Address ,L r I certify that I have read this application and state that the �d��T Issuance Fee "� �`5 LDN1A P/C q 3 above information is correct.I agree to comply with all County Investigation Fee �/ 'L� i Ijl jl Ij r-i;l_ _;,r'?1 a ordinances and'State laws relating to building construction, Total Fee �l T LDMA Perm. q s o = and hereby autliori ntatives of•this County to nit Z-1274 upon•thea n ed pro or inspection Pur ses. ®! _ oa SEE REVE OR EXPLANATORY LLAAN�GUAGE •�� • na ure Aq6te