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Home My Public Portal About5564 WELLAND AVE_Building__ WORKERS'COMPE14SATIIDN DECLARATION ` APPLICATION FOR BUILDING PERMIT I'hereb affirm ti,4t I have a certificate of consent to self insure,,ar•a certificate of Workers'Compensation Insurance, ccl or a cer(ified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY � r Policy No. Compon ey" ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING [V ADDRESS C5��T 6 ❑ Certified copy is filed with the county building inspec- BUILDING 556 lld (Type B) I� tion department. WeanAve yP aADDRESS ( Date �'.�/�C r7 Applicant CITY Tem le City ZIP 91780 LOCALITY CERTIFICATE OF EXEMPTION FR WORKERS' NO.OF BLDGS. NEAREST 1 COMPENSATION INS ANCE SIZE OF LOT82 X 300 NOW ON LOT CROSS ST. (This section need not be completed if the permit is for oneTRACT 10898 BLOCK A LOT NO. 27 ASSESSOR hundred dollars($100)or less.) :MAP BOOK PAGE PARCEL TEL. USE ZONE MAP I certify that in the performance of the work for which this OWNERH&S DevelO Ment I$].8 285-2 NO, /r�� —'2-7,? permit is issued, I shall not employ any person in any manner SPECIAL � so as to become subject to the Work ' ampensation Laws. ADDRESS 633 S. Sari Gabriel Blvd.. #207 CONDITIONS O �j. .q.F7 CITY San Gabriel ZIP 91776 09 Date Applicant ARCHITECT DISTRICT GROUP TYPE FIRE ESSED BY O NOTICE TO APPLICANT: If, after m ng this Certificate of ENGINEER 4'�e & Ch]11 Design t ib)960-198 CONST. ZONE S rD B A Exemption, you should become subject to the Workers' .�� Compensation provisions of the Labor Code, you must forth- ADDRESS 13523 FrancisquitO Ave.� Suite B —3 �� o o � with comply with such provisions or this permit shall be �` — TEL. �jy STATISTICAL CLASSIFICATION AOT. to deemed revoked. CONTRACTOR if 42 NO. 3077 a 0 LICENSED CONTRACTORS DECLARATION LIC �/� CLASS NO. 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, and my license is in full force and effect. CIT CLASS'F BK P PG [/5/ VALIDATION 0.OF 2 NO.OF 1 CHECK License Number 7 410-5 Lic.Class SIZE STORIE FAMILIES ONE e ' VALUATION n ' Contractor CAM- Date �� DESCRIPTION OF WORK NEW ® $ , '8Q 7 3 A F-11 am exempt under Sec. Detached Condo AD ER 1:1 k/��j/) , # 0 0 0 0 2 3 B.&P.C. for this reason USE OF REPAIR ❑ $ doe ° Date: EXISTING BLDG. Vacant DEMOL ❑ o 0 L Signature APPLICANT TEL. FINAL # 0 0 0 0 OWNER-BUILDER DECLARATION (PRINT) & u Design 6d8 960-1988 DAT , 0 6' 902 I hereby affirm that I am exempt from the Contractor's License 3523 FrariC1S ito AVe #B ° 4 9 Law for the following reason (Section 7031.5, Business and ADDRESS FIN _ Professions Code): PRESENT By / ° ° 4 4 9 4 5 v ❑ BUILDING I, as owner of the property, or my employees with ADDRESS 0 1.01 _8 6 wages as their sole compensation,will do the work and the structure is not intended or offered for sale(Section LOCALITY , as 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). 7 5 6 2 A REQUIRED TOTAL SETBACK FROM' X CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH # 0 0 0 0 0 1 1 hereby affirm that there is a construction lending agency for FRONT the performance of the work for which this permit is issued P.L. 15' t o 6 6 4 7 5 (Sec. 3097, Civ. C.). SIDE P.L. 10, 11' a a66075C Lender's Name jam.f LDMA Ref. # 0629-87 - Lender's Address P.C. Feel$ • yS Permit Fee r I certify that I have read this application and state that the T lO 3 • Issuance Fee �d'�v LDMA P/C# pool above information is correct. I agree to comply with all County Investigation Fee g / mj d ordinances and State laws relating to building construction, Total Fee GoA 0d an authorize representatives of this County to enter LDMA Perm.# pon th ab ve-mentioned property for inspection purposes. 9 a SEE REVERSE FOR EXPLANATORY LANGUAGE Si ature of Applicant or Agent Date 0 t ti. WORKERS'COMPENSATION DECLARATION ,A-sere o affirm that I have certificate of consent to self APPLICATION FOR BUILDING PERMIT ipsure, or a certificate of Workers'Compensation Insurance, or a certified copy thereof(Sec. 3800, Lob. C.) COUNTY OF LOS ANGELES BUILDING A SAFETY Policy No. S 7 Company_ 5:44/e ryIlp 4 0 . Ln�l Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING ADDRESS Certified copy is filed with the county building inspec- BUILDING r ` / tion department. ADDRESS J 0? o �/� �jlD, Date Z7 Applicant_ $frame //r( 4� CITY Ti-lo ell AY ZIP / l/ LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' A NO.OF BLDGS. NEAREST COMPENSATION INSURANCE SIZE OF LOT O Z NOW ON LOT CROSS ST. (This section need not be completed if the permit is for one TRACT ASSESSOR hundred dollars($100)or less.) D BLOCK LOT NO. MAP BOOK I PAGE I PARCEL r TEL. / USE ZONE MAP OWNER L� e�O Jl0Q/ _ NO. ��,Obi I certify that in the performance of the work for which this / ? �, rj{ NO. �. permit is issued, I shall not employ any person in any manner is�� jjLl/ ZOO SPECIAL ADDRESS ` d so as to become subject to the Workers'Compensation Laws. FrD' �j. CONDITIONS 00 Date Applicant CITY Ad-- /e ZIP 7. 09 NOTICE TO APPLICANT: If, offer making this Certificate of ARCHITECT OR '/ TEL. �! ,7 DISTRICT GROUP TYPE FIRE PROCESSED BY Exemption, you should become subject to the Workers',, ENGINEER r� C '� �'1_:. NO. e- < p CONST. ZONE Cle Compensation provisions of the Labor Code, you must forth- ADDRESS 23 �/P� 1j]r # �� r J•VU J with comply with such provisions or this permit shall be TEL STATISTICAL CLASSIFI TION APT. CONDO. Z deemed revoked. CONTRACTOR LICENSED CONTRACTORS DECLARATIONLIC, CLASS NO. y DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS �p - ,�/ 6IGj�NO. fta.3 L (commencing with Section 7000)of Division 3 of the Business and LIC SEWER MAP j Professions Code,and my license is in.full force and effect. CITY CLASS BK ,� PG t-f VALIDATION S .License Number 41911 03 y Lic.Class / SIZES I TORIES FAMILLIIES CO EK I �Cf��*yb Go'�f DESCRIPTI N OF WOK NEW E] VALUATION 4 J Contractor Date 3 z 9 ADD ❑ , ❑I am exempt under Sec. ❑ ALTER , B.BP.C. for this reason REPAIR ❑ $ Date: USE O SIE DEMOL EXBLDG. ❑ Signature APPLICANT C NO. ^2 FINAL ', OWNER-BUILDER DECLARATION PRINT DAT I hereby affirm that I am exempt from the Contractor's License (cF Law for the following reason (Section 7031.5, Business and ADDRESS �33 s-s/��,¢b,!;�t/ /�1ip 6,G r 20 FI Professions Code): WPREMSEMN"IiiiiiiiiiiiiiiiiRB -26750A ❑ BUILDING I, as owner of the property, or my employees with ADDRESS # 0 0 o a o wages as their sole compensation,will do the work and the structure is not intended or offered for sale(Section LOCALITY ' a 1 8 1, 1 3 7044, Business and Professions Code). MOVING TEL ❑ 1,as owner of the property,am exclusively contracting CONTRACTOR NO. 0 0 18 1. 135 with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). 3j,2 7—8 7 CONSTRUCTION LENDING AGENCY SETBACK YARD HWY TOTAL SETBACK LINEF 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 $ P.L. Lender's Name LDMA Ref. # Lender's Address P.C.Fee$ Permit Fee ' r I certify that I have read this application and state that the Issuance Fee , .� LDMA P/C# ( above information is correct. I agree to comply with all County Investigation Fee 3 3 ordinances and State laws relating to building construction, Total Fee LDMA Perm.# and hereby authorize representatives of this County to enter upona above-mentioned property r inspection purp ses. SEE REVERSE FOR EXPLANATORY LANGUAGE Si tura of Applicant or Agent D to O 1. WORKERS'COtAPENSATION DECLARATION hereby to certificate 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.) 0738247 CNC CONSTRIICTION COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company ' ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS BUILDING�-�� 11 ® Certified copy is filed wi he county bui g inspec- BUILDING �5 b� tilon department. (� ADDRESS Welland Ave. Date Loc �� Applicant v CITY Temple City. CA ZIP 91 LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. NEAREST SIZE OF LOT 300'X82' NOW ON LOT 6 CROSS ST. i�'L,�j COMPENSATION INSURANCE (This section need not be completed if the permit is for oneASSESSOR hundred dollars($100)or less.) TRACT 10898 BLOCK A LOT NO. 27 MAP BOOK PAGE PARCEL TEL. U ZONEMAP 1 certify that in the performance of the work for which this OWNER Albert Chen NO. — NO. permit is issued,I shall not employ any person in any manner ADDRESS 5311 N. T ler Ave. SPECIAL so as to become subject to the Workers'Compensation Laws. CONDITIONS O CITY Tem le City. CA ZIP 91U Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR EL. DISTRICT GROUP TYPE FIRE CESSED BY O ENGINEER Lee�Chiu Desi No.960-1988 CONSZONE T. U Exemption, you should become subject to the Workers' � Compensation provisions of the Labor Code, you must forth- ADDRESS 13523 Francis ito Lr l with comply with such provisions or this permit shall be IL deemed revoked. TEL. STATISTICAL CLASSIFICATION APT. CONDO. fn CONTRACTOR CNC CONSTRUCTION NO.575-1455 LICENSED CONTRACTORS DECLARATION LIC, CLASS NO. DWELL. UNITS — I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS 5311 N. Tyler Ave. NO. 477605 SEWER MAP (commencing with Section 7000)of Division 3 of the Business and LIC. Professions Code, and my license is in full force and effect. CITY Tem le City. CA CLASS BK PG VALIDATION TI—)LOS GinSFT. NO.OF CHECK License Number Lic.Class SIZE STOE STORIEIE S FAMILIES ONE (' Date VALUATION �� DESCRIPTION OF WORK Install enclosed NEW Contractor ❑ : �,`� ❑ ADD ® �✓ I am exempt under Sec. ❑ ALTER B.BP.C. for this reasonREPAIR ❑ $ USE OF ❑ Date: EXISTING BLDG. Resident Housing DEMOL Signature APPLICANT TEL. FINAL OWNER-BUILDER DECLARATION PRINT CNC CONSTRIICTION No57 — DATE I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and ADDRESS 5311 N. Tyler Ave. Tem le Citv FIpuld Professions Code): ❑ BUILDING l 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, ds owner of the property,am exclusively contracting CONTRACTOR NO. with licensed contractors to construct the project (Sec- ADDRESS ;2 8 6 7 tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY SETBACK YARD HWY TOTAPROP.L NE WIDTH # 0 0 0 o a 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. I o,o 8 7 3 8 (Sec. 3097, Civ. C.). SIDE o 0 0 87385 P.L. Lender's Name LDMA Ref. N 1 229-87 m P.C.Fee$ Permit Fee ,. Lender's Address I certify that I h�+r read this application and state that the Issuance Fee 51• 5 LDMA P/C p o bove info n is orrect. I agree to comply with all County Investigation Fee G 4 rdinances and Stat laws relating to building construction, Total Fee o LDMq perm. N R nd hereby out or a representatives of this County to enter upon the,abpv entioned property for inspection purposes. ^l yj m Y� SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date