HomeMy Public PortalAbout5313 PERSIMMON AVE_Building__ WORKERS'COMPENSATION DECLARATION
hereby affirm that I have certificate of Consent to self kPPLICATI%jim F � B U I L®I N�G p E ISM I T
insure, or a certificate of Workers'Compensation Insurance, �
or a certified copy thereof (Sec. 3800, Lab. C.) " " 1
Policy No. Company COUNTY OF LOS ANGELES BUILDING AND SAFETY `
Certified-copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING •_
ADDRESS
❑ Certified copy is filed with the county building inspec- IBUILDING r�•� y/ �+ �) /
tion department. DDRESS ''� &l3 E'Igsllvmo � A ver
Date - Applicant ITY P�(, -il ZIP CC./ LOCALITYCERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. NEAREST
COMPENSATION•INSURANCE IZE OF LOTQ:x4� NOW ON LOT CROSS ST.
(This section need not be completed if the permit-is for one ASSESSOR
LOT NO. MAP BOOK - PA
hundred dollars($100)or less.) TRACT BLOCK GE PARCEL
TEL. j , USE ZONE MAP
I certify that in the performance f the k for w is this OWNER R (��. NO.� 77 NO.
permit is issued, I'.shall not empl y any pe n in an nnerSPECIAL 4'
so'as to become subject to the orkers,' pens 1 'Law ADDRE fMA1642 CONDITIONS
Date' 2� Applicant CITY tetApLc I l ZIP
d7PQ
NOTICE TO APPLICANT: If, after ng'this } rtificate i ARCHITECT OR TEL. DISTRICTJ. ,GROUP TYPE FIRE PROCESSED BY
Exemption, you should becom s ject to •the Worke s' ENGINEER NO. CONST. Z NE
Compensation provisions of the abor Code, you must forth- ADDRESS y
with comply with such provisions or this permit shall be TEL. STATISTICAL C SI TION PT.' I'COR-DO.-.
deemed revoked. CONTRACTOR NO.
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. . DWELL. UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. SEWER MAP
(commencing with Section 7000)of Division 3 of the Business and LIC.
Professions Code, and'my license is in full force and effect. CITY CLASS BK PG. VALIDATION
SQ. IT. NO.OF y NO.-OF CHECK
License Number Lic.Cldss ' SIZE STORIES / FAMILIES ONE "',
�7�"{��/ UATI O
Contractor Date DESCRIPTION OF WORK � �—' r t.Yf ADD ❑ $
❑ I am exempt under Sec.
ALTER
B.BP.C. for this reason 70 6-.q &/ REPAIR $
Date: USE OF
EXISTING BLDG. k C DEMOL ❑. I t
Signature APPLICANTp TEL. FINA
OWNER-BUILDER DECLARATION
(PRINT) G/Z A% rj.`VO. q.3 �(jot'
I am exempt from the Contractor's License /►
Law for the following reason (Section 7031.5, Business and ADDRESS $' ►'
�G'�'thI tot) Av 7r FOAL J /
'Pr fessioris Code): PRESENT BY r ;; 6 6 Q R
BUILDING
I, as owner of the property, or my employees with ADDRESS � 11 0 0 0 0 0
wages as their sale compensation,will do the work and
the structure is not intended or offered for sale(Section LOCALITY
7044, Business and,Professions Code). MOVING TEL. 2
CONTRACTOR NO. -
❑ I,as owner of the property,am exclusively contracting i o 3 3 9,7.rd
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code). L0 S 3 _84,
CONSTRUCTION LENDING AGENCY' SET BACK YARD HWY TOTAPREOTPAINEEROM WIDTH
1 hereby affirm that there is a-construction lending agency for FRONT
the performance of the work for which this-permit is issued P.L. �.
(Sec. 3097, Civ. C.). SIDE
'o P.L.
Lender's Name LDMA Ref. #
P.C. Fee$ Permit-Fee
- Lender's Address .s
rI certify that I have read this application and state-that the Issuance Fee . CDMA P/C#
=
ab o n ormat n is c ect. I agree to comply with all County Investigation Fee
o inances an to la s relating to building construction, ,: Total Fee CDMA Perm. #
nd hereby a orize r resentat' es of thi ounty to enter
3 pon the a v -menti ed pro rty r i ction purposes.
= -ySEE REVERSE FOR EXPLANATORY LANGUAGE
o I
Si ature of Applicant Agent Date i t
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 BUILDING PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ALTERATION/REPAIR
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 BL 0508 0404130065
PHONE: (626) 285-0488 EXT:
LEGAL D: NO. OF 6UNU I BUILDING-ADDRESS:
TR: 13613 LT: 34 SQ. FT STORIES TYPE 5313 PERSIMMON AV
STRUCTURE: VN TEMP CA 917802802
ASSESSOR INFORMA ION UMBER: NEAREST CROSS STREET: FREER
8573-004-013 THOMAS PAGE: 597 GRID: C4 LOCALITY: TEMPLE CITY, C
TENANT: EXIST BLDG USE: RESID S ZONE: R-1 ISSUED ON- PROCESSED BY: EXPIRES ON:
EXIST OCC GRP: 04/13/04 VG 04/08/05
OWNER: TEL. NO: BLDGS. NOW ON LOT: VALUATION: FINAL DATE FINAL BY: CODE:
CABRERA, EFRAIN (626) 579-7972- 1,800 /1
5313 PERSIMMON AV - --� 6
TEMP 917802802 FEES PAID DESCRIPTION OF WOR
REMOVE AND REPLACE 9 WINDOWS (SAME SIZE)
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT:
APPLICANT: TEL. NO:
SAME AS OWNER - AA BLDG PERMIT ISSUANCE 27.75
AC STRONG MOTION RESID 1800.00 VAL 0.50 SPECIAL CONDITIONS:
D2 PERMIT W/O EN-HC 1800.00 VAL 82.20
TOTAL FEES 110.45
CONTRACTOR: TEL. NO: APPROVALS DATE INSPECTOR SIGNATURE
SAME AS OWNER -
LIC. NO LOCATION AND SETBACKS
SOILS ENGINEER APPROVAL
ARCHITECT OR ENGINEER: TEL. O: FOUNDATION/TRENCH FORMS
LIC. NO: SLAB/UNDER FLOOR
RAISED FLOOR FRAMING
MAP NO: SEWER MAP BOOK: PAGE: FIRE ZONE: CMP: UNDERFLOOR INSULATION
XX 3 01
FLOOR SHEATHING
NO. OF FAMILIES: DWELLING UNITS: APT COND: STAT CLASS:
NO 21 ROOF SHEATHING
SCHOOL IT I HAZARDOUS SHEAR PANELS
AIR QUALITY: 1000 FEET MATERIALS
NO NO NO FRAME INSPECTION
REQUIRED TOTAL SETBACIC FROM EXIST FIRE SPR KLER HA ERS
SET BACK YARD: HWY: PROP LINE: WIDTH:
FRONT PL- INSULATION/WEATHER STRIP
SIDE PL-
I TERIOR LATH/DRYWALL
EXTERIOR LATH
RATED FLOOR/CEIL ASSEM.
RATED WALL ASSEMBLIES
RATED SHA S/OPENINGS
T-BAR CEILINGS
LOT DRAI RG
REPORT ID: DPR261 ROUTE TO: BS0508