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Home My Public Portal About5562 WELLAND AVE_Building__ t WORKERS'COMPENSATION DECLARATION I rebaffirm that I have certificate of consent to self APPLICATION FOR BUILDING PERMIT ipsusure, o or ti certificate of Workers'Compensation Insurance, or a certified copy thereof(Sec. 3800, lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY PolicyNo._7 SIM. Company ti� F%/vD Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING ADDRESS Certified copy is filed with the county building inspec- BUILDING /� tion department. ADDRESS T( 2_ tv Rvp -,Lt 4 Date Y127127 Applicant�is.`��— CITY 'r-e6leleC � C� ZIP (/ V LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. NEAREST COMPENSATION INSURANCE SIZE OF LOT G NOW ON LOT CROSS ST. (This section need not be completed if the permit is for oneASSESSOR hundred dollars($100)or less.) TRACT 3S BLOCK 04 LOT NO. MAP BOOK PAGE PARCEL TEL. USE NE MAP I certify that in the performance of the work for which this OWNER l� 16QV(�b ptQ,v TEL. 2Q 6� E NO. y, permit is issued, I shall not employ any person in any manner ADDRESS S, $ �/ Q Ab.R'z' gG +�ZQ� �J SPECIAL � so as to become subject to the Workers'Compensation Laws. ' CONDITIONS 0 U Dafe Applicant CITY b px i-eL ZIP / 774 99 NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR / TEL. DISTRICT GROUP TYPE FIRE P� SSED BY O ENGINEER YY Cry! —f �(t!/ / �' ,� 6!! Exemption, you should become subject to the Workers' --. CONST.``// ZONE Compensation provisions of the Labor Code, you must forth- ADDRESS bAl with comply with such provisions or this permit shall be fA deemed revoked. TEL. STATISTICAL CLASSIFICATION APT. J#bNDO. CONTRACTOR tCfft /1-Q Qtl NO. 2f ` J1 LICENSED CONTRACTORS DECLARATION LIC. y o�/ CLASS NO. ll�DWELL UNITS — I l fo I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS 3 �� t NO. SEWER MAP (commencing with Section 7000)of Division 3 of the Business and n LIC 1 Professions Code, and my license is in full force and effect. CITY J-J f �/e'L� CLASS /J BK �PG / .VALIDATION License Number 4('C1?0 3 /� Lic.Class SI EFT. /r STORIES FAMILIES INC.OF NO.OF CHECK ONE / VALUATION Contractor rt^4? kacQ L'bAslpate 2 DESCRIPTION F WORK NEW ❑ $ `� V ADD ❑ , I am exempt under Sec. ALTER ❑ Orr B.BP.C. for this reason REPAIR ❑ $ Date: USE OF DEMOL EXISTING DG. ❑ Signature APPLICANT TEL. g OWNER-BUILDER DECLARATION PRINT) �� L �J7 e a�j]�N0.2 S 2�rI DATEFINAlT�r ;21 6 7 S 2 R I hereby affirm that I am exempt from the Contractor's License y Law for the following reason (Section 7031.5, Business and ADDRESS C 3 � ' 3 s S� gAbk el b WO S•L7, 07 0 0 0 o u 1 Professions Code): PRESENT B ❑ BUILDING / ' 10 1 81, 1 3 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 ' 0 0 1 8 1 1 3 7044, Business and Professions Code). MOVING TEL. I, as owner of the property, am exclusive) contracting CONTRACTOR NO. P P Y� Y 9 0327-8 1 with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY REQUIRED YARD HWY TOTAL SETBACK FRO SET BACK 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 a P.L. Q Lender's Name LDMA Ref. # - Lender's Address P.C.Fee$ Permit Fee x I certify that I have read this application and state that the Issuance Fee �+ J LDMA P/C# ' above information is correct. I agree to comply with all County Investigation Fee ordinances and State laws relating to building construction, Total Fee t LDMA Perm.# and hereby authorize representatives of this County to enter upon the above-merltioned property f inspection purposes. a = SEE REVERSE FOR EXPLANATORY LANGUAGE o � Si na t01 of Applicant or Agent Date j N WORKERS'COMPENSATI.QN DECLARATION 111�iD 1 r' I.here�,affirm that I Have a certificate of consent to self APPLICATION FOR BUILDING PERMIT ' "insure, or.a certificate of Workers'Compensation Insurance, � � ' or a'certified co y there of'(Sec. 3800,,^Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No.K1��73 Company . t� I/,(/� ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING ❑ ADDRESS Certified copy is filed wit a county building inspec- BUILDING �� tion department. ADDRESS 5562 Welland Ave (#l) Date QOM-; Appy CITY Temple City, CA ZIP 91780 LOCALITY �i CERTIFICATE OF EXEMPTIO ROM WORKERS' r r NO.OF BLDGS. NEAREST COMPENSATION I SU SIZE OF LOT 82 X 300 NOW ON LOT CROSS ST. (This•section need not be completed if the permit is for one TRACT 43590 BLOCK A LOT NO. 27 ASSESSOR -hundred dollars($100)or less.) MAP BOOK PAGE PARCEL OWNER H&S Development U18)285-29 USE Z NE MAP 1 -6 � . 1 certify that in the performance of the work for which this r NO. 7 7 permit is issued,I shall not employ any person in any manner r� SPECIAL so as to become subject to the Wo Compensation Laws. ADDRESS 633 S. San Gabriel Blvd, , #207 CONDITIONS 0 Date Applica CITY SaARCHITECTn Gabriel, CA zip 91776 td NOTICE TO APPLICANT: If, after ing this Certificate of ENGINEER Me & Chiu Design &8)960-1 98 DISTRICT GROUP TYPE FIRE PRO ESSED BY Exemption, you should become subject to the Workers' r CONST. Z�NE ri Compensation provisions of the Labor Code, you must forth- ADDRESS 13523 Francisquito, #B Baldwin P k r v IL with comply with such provisions or this permit shall be an fl. PL• STATISTICAL CLASSIFIC TION APT. NDO. deemed revoked. CONTRACTORft� d .NO � � LICENSED CONTRACTORS DECLARATION LIC, CLASS NO. 'J DWELL. UNITS 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, andel my license is in full force and effect. CITY l BK. F PG.114 VALIDATION �/ 76®s' Lic.Class SIZ " STONO. IE FA OF CHECK License Number SIZE 1511 STORIES 2 FAMILIES 1 ONE 4--qt? -yq�� VALUATION CA.1� Date DESCRIPTION OF WORK NEW � $ 78 000,OO # 6 1 a�3 Contractor Pilo, ADD o 0 0 0 Detached Condo ❑ I am exempt under Sec. ALTER I - 55272 B.&P.C. for this reason REPAIR ❑ $ Date: USE OF DEMOL ❑ ° - 552726 EXISTING BLDG. Signature APP(PRINT) Lee & Chiu Design (.4-s)960-1988 9 FINAL �/ r 122U-86 OWNER-BUILDER DECLARATION E g DATE I hereby affirm that I am exempt from the Contractor's License ADDRESS 1l56ancisquito Ave.,, #B Baldwin Law for the following reason (Section 7031.5, Business and (� �F�INProfessions Code): PRESENT ❑ 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. 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). „ CONSTRUCTION LENDING AGENCY EInvestigation OUIRCYARD HWY TOTAPROP. LIINESETBACK FROM WIDTH 7 3 6 5 A I hereby affirm that there is a construction lending agency for 0 0 0 o n the performance of the work for which this permit is issued (sec. 3097, Civ. C.). I ° 6 6 0 7 5 $ Lender's Name ° ° 6 6 C',7 5 x 3 LDMA Ref. # Lender's Address F�•Z / Permit Fee 6T ' G 6 G G � 7 r I certify that I have read this application and state that the Issuance Fee /67.6-V LDMA P/C# = above information is correct. 1 agree to comply with all County ee / j ordinances and State laws relating to building construction, Total Fee 6� �� LDMA Perm. # authorize representatives of this County to enter upon t ove-mentioned property for inspec/tion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE gnature of Applicant or Agent Date � 1 . I WORKERS'COMPENSATION DECLARATION hereby affirm that i have certificate of consent to self APPLICATION FOR BUILDING PERMIT insure, or a certificate of Workers' Compensation Insurance, or a certified copy thereof(Sec. 3800, Lab. C.) 4�_1,,j7 �� COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company ..i Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING ADDRESS �• (p /v Certified copy is filed wiF�ie county bui 'ng inspec- BUILDING ) /� +tion department. \ ADDRESS Date l — Applicant 1 Q CITY F /j` ZIP LOCALITY C . CERTIFICATE OF EXEMPTION FROM WORKERS' / d OF BLDGS. NEAREST COMPENSATION INSURANCE SIZE OF LOT ( OW ON LOT CROSS 57. 164111 (This section need not be completed if the permit is for oneQQ�} J ASSESSOR hundred dollars($100)or less.) TRACT VtJ / n BLOCK LOT NO. MAP BOOK PAGE I PARCEL TEL. US ONE MAP OWNER A C NO., I certify that in the performance of the work for which this O NO. f� permit is issued, I shall not employ any person in any manner �� SPECIAL so as to become subject to the Workers'Compensation Laws. ADDRESS ,. CONDITIONS O Date Applicant CITY Z . � y ZIP 1?0 ARCHITECT O / TEL. DISTRICT GROUP TYPE FIRE RO SSED BY O NOTICE TO APPLICANT: If, after making this Certificate of f 'I q _ CONST ZONE U Exemption, you should become subject to the Workers' ENGINEER f'SV �/� NO. 6(1—� Compensation provisions of the Labor Code, you must forth- ADDRESS c U W with comply with such provisions or this permit shall ben�/ IL deemed revoked. CONTRACTOR /Vl. ^� STATISTICAL CLASSIFICATION APT. CONDO. fn o.. ays' LICENSED CONTRACTORS DECLARATION s��7 LIC, , O� CLASS NO. DWELL. UNITS — J-.3 hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS CJ J 21 /� f G _ NO. (commencing with Section 7000)of Division 3 of the Business andy c� LIC. SEWER MAP Professions Code, and my license is in full force and effect. CITY / , ,i' // CLASS BK VALIDATION 1�� (Qt SQ.FT. INO.STORIES IE NO.OF CHECK License Number-} Lic.Class ZJ , SIZE STORIES FAMILIES ONE I Contractor �1 Date-�Z��—r7 DESCRIPTION OF WORK �$%��,�, '/ ADD +^J\EW ❑ ;VALUATION� I am exempt under Sec. � '�� lS � � .l �/ ALTER ❑ B.BP.C. for this reason REPAIR ❑ $ Date: USE OF DEMOL EXISTING BLDG. ❑ Signature APPLICANT TEIUI FINAL OWNER-BUILDER DECLARATION PRINT t '� Gc DO NO, /7/br DATE I hereby affirm that I am exempt from the Contractor's License �-+ J Law for the following reason (Section 7031.5, Business and ADDRESS 7c8// A �L �/ 1 `f 1/ FIN 1 Professions Code): PRESENT ❑ 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. I, as owner of the property, am exclusively contracting CONTRACTOR NO. with licensed contractors to construct the project (Sec- ADDRESS �z 6 7 6 A ` tion 7044, Business and Professions Code). REQUIRED TOTAL SETBACK FRO CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH / 7.hereby affirm that there is a construction lending agency for FRONT the performance of the work for which this permit is issued P.L. o u o 8 7.3 8 zo: (Sec. 3097, Civ. C.). SIDE ( 229-87 Lender's Name LDMA Ref. # o Lender's Address P.C.Fee$ Permit Fee i i I certifythat I have read this application and state that the J� kLDpp Issuance Fee P/C# above information is correct. I agree to comply with all County Investigation Fee dinances and State laws relating to building construction, Total Fee 7.3 LDMA perm. q v a d hereby au rize representatives of this County to enter $ on the ab v -m ntioned property for inspection purposes. o SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date