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HomeMy Public PortalAbout5609 WELLAND AVE_Building__ WORKERS'COMPENSATION DECLARATION reby affirm that. I havecertificate of consent to self u APPLICATION FOR BUILDING PERMIT � re, or a certificate of Workers'Compensation Insurance, r certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company � F-1Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING ADDRESS ('J ADDRESS c vlJ � L L Certified copy is filed with the county building inspec- FADDRESS / r �tion department..2 p IDate J � v 4_ Applicant i ZIP LOCALITY _CERTIFICATE OF EXEMPTI FROM WORKERS' NO.OF BLDGS. NEAREST /COMPENSATION INSURANCE NOW ON LOT CROSS ST. L 1 ✓2 OCL /(This section need not be completed if the permit is for onesASSESSOR hundred dollars($100)or less.) tem BLOCK LOT NO. O MAPBOOK PAGE PARCEL NO. USE ZONE MAP 1 certifythat in the performance of the work for which this >_ permit is issued, I shall not employ any person in any manner / SPECIAL D. so as to become subject to the Workers'Compensation Laws. �� CONDITIONS ItO Ge Applicant CITY ZIP 29 NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY EER NO. ENGIN Exemption, you should become subject to the Workers' _ CONST. ZONE U Compensation provisions of the Labor Code, you must forth- ADDRESS f. ye_Y'C1�' �j ajl 6 BM with comply with such provisions or this permit shall be _ H deemed revoked. TEL. STATISTICAL CLASSIFI TION APT. C O. CONTRACTOR NO. -j 066 LICENSED CONTRACTORS DECLARATION U LIC. CLASS NO. DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRES / CQ (commencing with Section 7000)of Division 3 of the Business and I LIC. g SEWER MAP Professions Code, and my license is in full force and effect. CITY a CLASS C'.3/ BK Vy VALIDATION .fl SQ. F7. NO,OF NO.OF CHECK License Number�/��L 7 Lic.Class C 3 SIZE STORIES I FAMILIES ONE VALUATION Contractor Date $" DESC PTION OF WORK NEW ❑ $ �/ ADD ❑ , I am exempt under Sec. C_�P ALTER ❑ c B.BP.C. for this reason REPAIR $ DatUSE OF e: DEMOL ��r�111 `ry �lV EXISTING BLDG. �� APPLICANT TEL. —�� Signature FINAL w` NER-BUILDER DECLARATION PRINT NO. DATE 4 °{ I hereby offirm at I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and ADDRESS FINAL Professions Code): PRESENT By V c n } ❑ BUILDING l"J 9 u o C' L t I, as owner of the property, or my employees.with ADDRESS wages as their sole compensation,will do the work and ✓'' '(�G' , — -_ the structure is not intended or offered for sale(Section LOCALITY -�' ' 1 y �` c e o 7044, Business and Professions Code). MOVING TEL. 1 ETI, 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 TOTAPROPAINEF FROM 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 i P.L. i Lender's Name ��t S LDMA Ref. # P.C. Fee$ Permit Fee b Lender's Address I certify that I have read this application and state that the Issuance Fee /of 7 ✓_ LDMA P/C# above information is correct. I agree to comply with all County i Investigation Fee ff L ordinances and State laws relating to building construction, Total Fee LJ/ 5 LDMA Perm. # i and hereby authorize representatives of this County to enter 7hae-mentioned property for inspection purposes. 1 � Frf, SEE REVERSE FOR EXPLANATORY LANGUAGE ignature of Applicant or Agent Date I pwssew oas-a a-@s � APPLICATION FOR BUI"LDING -P.ERMIT =� DIVISION OF BUILDING AND SAFETY ADDRESS -(C��.r� r 1104-IVAP V/C Depcmtnent of County Englneer County of LOS'Angeles LOCALITY •WM.J.FOX.COUNTY ENGINEER NEAREST CASSATT D.GRIFFIN,SUPT OF BUILDING CROSS ST. o A'Ir 1110111111021 DISTRICT NO. GROUP. I TYPE SEWER MAP yp0. 1 • FOR APPLICANT TO FILL IN coNST. F' BUILDINGNO"1.1 ' ADDRW ESS �?(`a JJ P. E� i tl A,0 A.-Y� '9'.C. •N MBER _d J `' STATE yES BLOCK USE ZONE SPECIAL LOT'NO. ry r/ CONDITIONS :i TRACT.. /n 'i- G „S•�7p - . NO.OF BLDGS. BUILDING EXIST. SIZE-OF LOT NOW ON LOT SETBACK YARD HWY STREET NAME WIDTH USEOP EXISTING BLDG._ t� FP TT OWNER 4 R It fil Y © V 1..•JS SIDE 1� P.L. MAIL /V ADDRESS 5''Ca II W�k L N N A A•Vf 9 p O TRACT DWELL. I UNIT 5 INDUSTRIAL TEL CITY T M 1�1� C lT Y NO.'h0 $-� 1 t DWELL.. I UNIT 6 PUBLIC BLDG. ARCHITECT OR TEL. 2 DUPLEX 1 UNIT 7 ADDN..ALT.. ETC. ENGINEER- NO. .3 APT. UNITS 8 MISCEL: ADDRESS _ 4. COMMERCIAL CONTRACTOR P\ TE INSPECrTIO�N. RECORD ADDRESS �,.�f� �trf of�C�P� —is DESCRIPTION OF WORg Cfl 'rfn v� / .�l�. Gui l NEW ADD ALTER REPAIR DEMOLISH. SO.IZ FT. � STORIES FAMILIES i SIZE /, USE USE OF STRUCTURE o N V Rr, ,L/ v/tJC. R4aM SIGNATURE OF fi APPLICAN .�t , , APPROVALS T y. ADDRESS��/I }� i YUI�-' frL aR S� i •r,-,j. DATE INSPECTORS SIGNATURE FOUNDATION:LOCATION V �q ^"r P.C. g FORMS,MATERIALS (I FEE FRAME:FIRE STOPS. BRACING.BOLTSVALUA FEE S!0 FURNACE:LOCATION. �/,/ �� GAS VENT.DUCTS 01"l� I �I�"✓'v'�'�v`` I HEREBY ACKNOWLEDGE'THAT I HAVE READ THIS APPLICgqTION AND STATE THAT THE ABOVE 1S CORRECT AND AGREE TO COMPLY.WITH ALL COUNTY ORDINANCES• LATH.INT. AND STATE LAWS REGULATING BUILDING CONSTRUC- TION. LATH.EXT. .'N f9 vl/l�iG' f/r/J�•� - SIGNATURE OF r� x <�"s ���fiE l�/ HOUSE NUMBER COR- r ` PERMEE-r '' I -'mss I °�" RECT AND POSTED- ITT a _ ADDRESS FINAL /mux WK J.FOX.COUNTY ENGINEER - - \5 VALIDATION C.N. DIRLAM,CHIEF BLDG. INSPECTOR f }J PGG�f11.-azk. x �l+✓' Gam' _ -, . !! f ` �°-f ',IC0 ecru 1 1 1 2:0 0 DEPARTMENT OF BUILDING AND SAFETY APPLICATION FOR PERMIT `COUNTY OF LOS ANGELES ( �[]� WM. :1. FOX, CHIEF ENGINEER FOR APPLICANT TO FILL IN FOR OFFICE USE ONLY BUILDING / DISTRICT NO. PLANCK. NO. - PERMIT NO. ADDRESS�� °/ _/r✓`.I AVAE LOCALITY ,•� RECEIVED BY DATE OF APPL. DATE ISSUED NEARE ST CROSS ST.. �'1�' t b fr ,if r A.-N,',1.0- A VF BUILDING y { ! '� ADDRESS OWNER EA V.4 r_S, MAIL LOCALITY r., ADDRESS_'- ,'/j •N, WAk..,L",vD AVE NEAREST —Fr-- p _ CROSS ST..:�'f, f ✓ �C' (,/Q / . CITY /' �� P j` c j r .. TEL �.n �G i v` FIRE NO. OF I TYPE I GROUP,,r ARCHITECT OR + TEL. ZONE .�^- PLANS�^ �f ENGINEER NO. BLDG. s ORD. NO. SETBACK LINE ! s ADDRESS APPROVED TEL.':" BY DATE CONTRACTOR r�'y,�/p{�' n .NO. USE APPROVED ZONE/4 ' BY DATE ADDRESS HOUSE NUMBERING LEGAL DESCRIPTION I LOT NO. f BLOCK MAP NUMBER FIELD CHECK BY TRACT Q NO. ASSIGNED 13Y--------.--'DAT- '71 Y /' 'DAT f. NO. OF BLDGS. CORRECTIONS SIZE OF LOT / r X :� I NOW ON LOT _ USE OF NO. OF EXISTING BLDG. ;.j (} I FAMILIES J 10 k`14 Js 0 �Q �� � N A d" — DESCRIPTION OF WORK Y5C W 6-t,%;,oS' 1 6 L-.r F'- 7'+.+►-, NEW I I ALTERATION I I ADDITION 1 I/ ! i '_ O REPAIR I [DEMOLITION SQ. FT. / NO. OF 'n SIZE �� d ' ROOMS STORIES EXT. WALL' ROOF >Y COVERING LJd I) f j/��I COVERING P, USE OF STRUCTURE � APPROVALS s INSPECTOR'S SIGNATURE DATE 1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS AP- FOUNDATION: LOCATION .PS LICATION AND STATE THAT THE INFORMATION GIVEN IS FORMS, MATERIALS 7•-rs-� /_/ ' CORRECT. I AGREE TO COMPLY WITH THE CORRECTIONS LISTED FRAME: FIRE STOPS, HEREON AND WITH ALL COUNTY ORDINANCES AND STATE BRACING, BOLTS LAWS REGULATING .BUILDING CONSTRUCTION. FURNACE: LOCATION, SIGNATURE OF GAS VENT, DUCTS PERMITTE -�� �!-• + +�• C LATH, INT. ADDRESS LATH, EXT. AUTHORIZED AGT. PLASTER, INT. 76AS88A•DDS8 10-80 $ h P. C. $ ® FEE "'"� PLASTER, EXT. ' VALUATION76" $' I� FEE '�'m'�� FINAL