HomeMy Public PortalAbout5407 WELLAND AVE_Building__ ' 1. ,•`%IVORKERS'COMPENSATION DECLARATION
APPLICATION FOR BUILDING PERMIT
..l:her6by-'affirm that I have a certificate of consent to self
j)• ;rys'�"ure;or o certificate of Workers'Compensation Insurance,
or a certified copy there (Sec. 3800, Lab.�C.)/ /� COUNTY OF,LOS ANGELES BUILDINGAND SAFETY
Policy No i5 ompony --�/�6� BUILDING O
Certified copy is hereby furnished. F R AP LI NT TO FILL IN ADDRESS
Certified copy is filed with the county building inspec- BUILDING
do epartme ADDRESS .v � O 7
Date Applicant f`-4 CITY ZIP LOCALITY _
ERTIF E OF EXEMPTION FROM WORKERS' (NO.OF BLDGS. NEAREST
COMPENSATION INSURANCE SIZE OF LOT tLe 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. USE QNE MAP
OWNER , NO. a-� /
I certify that in the performance of the work for which this NO. _
permit is Issued, I shall not employ any person in any manner Z SPECIAL
ADDRESS CONDITIONS
so as to become subject to the Workers'Compensation Laws, V
Date Applicant CITY A'(40 • Z P a/D �
ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY O
NOTICE TO APPLICANT: If, after making this Certificate of CONST. ZONE V
Exemption, you should become subject to the Workers' ENGINEER 2 NO. �/(�
Compensation provisions of the Labor Code, you must forth- ADDRESS
with comply with such provisions or this permit shall be / I-'
deemed revoked, CONTRACTO Or" STATISTICAL CLASSIN ATION APT. �CONDO. In
LICENSED CONTRACTORS DECLARATION LIC CLASS NO. DWELL UNITS t/_ '2 1.7 A
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. SEWER MAP
(commencing with Section 7000)of Division 3 of the Business and LIC.
g If 11111"9111111111
Professions Code, and my license is in full force and effect. CITY CLASS BK PGI L V mokfidN2 5
SQ. FT. NO.OF �7 NO.OF CHECK
License Numb—ere/ Lic. :1 .0 . SIZE STORIES !� FAMILIES ONE - 691j,256
VALUATION
p n_ DESCRI O OF WOR D NEW IV ( 0,27-87
Contractor �''"'� Date ADD ❑ $ O ,
❑ I am exempt under Sec. ALTER ❑ lo� / 4J
B.BP,C. for this reason REPAIR ❑ $ ( 65
(O
Date: USE OF I EXISTING BLDG. DEMOL ❑
Signature APPLICANT / TEL. FINAL
OWNER-BUILDER DECLARATION PRINT N NO. �"�� DATE
I hereby affirm that I am exempt from the Contractor's License r1 AOff/,
Law for the following reason (Section 7031.5, Business and ADDRESS 7 pl
Professions Code): ENT
9 6�•8 A
❑
I, as owner of the property, or my employees with ADDRESS
BUILDING
wages as their sole compensation,will do the work and LOCALITY # 0 0 0 0 0
the structure is not intended or offered for sale(Section ®,
7044, Business and Professions Code). MOVING TEL. ° 827.25
❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO.
with licensed contractors to construct the project (Sec- ADDRESS ° ° 8 2 7.2 5 r
tion 7044, Business and Professions Code).
REQUIRED TOTAL SETBACKFRO
CONSTRUCTION LENDING AGENCY SET BACK YARD HwY PROP. LINE WIDTH o524-88
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 ti ,
P.L.
Lender's Name LDMA Ref. fl
P.C. Fee$ Permit Fee K 16 -7S-
Lender's Address /') �]
I certify that I h read this application and state that the Issuance Fee V." LDMA P/C N
above informati s c I agree to comply with all County Investigation Fee
ordinances an a laws relating to building construction, Total Fee LDMA Perm. M
and hereby a t or a reou6sentatives of this CountWentr
upon the ab -m do d property for inspection SEE REVERSE FOR EXPLANATORY LANGUAGE
ture of p'licant or Agent