HomeMy Public PortalAbout5532 PERSIMMON AVE_Building_1/5/1993_ADD MISC STUCCO WORK, CENTRAL AIR HEAT WORKERS' COMPENSATION DECLARATION
•�I hereby affirm that I have certificate of consent to self APPLICATION F R BUILDING PERMIT
insure, or a certificate of Workers' Compensation Insurance,
or a certified copy thereof(Sec. 3800, Lab. C.) ;� COUNTY OF LOS ANGELES BUILDING AND SAFETY
0� c316
Policy No.® 3Company6 - VV 1! e
BUILDING
`❑ Certified copy is hereby furnished. `�' FOR APPLICANT TO FILL IN __`` : ADDRESS
Certified copy is filed with the county building inspec- BUILDING DRIENSSG �Z Sd(�4�d,V
��tii�on���depaarttment.
Date 'TSL A licant CITY ClT� ZIP LOCALITY
PP s 0. OF BLDGS. NEAREST
CERTIFICATE OF EXEMPTION FR WORKERS' SIZE OF LOT 0� S MOW ON LOT B iy CROSS S7.
COMPENSATION INSU NCE ASSESSOR
(This section need not be completed if the permit is for one TRACT BLOCK LOT NO. MAP BOOK 5773 PAGE OC6 PARCEL Lt
®�
hundred dollars ($100)or less.) TEL.
;%USE ZONE MAP
NO. �0
I certify that in the performance of the work for which this J JZ � _S SPECIAL
permit is issued, I shall not employ any person in any manner ADDRESS J CONDITIONS a
so as to become subject to the Workers'Compensation Laws. „�� - OO
C17Y L E lT ZIP '
Date Applicant .ARCHITECT OR TEL. r DISTRICT GROUP TYPE FIRE PR CESSED BY W
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. 0 CONST ZQNE
Exemption, you should become subject to the Workers' S ~
Compensation provisions of the Labor Code, you must forth- ADDRESS I N
with comply with such provisions or this permit shall be r coTEL. Z� do 0� STATISTICAL CLASSIFICATION APT. CONDO. Z
deemed revoked. CONTRACTOR 11U� O 1
LICENSED CONTRACTORS DECLARATION r, LIC. CLASS NO. 2 DWELL. UNITS
ADDRESS �'I�1 C� L ` NO,-4e-Zq �
I hereby affirm that I am licensed under provisions of Chapter 9 LIC /� SEWER MAP
(commencing with Section y license
of Division 3 of the Business CITY ��p �,6lQj�1�� CLASS � 57(D VALIDATION
and Professions Code,andmy lic�en"se is in full force
�aA�jd effect. BK. PG.
CHE
License Number-310
Z�J Lic. Class "— SIZE ® ST6RIIEES FAMILLIIES ONEK
P VALUATION
Contractor Date — DESCRIPTION OF WORK S GL`T- NEW ❑ $ 36 6 o� —
❑1 am exempt under Sec.
e7 u GGO ADD ❑
ALTER ❑ ';,:
BAP.C. for this reason 1a k4ewr REPAIR ❑ $
Date: US F
IXISTING BLDG. n, EMOL ❑
Signature APPLICANT TEL,e. 'n
(PRINT) &QLJ 5 �0 NO. "$ .'60FINAL
6f) ' --J f
OWNER-BUILDER DECLARATION DATE lr/
I herebyaffirm that I am exempt from the Contractor's License _
Law fothe following reason(Section 7031.5, Business and ADDRESS �� w S�� FINAL3
Professions Code): PRESENT By ACCT.Q
❑ I, as owner of the property, or m employees with BUILDING
P P Y� Yt.ADDRESS 33D7 4 u o
wages as their sole compensation,will do the work and LOCALITY
75
the structure is not intended or offered for sale(Section 1
7044, Business and Professions Code.) " MOVING TEL. _
❑ I,as owner of the property,am exclusively contracting CONTRACTOR NO. ACCT.o4
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code.) 1 3-307 506.25
REQUIRED TOTAL SETBACK FROM EXIST.
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH 7 ITEMS
I TOTALhereby 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 CHECK 555.0[1
Lender's Name G� LAMA Ref. # CHANGE 00
a P.C. Fee$ Permit Fee Q
Lender's Address ����
I certifythat I have read this application and state that the Issuance Fee tMA P/C# _
3 above formation is correct. I agree to comply with all County Investigation Fee � 1 JclSc�
ordinances and State laws relating to building construction, Total Fee 4/1.1 LDMA Perm. # !• 435 I 0:33
AM1
= and hereby authorize representatives of this County to enter rJ ..
upon th 3-e-mention r pert o6 ins ction purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date