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Home My Public Portal About5327 WELLAND AVE_Building__ WORKERS' COMPENSATION:DECLARATION hereby affirm that I have r certificate of consent to self A p p L I CAT�I O N .FOR. BUI L D ING P E RM I T insure, or a certificate of Workers' Compensdtion Insurance, •• - or a cc [ed cop thereof c.'38 , L . C.) COUNTY OF-LOS ANGELES BUILDING AND.SAFETY Policy ��•`� Co pony BUILDING ❑ Certified copy'is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS '❑ Certified copy is filed with the'cou ty buildin' ' sp. - ADDRIIN ttiio_nnddepaarttment. Dote )L Applicant' CIrY f .L ?IP LOCALITY CSX O.OF BLDGS. NEAREST &OF ie CERTIFICATE OF EXEMPTION F Nf WORKEti SIZE OF LOT NOW ON LOT CROSS'ST.COMPENSATION INSURANCE ASSESSOR (This section need not be completed if the permif, one TRACT BLOCK LOT NO. MAP BOOK• PAGE PARCEL hundred"do.11ars ($100) ,TEL• USE ZONE OP ;F-7OWNER NO. I 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 CONDITIONS IL .so as to.become subject to the Workers'Compensation.Laws. :' q .OV ' GIN ZIP •q Date Applicant ARCHITECT OR TEL, DISTRICT GROUP TYPE FIRE' �OCESSED BY Q NOTICE TO-APPLICANT: If, after making this Certificate of ENGINEER NO. CONST. ZO Ek o Exemption, you should..becomer-subject Y •. the.Workers' Compensation provisions of the Labor Code, you must forth- ADDRESSp�/ GL� with comply with.such provisions or this permit,shall be TEL STATISTICAL CLASSIFIC/�FI�I� APT CONDO. Z deemed revoked. CONTRACTOR� O.g ,y� i ,U.�°.. _ LICENSED-CONTRACTORS:DECLARATION' LIC. CLASS NO. DWELL:UNITS I hereby affirm tharl am licensed under provisions of Chapter 9 ADDRENO. SEWER MAP (commencing with Section 7000)of Division 3-of the Business LIC• and Professions Code;and my license Win full for and effect. CIN• cc. d— BK. PG. VALIDATION r�,II SQ. FT. NO.O NO. OF CHECK License Number3 1� _Lic. Class '1(0 SIZE. STORIES (FAMILIES ONE ' VALUATION ContractorR �'' Date K7'� 1` DESCRIPTION OF WORK +}vv �i..1�" NEW ❑ ADD ❑ ► 0'1 am exempt under Sec. Gl Ci- c ALTER ❑ B.BP.C. for this re on V REPAIR ❑ $ USE O EXISTING BLDG. DEMO' ❑ Signatur Q�� APPLICANT TEL FINAL OW R-BUILD EC RATION (PRINT) NO. ✓� DATE `z hereby affirm that I am exempt fro the Contractor's License - " Law for the following reason'{ cti' 7031.5, Business and ADDRESS S FINAL Professions Code): PRESENT By F ti,nry ❑ I, as owner of the roe or m employees with BUILDING property,rtY: YADDRESS 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 CONTRACTOR NO. ❑ I, as owner of the property,am exclusively contracting -A, rr n{ � • , with licensed.contractors to construct the project (Sec- ADDRESS '`' ` tion 7044, Business and Professions Code.), 3-yiC-•,/ [ o':,v. REQUIRED TOTAL SETBACK FROM EXIST. [•ti- 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 Lender's Name LDMA Ref. # - P.C. Fee$` Permit Fee ✓V5T�7` i� ':al•. Lender's Address: , I certify that I have re . this application-and state that the Issuance Fee LDMA P/C# above inform on is c re t. I agree to comply with all County Investigation Fee ordinance nd State relat' to building construction; Total Fee LDMA Perm. and y au rize• resent ti e's of this County to enter U. the bove•m ti ed-pro ty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Si nature of APpSc {or ent Date ; WORKERS'-COMPENSATION DECLARATION 'I Here'ora cer that I have r certificate ns consent r self A P P L I CAT I O•N FOR BUILDING PERMIT ' . insLre, or a certificate of Workers'Compensation Insurance, t.. or a�c�ertifi d cop ereof(Sec. 3800, Lab. C.) �. COUNTY OF LOS ANGELES BUILDING AND SAFETY o Icy No �~ � Company BUILDING' Z..1 ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ' ADDRESS Certified copy'is filed with the county building inspec-0 BUILDING tion ep invent. I ADDRESS T/ '/ . /f'J .� CITY' ' ZIP LOCALITY �•+ Date pplicant NO.OF BLDGS. NEAREST ERTI KATE OF EXEMPTION FROM WORKERS' i SIZE OF LOT NOW ON LOT CROSS ST. COMPENSATION INSURANCE Q ASSESSOR (This section need not be completed if.the permit is for.one', TRACT "� BLOCK LOT NO. MAP BOOK PAGE PARCEL hundred dollars•($.100)or-less.) TEL' USE ZONE MAP' y 11 OWNER N 2 n NO. A01 I certify that in the performance of the work for which this I SPECIAL permit is issued, I shall not employ any.person in any manner� V' ADDRESS �— CONDITIONS so as to become'subject to the Workers'Compensation Laws.,', J OO -CITY zip 91 Date Applicant ARCHITECT OR TEL NOTICE TO'APPLICANT: If, after making akin this Certificate of ENGINEER. NO."s"f�-� DISTRICT GROUP TYPE FIRE PROCESSED BY g CONST. ZONE • biemption, you.should become subject to the Workers' aU Compensation provisions of the Labor Code,.you must forth- . ADDRESS ,('� —3 with comply with such provisions or this permit shall be' TEL STATISTICAL CLASSIFICATION APT.• CONDO. u7 deemed revoked. CONTRACTOR NO. Z LICENSED.CONTRACTORS DECLARATION r LIC. `�� CLASS NO. OO` DWELL UNITS I hereby affirm that Lam licensed under provisions of Chapter 9 ADDRESS Gr NO � ' � SEWER MAP (commencing with Section 7000)of Division.3 of the-Business LIC. and Professions Code,and my license'is fn full force`and effect. CRY CLASS BK. VALIDATION FT. NO.'OF NO.OF f CHECK License Number Lic. Class SIZE STORIES FAMILIES �, ONE VALUATION Contrcictor -/ // / Date DESCRIPT NOF WORK02W , � NEW PAr If. � •e'' ADD ❑ ` ► ❑I am , t under Sec. '` • B.BP:C. for this reason ALTER .� /6 Q�ODD- REPAIR ❑ $ Date: USE OF 4.•, \ti EXISTING BC6'G.1.. \d DEl�10L ❑ ,•C .>,.a. " �� `+ :,` I Signature APPLICANT't"' '� i'STEL:` '.1=1• OWNER-BUILDER DECLARATION (PRINT) O. �+%� Z FINAL I � ��•.`Z G�-Q I hereby affirm'that I am exempt•from.the Contractor's License `A Law'fot'the following-reason (Section.7031:5, Business and.; �1` ADDRESSlcx�nn � + Vi DATE FINAL . ' Professions Code): = PRESENT By -. ❑ I, as owner.of.the property, or m employees.with I BUILDING i-li.: •'' P P Y. Y € � ADDRESS ' _• wages as their-sole compensation,will do the work and S. the structure is not Intended or offered for sale(Section ; LOCALITY 7.044,.Business and Professions Code.) MOVING•' =.TEL.. ' t CONTRACTOR �; Na. _ ❑ I,as'owner of the property,am exclusively contracting „ ;,t�_ti- �\ •��`�,;t' j with licensed contractors to construct the project (Sec- ' tion 7044, Business•an Professions Code. ADDRESS ; , , ,,, � '_ !r�—• d ) - Tr� REQUIRED TOTAL SETBACK FROM EXIST. KIN a- CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP.UNE WIDTH ,,; j,- �•-: I hereby ciffirm that•there is a construction lending agency for FRONT + . 1 M the performance of the work.for which this permit is issued 'P.L. (Sec. 3097, Civ. C.). SIDE TLE P L Lender's Name Lender's Address P.C. Fee$ �/- D Peimit Fee' l��O �• �� LDMA Ref.# CHAN E Pilo I certify that I have read this application and state that the `�� Issuance Fee. 7S LDMA P/C# above information is correct. I agree to comply with all County Investigation Fee ,- — . 1 92 ordinances and Stat s re ting to building construction, Total Fees f�+ v LDMA Perm. # - V ( and hereby au pr tali sof this County-to enter 17131ZF'{i�"r• -„ z upon th ent' pro .for inspection pur ses 32 [? Z �O / SEE.REVERSE FOR EXPLANATORY LAIGUAGE of t o ate