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Home My Public Portal About4922 PERSIMMON AVE_Building__ ENT OF BUILDING AND DEPART COUNTY OF LOS ANGE ESAFETY BUILDING UIL ® 1NG WM. J. FOX, CHIEF ENGINEER APPLICATION FOR APPLICANT TO FILL IN FOR OFFICE USE ONLY DISTRICT NO. PLAN CK. OR REC.NO. PERMIT O. BUILDING ��/es'�ll;ty®/� `-� �� ADDRESS -t7�-�,Z 2 :%� �D LOCALITY rf/yJ�D�( �' C1 T "y/ E BY DATE F APPL. DATE ISSUED - NEAREST C ��v-D BUILDING CROSS ST. {,,,. lT'/.0 ADDRESS i 1► �I/�.S/ OWNER ,'�BG•"�"'T MAIL QQ (� LOCALITY - ADDRESS 7Z?, 'I V o. �I�/�f,�,T NEAREST — '\ ' TEL CROSS ST. N CITY ,1-�r ��.'�/.� NO. FIRE NO. OF TY5ZP ZONE PLANS ARCHITECT OR TEL. ENGINEER NO. BLDG. SETBACK LINE (� [j ADDRESS USE APPROVED TEL ZONE BY DATE CONTRACTOR NO. HOUSE NUMBERING ADDRESS 1 MAP NUMBER IV 3 NO. ASSIGNED BY LEGAL � CORRECTIONS _DESCRIPTION LOT NO. BLOCK TRACT NO. OF BLDGS. ?d� 'y�� SIZE OF LOT ,.S„�r`X/3� I NOW ON LOT USE OFI NO. OF EXISTIN BLDG. FAMILIES DESCRIPTION OF WORK 00 NEW ALTERATION ADDITION Z D REPAIR DEMOLITION f' Sq. FT. NO. OF SIZE 7/p Q ROOMS STORIES EXT.WALL r ROOF .'I � " COVERING ,JT(,i�G.O C0VERING .4., USE OF STRUCTURE , ,'o L•- U1��"� X41 �..0/O.�Nt: INSPECTION FOR APPROVALS OCCUPANCY AS INSPECTOR'S SIGNATURE DATE FOUNDATION: LOCATION FORMS, MATERIALS ,�,. { f Z_ I hIEREBY ACKNOWLEDGE THAT I HAVE READ THIS AP- PLICATION AND STATE THAT THE INFORMATION GIVEN IS FRAME: FIRE STOPS, CORRECT. BRACING, BOLTS IAGREE TD COMPLY WITH ALL COUNTY ORDINANCES FURNACE: LOCATION, i �) AND STATE LAWS REGULATING BUILDING CONSTRUCTION. GAS VENT, DUCTS SIGNATURE OFv / � !,✓t,,^/y LATH, INT. PERMITTEE i ADDRESS _ �yZ��.�, J U. ��'�.��r LATH, EXT. T� PLASTER, INT. f OiJ AUTHORIZED AGT. PLASTER, EXT. / S FEE' HOUSE NUMBER COR- ' RECT AND POSTED VALUATION s FEE 2-3a FINAL >ti 76A636A DBS 3 7-51 WORKERS' COMPENSATION DECLARATION —I hereby affirm that I have insure, or a certificate of Workers' certificate of consent to self kers' Compensation Insurance, APPLICATION FOR BUILDING PERMIT or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company -522&:z Certified copy is hereby furnished. �-yr FOR APPLICANT TO FILL IN ADDRESS Certified copy is filed with the county building inspec- BUILDING tion"department. ADDRESS ��y -I�- � CITY �L C B . LOCALITY Date Applicant � NO. OF BLDGS. NEAREST ERTIFICATE OF EXEM N FROM WORKERS' SIZE OF LOT NOW ON LOT CROSS ST. COMPENSA N INSURANCE ASSESSOR (This section need not be completed if the permit is for one TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL hundred dollars ($100)or less.) TEL' D USE ZONE MAP OWNER NO. NO. I certify that in the performance of the work for which this SPECIAL >- permit is issued, I shall not employ any person in any manner ADDRESS CONDITIONS a so as to become subject to the Workers'Compensation Laws. O ' CITY ZIP U Date Applicant ARCHITECT OR TEL. tY NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO DISTRICT GROUP TYPE FIRE PROCESSED BY Exemption, you should become subject to the Workers' /�� CONST. ZONE Compensation provisions of the Labor Code, you must forth- ADDRESS ems'] 3 a with comply with such provisions or this permit shall beTEO.L. deemed revoked. CONTRACTOR LOC— NSTATISTICAL CLASSIFICATION APT. CONDO. Z — � _ LICENSED CONTRACTORS DECLARATION LIC. CLASS NO.agl� U.. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. 41P,I cKe (commencing with Section 7000)of Division 3 of the Business LIC. 1 SEWER MAP and Professions Code,and my license is in full force and effect. CITY L�—�' CLASS BK VALIDATION 4t/4 l SQ. FT. NO. OF NO. OF CHECK License Number ��l� Lic. Class / SIZE STORIES FAMILIES ONE G DESCRIPTION OF WORK NEW ❑ VALUATION Contractor b Date ❑ $ � a ❑1 am exempt under Sec. ADD ALTER ❑ B.&P.C. for this reason REPAIR ❑ $ Dote: USE OF y)y EXISTING BLDG. DEMOL ❑ Signature APPLICANT TEL. !� FINAL NER-BUILDER DECLA "TION (PRINT) NO. l�.✓�'�,.y/ I hereby m that I am exempt from the Contractor's License DATE G Law for a following reason (Section 7031.5, Business and ADD FINAL Professions Code): P ENT By El1, as owner of the property, or my employees with "A DRE55 F • t1! �--9i:t•i °= wages as their sole compensation,will do the work and the structure is not intended or offered for sale(Section LOCALITY ® L.�i`;` 71 ° 7044, Business and Professions Code.) MOVING TEL. T - ❑ I,as owner of the property,am exclusively contracting CONTRACTOR NO. i 1 E�5 with licensed contractors to construct the project (Sec- i I =# '��"' o ,_3 tion 7044; Business and Professions Code.) ADDRESS i•. H_ .� REQUIRED TOTAL SETBACK FROM EXIST. ;Ljt;;, '•I 7` CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH I hereby affirm that there is a construction lending agency for FRONT1=ti�it 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. q zl'•I(J (-rILE�I _ P.C. Fee$ Permit Fee � e Lender's Address +).=1 1 )a °tel I certify that I have read this application and state that the Issuance Fee �� LDMA P/C N 2 above information is correct. I agree to comply with all County Investigation Fee p` ordinances and State laws relating to building construction, Total Fee •�O LDMA Perm. #i and hereby authorize representatives of this County to enter upo he ab -me 'o d property for inspectlo purp ses. o y 7 SEE REVERSE FOR EXPLANATORY LANGUAGE igna u e of Applicant or Agent ate