HomeMy Public PortalAbout5532 PERSIMMON AVE_Building_7/1/1988_FIBERGLASS SHINGLE ROOF WORKERS'COMPENSATION DECLARATION
hereby affirm!.rfI have certificate of consent to self APPLICATION 1
inse, or a'°certificaicate of Workers' Compensation Insurance, FOR BUILDING PERMIT �J
or a certified copy thereof ( 3800, Lab. C.)
C37�/ GG S �� G ,��JJ COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company f/Pn
: BUILDING Certified copy is hereby furnished. FOR APPLICANT TO FILL IN '
El n
n `= ADDRESS oC
ElCertified copy is filed with the county building inspec- BUILDING
tion ^7
epartment. ADDRESS�_7 �
� •`✓
Date APPlica�vCITY �� CTIX ZIP 71 AV LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. NEAREST
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT ;CROSS ST.
(This section need not be completed if the permit is for one ASSESSOR
hundred dollars ($100)or less.) TRACT p BLOCK /�, �;LOT NO.
MAP BOOKTEL. PAGE PARCEL
I certify that in the performance of the work for which this OWNER1���b' � ���`rt/��,��Y/ NO/].� ]� USE 7QNE O
permit is issued, I shall not employ any person in any manner ADDRESS✓��� /�J� �� `wA AD (!1/7�) SPECIAL t
CONDITIONS
so as to become subject to the Workers'Compensation Laws. /� V.•
Date Applicant CITY T. r UJF C.) ZIP /7 O
NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL. DISTRI R UP I TYPE FIRE I PROCE BY O
ENGINEER NO. CONST. Z I'-'
Exemption, you should become subject to the Workers' (�
Compensation provisions of the Labor Code, you must forth- ADDRESS a
with comply with such provisions or this permit shall be �.� gTEL.? r STATISTICAL CLAS FIC TION APT. CON fA
deemed revoked. CONTRACTOR j„-L4(NOS 1G ,ii
LICENSED CONTRACTORS DECLARATION y— LIC. CLASS NO. V DWELL. UNITS
-
-7 hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS / L' NO/ ✓�
(commencing with Section 7000)of Division 3 of the Business and /��/� LIC p SEWER P
Professions Code, and my license is in full force and effect. CITY C-O/� IV CLASS BK S �v VALIDATION
J � SQ. FT. NO.OF NO.OF CHECK
License Number ——'�v Lic.Class SIZE I STORIES FAMILIES ONE '
yy77 VALUATION
C��++
Contractor Date
DESCRIPTION OF WORK � 1` NEW ❑
� { � �{( ADD ❑ .� $.2�
❑I am exempt under Sec. �6Y-5 A r ocaAS
_ ALTER ❑;t
I B.BP.C. for this reason REPAIR ❑ $
Date: USE OF DEMOL ❑ ;90069A
EXISTING BLDG.
Signature " APPLICANT TEL. FINAL
OWNER-BUILDER DECLARATION PRINT NO. DAT # 0 0 0;o o
I hereby affirm that I am exempt from the Contractor's License ADDRESS FIN o o59,25
Law for the following reason (Section 7031.5, Business and
Professions Code): PRE RE TB =
❑ BUILDING a a o 5 9.2 5 5
I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work andPoo-
1,
-88
the structure is not intended or offered for sale(Section LOCALITY 7'0
7044, Business and Professions Code). MOVING TEL.
❑ as owner of the property, am exclusively contracting I CONTRACTOR NO.
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY SETT BACK YARD HWY TOTAL SETBACK
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 r.
LDMA Ref. #
P.C.Fee$ Permit Fee S
Lender's Address
I certify that I have read this application and state that the Issuance Fee V' 1 LDMA P/C#
above information is correct. I agree to comply with all County Investigation Fee �J
ordinances and State laws relating to building construction, Total Fee ( 4 LDMA Perm.#
v a hereby author' a epresentatives of this County to enter
p th bov- ned property for inspection
purposes.
a r �/_ SEE REVERSE FOR EXPLANATORY LANGUAGE
m
Signature of Applicant or Agent Date