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Home My Public Portal About5572 WELLAND AVE_Building__ WORKERS'COMPENSATION DECLARATION • t APPLICATION FOR BUILDING PERMIT cU • •I`hek. affirm that I'have a certificate of consent to self • insurPr,,.or a certificate of„Workers'Compensation Insurance, or'a certified copy thereof(Sec. 3800, Lob. C.) COUNTY OF LOS ANGELES BUILDING AN SAFETY Policy No. Compomr�-t LC./ify�. ❑ BUILDING Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS ❑ Certified copy is filed with the county building inspec- BUILDING tion department. ADDRESS 5 2 Welland ve $ #U .4-IL �� /A 14M Date Applic CITY ZIP LOCALITY i CERTIFICATE OF EXEMPTIO F M WORKERS' NO.OF BLDGS. NEAREST COMPENSATION I RANCE SIZE OF LOT 82 r x3 t NOW ON LOT CROSS ST. /� iP/ *J (This section need not be completed if the permit is for one ASSESSOR hundred dollars($100)or less.) TRACT 43590 BLOCK A LOT NO. 27 MAP BOOK PAGE PARCEL EL. OWNERDevelopment 8 285-290 USE MAP 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 ADDRESS 33 S. San Gabriel Blvd, #207 SPECIAL so as to become subject to the r s'Compensation Laws. CONDITIONS 8 Date b a9 F7 A CITY an Gabriel CA zip 91776 29 ARCHITECT OR TE. 0 NOTICE TO APPLICANT: If, afte Ing this Certificate of ENGINEER e & Chiu Desi n N%818)960-19 DISTRICT GR P TYPE FIRE P ESSED BY Exemption, you should becom subject to the Workers' /�`(� CON . NE Compensatin provisions of the Labor Code, you must forth- ADDRESS 13523 Francis ito, #B Baldwin P . !T rIL with comply with such provisions or this permit shall be IN n` deemed revoked. 1.k� TEL P*7 STATISTICAL CLASS IFIC/yTION 1 APT. 1$5NDO. CONTRACTOR N /V9 LICENSED CONTRACTORS DECLARATION 3 LIC..e/77 CLASS NO. V DWELL. UNITS—L– I NITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS �� C 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. CLASS VALIDATION S . BK. F PGHECK . License Number 'i1771,1 S Lic.Class !3 SIZEFT 1511 STORIIEES 2 FAMILOIES 1 CONE -ep 6 1 6 1 A /� / /7 /a �/ NEW ® VALUATION # 2 3 Contractory�/[i Date K� �a DESCRIPTION OF WORK o 0 0 0 ❑ I am exempt under Sec. Detached Condo ❑ADD $ 78 000.00 , 1 - 38690 . ALTER ❑ B.BP.C. for this reason REPAIR ❑ $ ° ° 3 8 6 9 0 3 Date: USE OF DEMOL ❑ 1 `L'2 3-8 6 EXISTING BLDG. Signature APPLICANTFINAL OWNER-BUILDER DECLARATION PRINT n U18)960_198 960-198 DATE I hereby affirm that I am exempt from the Contractor's License 13523 Francisquito Av.,#B Bal1�iT]4_ 731,, Law for the following reason (Section 7031.5, Business and ADDRESS U FIN Professions Code): PRESENT BY A ,2 ❑ 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 SETT BACK YARD HWY TOTAPREOTPACNEFR M WIDTH 9 7 3 63 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. #,! 0 0 0 0 0 1 (Sec. 3097, Civ. C.). SIDE P.L. 1 - 660.75 Lender's Name LDMA Ref. # o o660.7530: Q Lender's Address P.C. Fee$ 3(J V Permit Fee loop0629-87 I certify that I have read this application and state that the Issuance Fee LDMA P/C# W above information is correct. I agree to comply with all County Investigation Fee / �+ g ordinances and State laws relating to building construction, Total Fee & 0 "� LDMA Perm. # u and hereby authorize representatives of this County to enter upon above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE azure of Applicant or Agent Date WORKERS'COMPENSATION DECLARATION '•I.hereby affirm that I have certificate of consent to self APPLICATION FOR BUILDING PERMIT insure, or 6 certificate of Workers'Compensation Insurance, or a certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND AFETY P❑olicyNo.7�Company S f�L7er A11VD Alt A Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING ❑ ADDRESS Certified copy is filed with the county building mspec- BUILDING tion department. ADDRESS �(/ Z �1 Date 3 Applicant l% CITY re Iyp to (/ ZIP LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. NEAREST COMPENSATION INSURANCE SIZE OF LOT L K 3QD NOW ON LOT CROSS ST. (This section need not be completed if the permit is for one1-13-5111 ' ASSESSOR hundred dollars($100)or less.) TRACT 1- -5p D BLOCK LOT NO. 2-7 MAP BOOK PAGE PARCEL L' USE NE MAP I certify that in the performance of the work for which this OWNER N� �P//Q�O .r9 NO. —2 NO -� permit is issued,I shall not employ any person in any manner SPECIAL so as to become subject to the Workers'Compensation Laws. ADDRESS A �� rr' �Lv 2 CONDITIONS O Date Applicant CITY .SA, - �� ZIP l09 9 NOTICE TO APPLICANT: If, after makingthis Certificate of ARCHITECT OR �/ �/ , TEL. �j DISTRICT G UP TYPE FIRE PR CESSED BY ENGINEER Zee 9- Cl- f'& � O. IF Exemption, you should become subject to the Workers' , �� CONST. ZONE Compensation provisions of the Labor Code, you must forth- r r ADDRESS Z /� a/ b �.. with comply with such provisions or this permit shall be TEL. / STATISTICAL CLASSIFICATION APT. NDO. 'T deemed revoked. CONTRACTOR ,a1�L.�N e NO. 2 2 0 LICENSED CONTRACTORS DECLARATION LIC, CLASS NO. DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS 05 3 NO. 6 .4 (commencing with Section 7000)of Division 3 of the Business andLISEWER MAP SAA,-Professions Code, and my license is in full force and effect. CITY A � e CLAC.SS / VALIDATION ([ n SQ. FT. NO.OF NO.OF CHECK BK. PG. License Number (fgpo 36 Lic.Class_-1 l SIZE 1� STORIES FAMILIES ONE 'Q,_LKE O Cq_ti_�Date 21-2 7 ❑ VALUATION DESCRIPTION OF ORK NEW Contractor_ r $ /p ADD ❑ , ❑I am exempt under Sec. (/ ❑ ALTER B.BP.C. for this reason REPAIR ❑ $ Date: USE OF DEMOL EXISTING BLD ❑ Signature APPLICANT 1 TEL. 7 FINAL OWNER-BUILDER DECLARATION PRINT yf L,f d,(i NO. — DAT I hereby affirm that I am exempt from the Contractor's License s 5 / �LY s G �i2O Law for the following reason (Section 7031.5, Business and ADDRESS �A �RbR�,r ' F ;26755A Professions Code): PR ENT ❑ BUILDING I, as owner of the property, or my employees with ADDRESS # 0 0 0 o a 1 wages as their sale compensation,will do the work and the structure is not intended or offered for sale(Section LOCALITY ' (. ° 1 8.1. 1J 7044, Business and Professions Code). MOVING TEL. 11- CONTRACTOR NO. LJ I, as owner of the property,am exclusively contracting ° ° 181. 136 with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). 3.27"87 CONSTRUCTION LENDING AGENCY REQUIRED YARD HWY TOTAL SETBACK FRO I O 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 P.L. Lender's Name LDMA Ref.# P.C. Fee$ Permit Fee - Lender's Address ' 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 ordinances and State laws relating to building construction, Total Fee / 1 13LDMA Perm. # and hereby authorize representatives of this County to enter 2� upon a bove entio d properNjor inspection purposes. �� SEE REVERSE FOR EXPLANATORY LANGUAGE nature of Applicant or Agent ate 0 WORKERS'COMPENSATION DECLARATION I IPj insureborrafcertifcarteofWokes' CompensafoI have a certificate of neInsuranent to lf APPLICATION FOR BUILDING PERMIT or a certified copy thereof (Sec. 3800, Lab. C.) Policy No. 0738247 Company CNC CONSTRUCTION COUNTY OF LOS ANGELES BUILDING AND SAFETY 1:1Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING S 7 1 ADDRESS ® Certified copy is filed wi county bui • g inspec- BUILDING tion department. a ADDRESS 2 Welland Ave. , Date - Applican CITY ZIP 91780 LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' No.OF SIZE OF LOT 300'x82' Now ON ioTS. 6 C NEAREST COMPENSATION , COMPENSATION INSURANCE (This section need not be completed if the permit is for one TRACT 10898 BLOCK A LOT NO. 27 ASSESSOR hundred dollars ($100)or less.) MAP BOOK PAGE PARCEL ' TEL. U E MAP I certify that in the performanc f the work for which this OWNER Albert Chen NO. 575-1455 NO. — Z 7-2 permit is issued, I shall not empI y ny person in manner ADDRESS 5311 N. Tyler Ave. 3 SPECIAL so as to become subject to the or ers'Com a ti n Laws. CONDITIONS O CITY Temple City, CA ZIP 91780 V Dot ppl icant Im NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE P OCESSED BY O ENGINEER Lee&Chiu DesigM NO. 960-1 CONST. ZONE U Exemption, you should become subject to the Workers' 0 V (//��_ Compensation provisions of the Labor Code, you must forth- ADDRESS 13523 Francis ito S U_6 V� -3 --*t--/,-�� W with comply with such provisions or this permit shall be ' LL deemed revoked. TEL. STATISTICAL CLAS IFI/TION APT. CONDO. to CONTRACTOR CNC CONSTRIICTION NO.575-1455 z 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 (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. CITY TemleCLASS BK PG VALIDATION �_/� SQ.FT. NO.OF NO.OF CHECK License Number L1 � Lic.Class � SIZE STORIES FAMILIES ONE AL ContractorCyI�� Date U� DESCRIPTION OF WORK Install enclosed ADD NEW E] VALUATION ® ,❑I am exempt under Sec. ALTER ❑ B.&P.C. for this reason REPAIR ❑ $ Date: USE OF DEMOL ❑ EXISTING BLDG. Resident Housing F Signature APPLICANT TEL. FINAL OWNER-BUILDER DECLARATION PRINT CNC CONSTRUCTION NO.575-1455 DATE / J I hereby affirm that I am exempt from the Contractor's License nn Law for the following reason (Section 7031.5, Business and ADDRESS FINAL `V 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 IF OCALITY 7044, Business and Professions Code). MOVING TEL. ❑ CONTRACTOR NO. # 4 C3 1,as owner of the property,am exclusively contracting i, v with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). REQUIRED TOTAL SETBACK F EEE CONSTRUCTION LENDING AGENCY SET BACK YARD HWY 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 Lender's Name /- LDMA Ref. q X1'7 3,k k m .C.Fee$ Permit Fee (� d� ' (((/// Lender's Address I certify that I have read this application and state that the Issuance Fee �• U EA P/C# y Q above information is correct. I agree to comply with all County nvestigation Fee �/ oZes and S laws relating to building construction, Total Fee 7�u LDMA Perm.# N by outho ize epresentatives of this County to enter ab ve-m nt' ned property for inspection purposes. i m � a I�-� - SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Ap licant or Agent Date