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HomeMy Public PortalAbout5566 WELLAND AVE_Building__ WORKERS'COMPENSAT40N DECLARATION 1 her affirm.that I have certificate of consent to self APPLICATION FOR BUILDING PERMIT , insures or a certificate of Worr kers'Compensation Insurance, or a cer't��I lied_copy¢thereof(Sec. 3800, Lab. C:) COUNTY OF LOS ANGELES BUILDING AND SAFETY /�11 Policy No( � V 7 ompany __T� fzG/l•t� ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUADDRESSILDING IkAffmag ❑ Certified copy is filed with the county building inspec- BUILDING N�q / tion department. ADDRESS 5564 Welland Ave 03) Date 6'079.87 Applica CITY Temple City, CA zip 91780 LOCALITY VlA CERTIFICATE OF EXEMPT+FMRKERS' NO.OF BLDGS. NEARESTCOMPENSATIOSIZE OF LOT 82 i x 300 1 NOW ON LOT CROSS ST. (This section need not be completed if the permit is for one ASSESSOR hundred dollars($100)or less.) TRACT43590 BLOCK A LOT NO. 27 MAP BOOK PAGE PARCEL OWNER H&S Development (A'8)285-2906 USE NE MAP �`� I certify that in the performance of the work for which this NO. ~(J permit is issued, I shall not employ any person in any manner ADDRESS 633 S. San Gabriel Blvd.,, #207 SPECIAL !� so as to become subject to the Wo Compensation Laws. CONDITIONS O Dated-a9 97Al; CITY San Gabriel, CA zip 91776 pp NOTICE TO APPLICANT: If, after ng this Certificate of ENGINEERARCHITECTee ee & Chiu Design TE_L DISTR CT GR;P TYPE FIRE CONST ZONE PROCESSED BY Exemption, you should become subject to the Workers' NDS 8)960-198 J� 419 (// Compensation provisions of the Labor Code, you must forth- ADDRESS 13523 Francis uit0 Ave., #B Bald n Park ►/ 0. with comply with such provisions or this permit shall be TEL.. �7�[p STATISTICAL CLASSIFICATION APT. rNDO. us deemed revoked. CONTRACTOR �rlgT NO�7 /Ty /,��`��'1� LICENSED CONTRACTORS DECLARATION LIC, CLASS NO. 611) DWELL. UNITS -/— I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS—:?//2f NO. (commencing with Section 7000)of Division 3 of the Business and LIC SEWER MAP Professions Code, and my license is in full force and effect. CI CLASS BK.F PdL14 VI NO&$'A ���0 SQ.��TT NO.OF NO.OF CHECK 'z 3 License Number Lic.Class -3 SIZEl511 STORIES 2 FAMILIES 1 ONE © VALUATION 1 - 38690 a —�7 DESCRIPTION OF WORK NEW Contractor �� Date ADD ❑ $ 78.000.00 , 0 0 38690x: ❑I am exempt under Sec. Detached Condo ALTER ❑ 1223-86 B.&P.C. for this reason REPAIR ❑ $ Date: USE OF DEMOL EXISTING BLDG. ❑ Signature APPLICANT TE FINAL/ PRINT Lee & Chiu Design N�$18�960-19 , L OWNER-BUILDER DECLARATION DATE I hereby affirm that I am exempt from the Contractor's License 13523 Francis lt0 Ave., B Law for the following reason (Section 7031.5, Business and ADDRESS �• i FIN Professions Code): PRESENT BY ��• ❑ 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 j 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 REQUIRED YARD HWY TOTAL SETBACK FROM T. �7 3 5 9 A SET BACK PROP. LINE WIDTH I hereby affirm that there is a construction lending agency for FRONT # o 0 0 0 0 the performance of the work for which this permit is issued P.L. (Sec. 3097, Civ. C.). SIDE I - 660.75 $ P.L. Lender's Name '• LDMA Ref. # , �. \ b 6 6 0 7 5 L6 P.C.Fee$ Permit Fee •2✓�` ' Lender's Address / 0629-87 �fO L I certify that I have read this application and state that the 3r Issuance Fee 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 LDMA Perm. # and hereby authorize representatives of this County to enter upon th above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE (J ature of Applicant or Agent Date WORKERS'COMPENSATION DECLARATION 'i'hereby affirm that I have d certificate of consent to self APPLICATION FOR BUILDING PERMIT � insure, or certificate of Workers'Compensation Insurance, or a certified copy thereof(Sec. 3800, Lob. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy Nol��87.3 Company_ 6n6il-LY Fil&/P r_1 Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESSBUILDING -,6 Certified copy is filed with the county building inspec- FADDRESS ct tion department {erL zip .Date AP7 Applicant Cp CITY CITY LOCALITY CERTIFI ATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. NEAREST COMPENSATION INSURANCE SIZE OF LOT 062,' O D NOW ON LOT CROSS ST. (This section need not be completed if the permit is for one �3 S Q BLOCK LOT NO. 2 ASSESSOR .hundred dollars($100)or less.) TRACT MAP BOOK PAGE PARCEL TEL' USE ZONE L I certify that in the performance of the work for which this OWNER '♦t.S P Q NO. a -2 permit is issued, I shall not employ any person in any manner ADDRESS C33 V G ' 2N � �so as to become subject to the Workers'Compensation Laws. h. ONS 0 CITY ,j AA/ ZIP(p ' Id Date Applicant ARCHITECT OR TEL. 8 NOTICE TO APPLICANT: If, after making this Certificate of DISTRICTIlk GRAOUP TYPE FIRE P OCESSED BY Exemption, you should become subject to the Workers' ENGINEER �' X10. CONSIT/ ZONE Compensation provisions of the Labor Code, you must forth- ADDRESS ��� A Gi :a +`v V 3 with comply with such provisions or this permit shall be ty deemed revoked. LL TEL•8f STATISTICAL CLASSIffIC/}PION APT. CONDO. g CONTRACTOR (j,lrsT NO. Z -2 () (J U LICENSED CONTRACTORS DECLARATIONLIC, Q CLASS NO. DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS S f, SA4/ '.p NO. O,JyyER MAP (commencing with Section 7000)of Division 3 of the Business and LIC. Professions Code,and 3 my licensee is in full force and effect. CITY S�A- A ' CLASS BK �PG VALIDATION HECK License Number 1V ?oy Lic.Class SIE J t STORIES FAMILILIES CONE NEW ❑ VALUATION Contractor K-WAd&fD CbbS6Date Z DESCRIPTION OF WORK ADD ❑ $ ❑I am exempt under Sec. ❑ , ALTER B.BP.C. for this reason REPAIR ❑ $ Date: USE OF V EXISTING BLDG. DEMOL ❑ Signature APPLICANT TEL. FINAL /�� OWNER-BUILDER DECLARATION PRINT or NO.z S-- DAT ill I hereby affirm that I am exempt from the Contractor's License ADDRESS �D 3 s. S4v �¢Fj ;P BLrr p��7 Law for the following reason (Section 7031.5, Business and FI Professions Code): PRESENT ❑ I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and ' ;96751 A the structure is not Intended or offered for sale(Section LOCALITY , 7044, Business and Professions Code). MOVING TEL. # 0 0 0 0 0 1 ❑ I,as owner of the property,am exclusively contracting CONTRACTOR NO. with licensed contractors to construct the project (Sec- 0 1 8 1. 1 3 tion 7044, Business and Professions Code). ADDRESS , CONSTRUCTION LENDING AGENCY SETT BACK YARD HWY TOTAPROP.LNECK FROM WIDTH o 0 1 8I'll 3 -61 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. 0 2 7-8 7 (Sec. 3097, Civ. C.). SIDE g 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 l� D 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 LDMA Perm.# J and hereby authorize representatives of this County to enter 9 upon th ove-mentioned propert f r inspection purposes. r27 SEE REVERSE FOR EXPLANATORY LANGUAGE D ign ure of Applicant ar Agent Date OO I WORKERS'COMPENSATION DECLARATION Ihereby 6ffir�n that I have certificate of consent to self insure, or o certificate of Workers'Compensation Insurance, APPLICATION F®R BUILDING PERMIT or a certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No, 0,738247 Company CNC CONSTRUCTION 1:1Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING/� ADDRESS a Certified copy is filed with the county building inspec- BUILDING $ tion department. ADDRESS Welland Ave. Date Q— Applicant tl CITY Temple Cit CA zip 91780 LocALIT CERTIFICATE OF EXEMPTION FROM WORKERS' OF LOT NO.OF BLDGS. NEAREST SIZE COMPENSATION INSURANCE 300■X82 NOW ON LOT CROSS ST. (This section need not be completed if the permit is for oneTRACE 10898 BLOCK A LOT NO. 2'] ASSESSOR hundred dollars($100)or less.) MAP BOOK PAGE PARCEL TEL. ONE MAP OWNER Albert Chen NO.575-1455 —2 I certify that in the performance of the work for which this NO. l permit is issued, I shall not employ any person in any manner ADDRESS SPECIAL so as to become subject to the Workers'Compensation Laws. CONDITIONS Date Applicant CITY Temple City, CA ZIP 91780. C ARCHITECT OR �_ TEL. NOTICE TO APPLICANT: If, after making this Certificate of DISTRICT GROUP TYPE FIRE PRO SED BY p Exemption, you should become subject to the Workers' ENGINEER LeeatChi u ;Desi f NO.960-1988 ^ CONST. ZONE Compensation provisions of the Labor Code, you must forth- ADDRESS 13523 Francis ito R W with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION APT. CONDO. N deemed revoked. 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 NO. 47760 (commencing with Section 7000)of Division 3 of the Business and LIC SEWER MAP Professions Code and my licenseisin full force and effect. CITY Tem le Clty, CA CLASS BK PG VALIDATION CK License Number 1A Lic.Class �SlJrl SIZE TORIES FAMILOIES CONE VALUATION Contractor 0-0-C " Date � � DESCRIPTION OF WORK Install enclosed NEW ❑ $ S;6 I am exempt under Sec. vatio to existing dwelling ADD ® [_] oil,ALTER B.BP.C. for this reason REPAIR ❑ $ Date: USE OF -��- DEMO" EXISTING BLDG. Resident.l[oUS]II ❑ Signature APPLICANT TEL. FINAL © OWNER-BUILDER DECLARATION PRINT CNC CONSTRUCTION NO. 575-1455 DATE I hereby affirm that I am exempt from the Contractor's License ADDRESS 5311 N. Low for the following reason (Section 7031.5, Business and ler Ave. Tem le i FINAL W Professions Code): MPRENTEREEREERES BY BUILDING El 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 $6 7 8 tion 7044, Business and Professions Code). REQUIRED TOTAL SETBACK0 0 0 0,0 1 CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP.LINE WIDTH I hereby affirm that there is a construction lending agency for FRONT ( 0 - 87,38 8'] 3 the performance of the work for which this permit is issued P.L. (Sec. 3097, Civ. C.). SSIDE 8,�3$U 0 o o = Lender's Name / LDMA Ref. p 1 229-87 S Lender's Address P.C.Fee$ Permit Fee I certifythat I have read this application and state that the pP Issuance Fee U � LDMA P/C tf Ldh mation is orrect. I agree to comply with all County Investigation Fee �] and St a laws relating to building construction, Total Fee / IDMA perm.N author representatives of this County to enter �O m loned property for inspection purposes. o l — SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date