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HomeMy Public PortalAbout4955 PERSIMMON AVE_Building__ t 'WORKERS"CGMRENSArION DEGEARATION '■ , - I' ereby�affirm that I }rave a CQrtificatdoof conse#it to self _ -APPLICATION F®R WILDING P E RM I T insur;, or a certificate of Workers' Compensation Insurance, or a certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company ElCertified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRIESS 249ISS ❑ Certified copy is filed with the county building inspec- BUILDING ���S I O� tion department. ADDRESS J J CITY T C ZIP LOCALITY Date Applicant j f- t7 NO.OF BLDGS. NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT y 5 y � L � NOW ON LOT 3 `. CROSS ST. COMPENSATION INSURANCE (�qq �a ASSESSOR This section need not be completed if the permit is for one TRACT 9 V 2 BLOCK F LOT NO.(V5L34 MAP BOOK I PAGE PARCEL hundred dollars ($100)or less.) TEL 45 2900 USE ZONE EN � 7 -7 OWNER i Il Tarn J , Coy k Ih N� � -- Z. I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner ADDRESS 955 Pers 1 mrn on - a. S so as to become subject to the WoO Workers'Compensati n Laws. �. CJ 11 -7-80, CITY I C ZIP Date Applicant�� ARCHITECT OR TEL. NOTICE TO APPLICANT: If, after making this ertificate of ENGINEER L) wrier NO. DISTRICT GROUP ONSJ'_'J TYPE ZREE PRO`ESSE BY Exemption, you should become subject to the Workers' Sc�m e U Compensation provisions of the Labor Code, you must forth- ADDRESS N with comply with such provisions or this permit shall be TEL. <�STATISTICAL CLASSIFICATION APT. CONDO. Z deemed revoked. CONTRACTOR. OW�a Cr NO. /� ' _ LICENSED CONTRACTORS DECLARATION LIC. CLASS No.A ° NO. UNITS IS Z V- l_ • I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS LIC SEWER MAP (commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full force and effect. CITY CLASS BK PG VALIDATION License Number Lic. Class SIZE T LI E 144 TORIES FAMILIES ONE VALUATION VALUATION (0,0 / Q Contractor Date DESCRIPTION OF WORK /�A N VL Ann $ �) I O 415 6• v A El am exempt under Sec. A - a 2 $ R 2_9A Ann k, ❑ ® l I���0 1 BAP.C. for this reason USE OF 0 s 151 serN Sp- REPAI •t❑ $ � �D v Date: 71 EXISTING BLDG. -'RP-S DEMO Signature APPLICANT'�r TEL, q (PRINT)W) Ian t COAklW, NO. _Z��rj FINAL/ OWNER-BUILDER DECLARATION _ DATE// I hereby affirm that I am exempt from the Contractor's License /'//;; p ` Law for the following reason (Section 7031.5, Business and ADDRESS 44'1 J_.� 1 e1-51rkAVYi0 in FIA � e i' ti__. Professions Code): . PRESENT B ACCT.!■s ❑ I, as owner of the property, or m employees with BUILDING _t wages as their sole compensation,will do twork and ,ADDRESS 3307 7L 3.7 the structure is not intended or offered for sale(Section LOCALITY rotes 7044, Business and Professions Code.) MOVING TEL. ® 1 ITEiJ: ®. I,as owner of the property,am exclusively contracting CONTRACTOR NO. TOTAL _703. 75 with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code.) CHECK 1113 75:. REQUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WA PROP. r- I hereby affirm that there is a construction lending agency for FRONT ■L! the performance of the work for which this permit is issued P.L. (Sec. 3097, Civ. C.). SIDE P.L. � ' U1 1,r' 11910Lender's Name pL LDMA Ref:#i Lender's Address P.C. Fee$ �� Permit Fee ✓ 7924 1 AN 9:7, I certify that I have read this application and state that the Issuance Fee 1-3 LDMA P/C a pop above information is correct. I agree to comply with all County Investigation Fee ordinances and State laws relating to building construction, Total Fee LDMA Perm. N and her authorize representatives of this County to enter Npon ove-ment' ed (dperty or inspection purposes. q 7 �,/ SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Apblicant or Agent Date APPLICATION FOR BUILDING PERMIT � COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS 42 I hereby affirm that 1 have a certificate of consent to self Insure. Bd�Q 5S RES or a certificate of Workers'Compensation Insurance,or a Certified a r., (mm V� copy thereof(Sec.3800,Lab.C.) CITY Vtll �� , ZIP LOCALITY Policy NO. Company SIZE CIF Lair NO OF BLDGS.NOW O LO ❑ Certified copy is hereby furnished. �V ) 4e �q' %Or NEAREST CROSS ST. ❑ Certified copy is filed with the county building inspection TRACT BLO �pT ). USE ZONE MAP NO. department. ZC1©� /v `�pd« Date Applicant ASSESSOR MAPO K PAGPACEL 41Y 1SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER e O YES NO • COMPENSATION INSURANCE w ' iku J. Con 1'A i) WITHIN 100D FT.OF SCHOOL? ADDR (This section need not be completed if the permit is for one hundred 1 r S DISTRICT GROUP3 TYPE CONST.' FIRE ZONE OCESSE BY dollars($hat or less.) OK /j. fL I certify that in the performance of the work for which this permit CITY �' ZIP 0© K IS issued, I shall not employ any person In any manner so as t0 ARCHITECT OR ENGINEER TEL NO. Tf becomegubir to the Workers' Om�e On L �® STATISTICAL C IFICATION rr11 APT C O Date Applicant , ADDRESS CLASS NO. DWELL UNITS NOTICE TO APPLICANT. If, after makingIs Certificate of REQUIRED TOTAL SETBACK FROM EXIST Exemption, I CONTRACTOR TEL NO. p you should become subject to the Workers' SETBACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code,you must forthwith FRONT ADDRESS LIC.NO. comply with such provisions or this permit shall be deemed revoked. PL SIDE } LICENSED CONTRACTORS DECLARATION CITY LIC.CLASS PL C I hereby affirm that I am licensed under provisions of Chapter 9 SEWER MAP CD (commencing with Section 7000)of Division 3 of the Business and SQ.FT.SIZE NO.OF ORES I NO.OF FAMILIES Professions Code,and my license is In full force and effect. �.�� NEW ❑ BK PG Fe License Number Lic.Class DESCRIPTION OF RK ADD ❑ VALUATIONW p, Contractor Date O !b� NJ ALTER ❑ _� ❑ I am exempt under Sec. ��� ❑ B.BP.C.for this reason QZ��� REPAIR DEMOL Date: OF ING BLDG URM ❑ LDMA P/C N Signature APPLI ANT(PRI O. LDMA Perm Ne• Z ACCT.•� ❑ I,as owner of the property, or my employees with wages as �� �� O their sole compensation,will do the work and the structure is ADDRESS H 3-07 R not Intended or offered for sale (Section 7044, Business andAVAbFINAL DATE a Professions Code.) F'� ® 1 ITEMS WILLTHEAPPLICANT OR FUTURE BUILDING OCCUPANT HANDLEA HAZARDOUS MATERIAL ❑ I, as owner Of theproperty, OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN q am exclusively contracting with THE AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY TOTAL 438 _ A licensed contractors to construct the project (Section 7044, �] y 90k7 T3 — 38.130 Business and Professions Code.) YES❑ NO G� CHECK WILL THE INTENDED USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING OCCUPANTIPERMITCONSTRUCTION OKATION F SOUTH CONSTRUCTION LENDING AGENCY COASTAIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST CHANGE Ar u FOR GUIDELINES. I hereby affirm that there is a construction lending agency for YES❑ NO the performance of the work for which this permit Is Issued(Sec. 3097,CIV.C.). I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE ANGELES 00120-1,113131 v f 2/90 PERMITTING CHECKLIST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES IJtJ}�J Lendel'sName— /9/1� COUNTY CODE,TITLE 220 SECTIONS 2.20.1 OTHROUGH22MI4000NCERNIN6 7�: � ��1G�4� U IALSR NGAN iR OBTAI NG PERMIT FROM THE SCAQMD. '; -1 a Lender's Address ` [1 ER OR AGENT 0 1 certify that I have read this application and state that the above P.C.FEE PERMIT FEE /7 information is correct. I agree to comply with all county �! ordinances and State laws relating to building construction,and hereby authorize rep entatives of this County to enter Upon ISSUANCE FEE n t a n ntioned pert r r insp ction purpo s. . 00 © INVESTIGATION FEE TOTAL FEE ev dAppYmgaApmt / SEE REVERSE FOR EXPLANATORY LANGUAGE APPLICATION FOR BUILDING PEIRMI � r COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING yWRESS I hereby affirm that I have a certificate of consent to self Insure, BUILDING ADDRESS C or a certificate of Workers'Compensation Insurance,or a certified 55 � rYA 54 copy thereof(Sec.3800,Lab.C.) OITY�� f e C` ZIP LO `� Policy No. Company SIZE O L T 1 NO.OF DGS.NOW ON LOT Certified copy is hereby furnished. NEAREST CROSS ST. ❑ Certified copy is filed with the county building Inspection TR^ BLOCK NO.a 6- USE ZONE MAP NO. n department. ® 4 4.5 44 3- �� OC Date Applicant ASSESSOR MAP BOOK PAGE CEL 96 Ru B'l I R„ I SPECIAL CONDITIONS OWNER CERTIFICATECOMPENSATIONION FROM INSURANCEORKERS' ADDR William ° tl 8 4 ^2-90® WITHIN 1000 FT.OF SCHOOL? YES NO (This section need not be completed if the permit is for one hundred L Oc+le St.. �1 DISTRICT GROUP TYPE CONST.' FIRE ZONE OCESSE dollars($hat or less.) , 06 �y I certify that in the performance of the work for which this permit CITY ty° k I C A Z g 0®& �e !a/( P. Is Issued, I shall not employ any person in any manner so as to ARCHITECT OR ENGINEER TEL NO. v11 1W 1) become bj t�othe Workers'Cc en 'on Law t �1���� STATISTICAL CLASSIFICATION APT DO Date g� Applicant .o l ADDRESS CLASS NO. Q ELL UNITS NOTICE TO APPLICANT: If, after making th s Certificate of REQUIRED TOTAL SETBACK FROM EXIST Exemption, you should become subject to the Workers' CONTRACTOR TEL NO. SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code,you must forthwith ®uo n e— —b u Aar comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC.NO. FRONT PL LICENSED CONTRACTORS DECLARATION CITY LIC.CLASS PIL ,nhT n CL 1 hereby affirm that I am licensed under provisions of Chapter 9 SEWER M P _� (commencing with Section 7000)of Division 3 of the Business and SQ. SIZE NO.OF STORES NO.OF FAMILIES o NEW ❑ BK PG 3307 4 i5 0 4l•RO0 Professions Code,and my license is in full force and effect. _ F� 1/3 DESCRIPTION OF WORK ,. License Number Lic.Class AAJ I O ADD vaLtl ®� Poo' i ITEMS EMS a Contractor Date ALTER ❑ �0TOTAL - :15o40 ❑ I am exempt under Sec. ° y REPAIR ❑ $ CHECK 415 044'j B.SP.C.for this reason DEMOL ❑ LDMA P/C# CHANGE .00 Date: E OF EXISTING BLQG. t o URM ❑ It[1�tn�p J , �' Irk Signature APPLICANT(PRINT) TEL NO. ❑ roLDMA Perm# Z CID _C�Q1'I �� i� I,as owner of the property, or my employees wages as ADDRESS C F 9 74 1 AM 1 G 4-4h their sole compensation,will do the work and the structure is not Intended or offered for sale (Section 7044, Business and c FINAL/DATE Q a 1 Professions Code.) WILLTHEAPPLICANTOR FUTUREBUILDING OCCUPANT HANDLEA HAZARDOUS MATERIAL /�v�� " AC41 n ❑ I, as owner of theproperty, am exclusively contracting With OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN a n S Y 9 THE AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY�� ' tr licensed contractors to construct the project (Section 7044, YES El No K 35307 ..,1062 Business and Professions Code.) WILL THE INTENDED USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING ITEMS EJ OCCUPANT REOUIREA PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THESOUTH /� CONSTRUCTION LENDING AGENCY COAST AIINQUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLISTFOR TOTAL AL51336 o 22 I hereby affirm that there is a construction lending agency for YES 11 1M ti the performance of the Work for Which this permit Is Issued(Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD CHECK` Lr�n L 3097,Civ.C.). PERMITTING CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES CHANGE I]I] p� {� COUNTY CODE.TITLE2,CHAPTER 220 SECTIONS 220.100THROUGH 220.140 CONCERNING .013 Lender's Name W °'� RV�SRE TING ROBTA IN APERMIT FROM THE SCAQMD. a Lender's Address ORAGUJT r o aMM 0 1 certify that I have read this application and state that the above 0000 1 /23/90 Information is correct. I agree to Comply with all county P.C.FEE PERMIT FEE ordinances and State laws relating to building construction,and o � 4 A� ( a'12)� hereby authorize representatives of this County to enter upon ISSUANCE FEE Neabqv4e-ment IS party r inspection purpo3 2 �® INVESTIGATION FEE TOTAL FEE SEE REVERSE FOR EXPLANATORY LANGUAGE