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Home My Public Portal About5440 PERSIMMON AVE_Building__ WORKERS' COMPENSATION DECLARATION insure, or affcertif catte of Wo ke s'tCompensat on insurance, APPLICATION FOR PUILDING PERMIT or a certified copy thereof(Sec. 3800, Lab. C.) I COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company BUILDING Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS � 4 � Q, S ❑ Certified copy is filed with the county building inspec- BUILDING Sit y0,( iR��f�0/r tion department. Date Applicant aTY r� L E c 1 T ZIP W�`Sa LOCALITY NO.OF BLDGS. NEAREST CERTIFICATE OF EXEMPTION-FROM WORKERS' SIZE OF LOT NOW ON LOT CROSS ST. COMPENSATION INSURANCE 1 ASSESSOR This section need not be completed if the permit is for one TRACE 3BLOCK LOT NO. MAP BOOK PAGE PARCEL undred dollars ($100)or less.) TEL. OWNER^ • �^f S v L I L Al NO, yl/'/- �!Sy2 USE ZONE OP I certify that in the performance of the work for which this � ,Si d 4.-4 C O/� / SPECIAL } permit is issued, I shall not employ-any person in any manner ADDRESS �y /" •l CONDITIONS so as to become subject to the Workers'Compensation Laws. , c� /� CITY t-4 Q Y ZIP / / $a U Date Applicant ARCHITECT OR TEL. Ix DISTRICT I GROUP TYPE FIRE PROCESSED BY O NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. / �! n � CONST. � ZONE Exemption, you should become subject to the Workers' -� CY] Ifs 3 Compensation provisions of the Labor Code, you must forth- ADDRESS a with comply with such provisions or this permit shall be c V (,�a_ TEL. STATISTICAL CLASSIFICATION APT. CONDO. N deemed revoked. ' CONTRACTOR �/� r NO. Z LICENSED CONTRACTORS DECLARATION � � NO. CLASS NO.�DWELL. UNITS ADDRESS L I hereby affirm that I am licensed under provisions of Chapter 9 SEWER MAP (commencing with Section 7000)of Division 3 of the Business LIC. and Professions Code,and my license is in full force and effect. CITY /� CLASS BK. PG.SS VALIDATION License Number Lic. Class SIQZEFIg ! 3 STORIIEES AMILLIIES + ONEK � s y� / VALUATION � �To Contractor Date DESCRIPTION OFF WORK 2- e-,e/� a-� S NEW El' $ n ` �O 33307 - 535.50 El am exempt under Sec. 9 c4— /t/ h S vL A/ ADD ® % YTSi5 1 q BAP.C. for this reason GY Q`��r ��t✓s ALTER 10 _ ,.. a'G USE OF REPAIR 1-1 $ TOTAL 535 c 50 Date: EXISTING BLDG. DEMOL ❑ �a1�41\ yob Signature APPLICANT TEL. OWNER-BUILDER DECLARATION (PRINT) NO. FI TE CHANGE I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and ADDRESS FIN Professions Code): PRESENT B 7 j ❑ I, as owner of the property, or m em to ees with BUILDING Y _ p/y�'3f P P Y� Y P Y ADDRESS f 3466 AN110-24 wages as their sole compensation,will do the work and pool 1 the structure is not intended or offered for sale(Section LOCALITY 7044, Business and Professions Code.) MOVING TEL. ❑ I,as owner of the property,am exclusively contracting CONTRACTOR NO. with licensed contractors to construct the project (Sec- tion 7044, Business and Professions Code.) ADDRESS REQUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE 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. Lenders Name -3 , b LDMA Ref.# Lenders Address i P.C.Fee$ , Permit Fee , I certify that I have read this application and state that the Issuance Fee LDMA P/C# above information is correct. I agree to comply with all County Investigation Fee ordinances and State laws relating to building construction, I Total Fee LDMA Perm. # and hereby authorize representatives of this County to enter i upon the above-mentioned property for inspection purposes. o SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date 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 0201250029 PHONE: (626) 285-0488 EXT: LEGAL ID- 0. OF CONST BUILDING ADDRESS: TR: 13613 LT: 15 SQ. FT STORIES TYPE 5440.PERSIMMON AV STRUCTURE: VN TEMP CA 917802803 ASSESSOR I0 0NUMBER: NEAREST CROSS STREET: DAINES 8573-005-003 ; THOMAS PAGE: 597 GRID: C3 LOCALITY: TEMPLE CITY DG USE: RESID SE. ONE: R-1 ISSUiD 0 : PROCESSED EXPIRES N: EXIST OCC GRP: 01/25/02 JK 07/24/02 OWNER: TEL. NO. BLDGS. NOW 0 LO T VALUATION: FINAL DATE FI BY: CODE: SHIRAI KASUMI - 5,400 1;21 5440 PERSIMMON AV TEMP 917802803 FEES PAID OESUKIPTIONOF WORK T/0; RESHEATH AND INSTALL 25YR ASPHALT SHINGLES OVER HOUSE APPLICANT: FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: ATTACHED GARAGE AND PATIO ALLEN LINA EL. 0:(626) 284-3260- AA BLDG PERMIT ISSUANCE 27.75 2618 W MAIN ST #C AC STRONG MOTION RESID 5400.00 VAL 0.54 SPECIAL CONDITIONS: ALHAMBRA D2 PERMIT W/0 EN-HC 5400.00 VAL 149.40 TOTAL FEES 177.69 CONTRACTOR: TEL. NO: APPROVALS DATE INSPECTOR SIGNATURE AMPS GENERAL CONSTRUCTION (626) 284-3260- 2618 W MAIN ST #C LIC. NO MOTION AND SETBACKS ALHAMBRA, CA 91801 549061B SOILS ENGINEER APPROVAL ARCHITECT OR ENGINEER: TEL. NO: FOU D ON/ RENC FORMS LIC. NO: SLAB/UNDER FLOOR RAISED FLOOR FRAMING P NO: SEWER MAP BOOK: PAGE: FIRE ZONE: ,CMP- UNDERFLOOR INSULATION 147H277 3 01 FLOOR SHEATHING 0. 0 DWELLING ITS: C N S A C S: _ NO 21 ROOF SHEATHING �� v C L WITHINHAZARDOUS SHEAR PANELS AIR QUALITY: 1000 FEET MATERIALS NO NO NO FRAME INSPECTION REQUIRED O L SETBACK FROMS E SP N R A GERS SET BACK YARD: HWY: PROP LINE: WIDTH: FRONT PL- INSULATION/WEATHER STRIP Z SIDE PL- j IOR LATH/DRYWALL EXTERIOR LATH I RATED FLOOMETI-A-S-SER7. RATTED WALL ASSEMBLIES- RATED SEMBLI S SHAFTS/OPENINGS T-BAR CE LINGS REPORT ID: DPR261 ROUTE TO: BS0508