HomeMy Public PortalAbout5405 WELLAND AVE_Building__ <<M° IL.? iWORKERS'COMPENSATION DECLARATION
I `.' reb'y j r that I have certificate of consent to self
':irsure, fr dcertificate of Workers'Compensation Insurance, APPLICATION F OR BUILDING PERMIT
3s or a certifiJ, copy thereof (Sec. 3800, Lab C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No.�JQ�G� ompany
❑ Certified copy is hereby furnished. F R APPLICANT TO FILL IN BUILDING /)�
ADDRESS 0/
r-fxrrvertified copy is filed with the county building inspec- FADDR
NG /�
�f' �fion �/bartmen. SS y
Date i/ licant ZIP � LOCALITY r
RTIFI E OF EXEMPTION M WORKERS' G NO.OF BLDGS. ^ NEAREST
COMPENSATION INSURANCE F LOX NOW ON LOT CROSS ST. / �•(This section need not be completed if the permit is for one ASSESSOR
hundred dollars($100)or less.) BLOCK LOT NO. MAP BOOK PAGE PARCEL
TEL. gMAP
R ( / NO. /A��� A/7-2-7-7 _
I certify that in the performance of the work for which this NO.
permit is issued, I shall not employ any person in any mannerZ SPECIAL
ADDRESS i
so as to become subject to the Workers'Compensation Laws. 20 CONDITIONS O
Date Applicant CITY N' ZI I DI y
NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR _ TEL DISTRICT I-GR UP TYPE FIRE PRO SSED BY O
Exemption, you should become subject to the Workers' ENGINEER NO. ��� -// tel CpN57t Zp�IE W
Compensation provisions of the Labor Code, you must forth- ADDRESS `/v�U[ JV/ /
with comply with such provisions or this permit shall be i3 G.
deemed revoked. L• STATISTICAL CLASSIFICATION APT. DO. N
CONTRACTO T NO. Z
LICENSED CONTRACTORS DECLARATION LC
• o // CLASS NO. DWELL. UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO.T `47 T;r ER AAAP
(commencing with Section 7000)of Division 3 of the Business and LIC r
Professions Code, and my license is in full force and effect. CITY CLASS BK PG / VALIDATION
SQ.FT. NO.OF NO.OF CHECK
License Number Lic.Class SIZE STORIES FAMILIES ONE 8 2 1.5 A
C VALUATION
Contractor 6-)''-'�'� Date V DESCRIPTION OF WORK NEW $ O�/hi r # o 0 0 0 2 3
❑I am exempt under Sec. ADD [/ 4 8 S 9 8
ALTER [:]
B.BP..C. for this reason Date: REPAIR
EMOL ❑ $ 0 2 8 S 9 8 U
USE OF
EXISTING BLDG. a
Signature APPLICANT TEL
OWNER-BUILDER DECLARATION PRINTN'O. � DATE
I hereby affirm that I am exempt from the Contractor's License ADDRESS "/� /"s til
Law for the following reason (Section 7031.5, Business and FIN
Professions Code): FRE5ENT B
❑ BUILDING
I, as owner of the property, or myemployees 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 TOTALS ETBACK
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY pROP. LINE WIDTH
I hereby affirm that there is a construction lending agency for FRONT 9 6 7.7 A
the performance of the work for which this permit is issued P.L.
(Sec. 3097, Civ. C.). SIDE 0 0 0 o
P.L.
Lender's Name �J ( LDMA•Ref. # •)' - 827.25
TY
Lender's Address P.C.Fee$ ( 3 Permit Fee �r o o 8 2 7.2 5 czt
I certify that I have read this application and state that the Issuance Fee Ar -0LDMA P/C#
above in matio ' orrect. I agree to comply with all County Investigation Fee 0 S 2 4—8 8
0 ordina State laws relating to building construc' n, Total Fee S
$ and r outhori representatives of this County nter LDMA Perm. #
up
e a ve- ntioned property for inspect' u ;Zes.
a � _ 'Z SEE REVERSE FOR EXPLANATORY LANGUAGE
Signal of Applicant or Agent Dat