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Home My Public Portal About5401 WELLAND AVE_Building__ . w A f 'WORKERS'COMPENSATION DECLARATION of coent to sel sureboracertifcatteofWokes''ificate CompensatonInsurance, APPLICATION FOR BUILDING PERMIT or i y No._ ccop there (Se . 3800, Lab._C.) r Zed IoLob. C.) y1 COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. ❑ Certified copy is hereby furnished. FOR APP CANT TO FILL IN ADDRESS / J= oCertld cop is fil d with th ounty building inspec- BUILDING0I _ par a t. ADDRESSDate Applicant CITY t®G ZIP LOCALITY TE OF EXEMPTION FROM WORKERS' (, O.OF BLDGS. NEARESTCOMPENSATION INSURANCESIZ OF LO 7. NOW ON LOT CROSS ST.(Thisneed not be completed if the permit is for one ASSESSOR hundred dollars($100)or less.) BLOCK LOT NO. MAP BOOK PAGE PARCEL TEL USE NE MAP -- �i —/ Iq I certify that in the performance of the work for which this OWNER :�✓ NO. �� NO. 4 permit is issued, I shall not employ any person in any manner SPECIAL a so as to become subject to the Workers'Compensation Laws, ADDRESS CONDITIONS U CITY �AX ZIP91 a 1 Date Applicant IX NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL. DISTRICT G UP TYPE FIRE PROCESSED BY O Exemption, you should become subject to the Workers' ENGINEER NO. � CONST. ZONE F- Compensation provisions of the Labor Code, you must forth- ADDRESS �� V S L W with comply with such provisions or this permit shall be IL deemed revoked. / TEL. STATISTICAL CLASSIFICATION APT. CON N CONTRACTOR &�+ /F7 T-NO. y Z LICENSED CONTRACTORS DECLARATION LIC, CLASS NO.61DWELL. UNITSI_L__ I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. (commencing with Section 7000)of Division 3 of the Business and LIC SEWER MAP ' Professions Code, and my license is in full force and effect. CITY — CLASS f5 VALIDATION SQ. INC.OF NO.OF CHECK BK. PG. License Numbe Lic.Clo ss SIZE STORIES � FAMILIES ONE N� '� NEW VALUATION �- Contract or'F tl� �—� Date DESCRIPTION OF WORK $ ❑ &DNOa ADD I am exempt under Sec. ❑ 8 2 �,8 A ALTER B.BP.C. for this reason REPAIR ❑ $ ( J ~ # 0 0 0 0 2 3 Date: USE OF DEMOL ❑ EXISTING BLDG. I - 73632 Signature APPLICANT TEL. 7,r� FINAL OWNER-BUILDER DECLARATION PRINT SQ� NO. 1 hereby affirm that I am exempt from the Contractor's License ��y I lG� DATE o o 7 3 &3 2 5 Law for the following reason (Section 7031.5, Business and ADDRESS FI Professions Code): PRESENT B Q 27-87 ❑ 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. , ❑ 1, as owner of the property,am exclusively contracting CONTRACTOR NO. with licensed contractors to construct the project (Sec- ADDRESS9 6 7 6 A tion 7044, Business and Professions Code). REQUIRED TOTAL SETBACK # 0 0 0 0 0 CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH I hereby affirm that there is a construction lending agency for FRONT - 87675 the performance of the work for which this permit is issued P.L. (Sec. 3097, Civ. C.). SIDE P.L. o - 876755 Lender's Name LDMA Ref. # G 4—88 m P.C.Fee$ � • Permit Fee Lender's Address 1 certify th I have read this application and state that the Issuance Fee l-7 V LDMA P/C q above inf r ation is correct. I agree to comply with all County Investigation Fee 9 ordinan an a laws relating to building constru on, ` �] R and h y utho ze representatives of this County enter Total Fee CJ ,/ MA Perm.q upon 3a ove- entioned property for inspectio posses C SEE REVERSE FOR EXPLANATORY LANGUAGE ignat of Applicant or Agent Dat ` APPLICATION FOR BUILDING PERMIT f .i COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN f BUILDING ADDRESS I hereby affirm that I have a certificate of consent to self insure, BUILDING ADDRESS�. �/ ��MD �. //� or a certificate of Workers'Compensation insurance,or a certified V copy thereof(Sec.31100,Lab.C.) ITY Policy No. Company -rRAfRe r Nair ZIP 91 790 LOCALITY qTrte" / Ir C r� SIZE OF LOT NO.OF BLDGS.NOW ON LOT r ❑ Certified copy is hereby furnished. i NEAREST CROSS ST. ❑ Certified Copy is filed with the County building inspection TRACT BLOCK LOT NO. USE ZONE MAP NO. department. ASSESSOR MAP BOOK PAGE PARCEL Date Applicant S b D B•,^ v - SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS OWNER); TEL NO. YES NO COMPENSATION INSURANCE S. HAB 5 0 �' Sl9 IIS -6"L WITHIN 1000 FT.OF SCHOOL? ADDRESS DISTRICT0 GROUP TYPE CONST.' FIRE ZONE OCESSE BY (This section need not be completed if the permit is for one hundred �e�LJ n/p f}�/ - liars($100)or less.) CITY zip t ]� 1"C..6,>Vy0 ertify that in the performan�§Rw t /,� Lri/Ty �17�� ✓]' ✓ /r7 issued, I shall not employ aARCHITECT OR ENGINEER TEL.NO. come subject to the Workers' STATISTICAL CLASSIFICATION APT CONDO Applicant ADDRESS CLASS NO. DWELL UNITS NOTICE TO APPLICANT f,Lafterma g s Certificate of REQUIRED TOTAL SETBACK FROM IXIST Exemption, you shout" be j to the Workers' CONTRACTOR TEL NO. SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of thde,you must forthwith FRONT comply with such provisions or this permit shall be deemed'revoked. ADDRESS LIC.NO. P L LICENSED CONTRACTORS DECLARATION CITY LIO.CLASS SIDE 0 PL O V 1 hereby affirm that I am licensed under provisions of Chapter 9 SEWER MAP It with Section 7000)of Division 3 of the Business and So.FT.SIZE NO.OF STORES NO.OF FAMILIES Professions Code,and my license is in full force and effect. Z / NEW ❑ BK PG DESCRIPTION OF WORK ADD ® VALUATION , LU Licence Number Lic.Class 7X !O� P ,4-vo. 013 Contractor Date ALTER ❑ $ ❑ I am exempt under Sec. REPAIR ❑ $ B.&P.C.for this reason DEMOL ❑ LDMA P/C# ' USE OF EXISTING BLDG. Date: 61ARX' PAX&Y ff014ff URM ❑ lieIgnature APPLICANT(PRINT) TEL.NO. LDMA Perm# I, as owner of the property, or my employees with wages as �t S- $ANT/LL/3 / [t- 8(o C their Sole compensation,will do the work and the structure is ADDRESS H AB intended or offered for sale (Section 7044, Business and J D &Vfl- Q�JQ 406 T P4 / W qpm FINA1 D a AICT.a IA essionsCode.) WILLTHEAPPLICANT OR FUTURE BUILDING OCCUPANT HANDLEA HAZARDOUS MATERIAL 3307cLiol owner of the roe y g OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN p p rty, am exclusive) contracting with THE AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY j 7 TEM eed contractors to construct the project (Section 7044, YES q� 11 CI 1 Hess end Professions Code.) NO WILLTHE INTENDS USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING TOTAL 548,=75 OCCUPANT REQUIREA PERMITFOR CONSTRUCTION OR MODIFICATION FROM THESOUTH CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST r.�(C fY 92.75 FOR GUIDELINES. ►,(7Gl•,4 I hereby affirm that there is a construction lending agency for YES ❑ NO W .013 the performance Of the work for which this permit Is Issued(See. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD CHANGE W 3097,CIV.C.). PERMITTING CHECKLIST.I UND D MY REQUIREMENTS UNDER THE LOS ANGELES COUIbKY CODE,TITLE SECTIONS 22MI00THROUGH 220.140 CONCERNING Lenders Name US MATER R RTI FOR OBTAINING A PERMIT FROM THE SCAOMD. 0090-0001tC/i{ l y IL{I Lenders Address 7'r-=/ G/ 5 r! 0 1 certify that I have read this application and state that the above13476 J. AM 10°13 informati n is correct. I agree to comply with all county C.FEE PERMIT FEE ordm and State laws relating to building construction,and Whethonze repress a Is County to enter Upon ISSUANCE FEE ` `Omention fo i pection pu oses. /INVESTIGATION FEE TOTALFEE aApanl SEE REVERSE FOR EXPLANATORY LANGUAGE