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Home My Public Portal About5509 PERSIMMON AVE_Building__ W,1U14 WORKERS'COMPENSATION DECLARATION I hereby affirm that I have certificate of consent self APPLICATION FOR BUILDING P E RM I T insure, or a certificate of Workers'Compensation Insurance, or d certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No, Company BUILDING ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS �� ❑ Certified copy is filed with the county building inspec- BUILDING 5�0 FL d l�QHv tion department. e Date Applicant CITY ZIP q 1-7goLOCALITY p� NO.OF BLDGS. NEAREST j CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT O 1C 2® NOW ON LOT CROSS ST. COMPENSATION INSURANCE ��gg--,�� ASSESSOR (This section need not be completed if the permit is for one TRACT 1 01 BLOCKS5700 LOT NO. [SM MAP BOOK PAGE PARCEL hundred dollars ($100)or less.) p `��+ ,� gp TEL' USE ZONE MAP a�3 OWNER L �Vtr7seo NO. �- NO. I certify that in the performance of the work for which this ,y� SPECIAL permit is issued, I shall not employ any person in any manner ADDRESS �� C7�� CONDITIONS CL so as to become subject to the Workers'Compensation Laws. � � O ��dd�� QQ►► � cITY �empL q ziP a8 DateIr Applicant PCARCHITECT OR NOL. a DISTRICT GROUP TYPE FIRE OCESSED BY V NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER CONT ZONE Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- ADDRESS "—�� C2 a with comply with such provisions or this permit shall be0��QZ NO. �S_c/swC' STATISTICAL CLASSIFICATION APT. CONDO. N deemed revoked. CONTRACTOR LICENSED CONTRACTORS DECLARATION LIC. CLASS NO.e.2�— U..ADDRESS NO. UNITS — I I hereby affirm that I am licensed under provisions of Chapter 9 SEWER MAP (commencing with Section 7000)of Division 3 of the BusinessLIC. and Professions Code,and my license is in full force and effect. CITY —rb;MP(_a CLASS BK PG VALIDATION SO. FT..6j5° NO.OF NO.OF r CHECK License Number Lic. Class SIZE �7 STORIES 4 OFFAMILIES ONE Contractor Date DESCRIPTION OF WOORKy �`2 ) J34r-2rf NEW � VALUATION ❑I am exempt under Sec. DW 6W� ADD ❑ $ DD Bo ALTER El polo Le lob �� B.&P.C. for this reason �F-1V� REPAIR ❑ $ Date: USE OF EXISTING BLDG. DEMOL F-1 Signature APPLICANT TEL. FINAL OWNER-BUILDER DECLARATION (PRINT) NO. I hereby affirm that I am exempt from the Contractor's License DATE Law foP the following reason (Section 7031.5, Business and ADDRESS FINAL -- s Pro essions Code): PRESENT By v_—• — -- I, as owner of the property, Y P Y ees or m employees with BUILDING �-+-'-� a�= wages as their sole compensation,will do the work and ADDRESS �� the structure is not intended or offered for sale(Section LOCALITY 7044, Business and Professions Code.) MOVING TEL. _ t :. r,-, _, ❑ I,as owner of the property,am exclusively contracting CONTRACTOR NO. ; _f±N� 3.,_} - :�.,�, with licensed contractors to construct the project Sec- CK — - P I ( ADDRESS CHECK ��a i.,! tion 7044, Business and Professions Code.) _ CONSTRUCTION LENDING AGENCY SETT BACK YARD HWY TOTAL PROP. LINE FROM EXIST. "A tat.� - I hereby off irm 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. U_Ii.E 1—tl�l�l1 !-.-J/I:Dic,_ Lender's Name �! f!' P.C. Fee$ Permit Fee �O •JPo LDMA Ref.# � Lender's Address 0 1 certify that I have read this application and state that the Issuance Fee 7� LDMA P/C# above information is correct.I agree to comply with all County Investigation Fee p ordinanc and State laws relating to building construction, Total Fee a � 5 LDMA Perm. # and y authorize r res a es of this County to enter up t above-menti rty for inspection purPo s �O 0 4 ,J SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date ..,jN DECLARATION a�eb w7 -ave certificate of consent to self Worrkkers'Compensation Insurance, A p p�o CaU o o N Ran o.u o Elm No, p E pi o u , �o•ctti _ :ertified ccpy thereoS (Sec..3800; Lab. C.) COUNTY OF LOS ANGELES 13LDOdDIING AND SAFETY •+No. Company . . BUILDING •- /� f - J- certified copy is hereby fuiInished. FOR APPLICANT TO FILL IN ADDRESS F1Certified copy is file•f with the county building inspec- BUILDING 1 i tion department. ADDRESS / ( 1I� Date Applicant CITY zip /7G1C LOCALITY NO.OF BLDGS. NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' G'� R r ' COMPENSATION INSURANCE SIZE OF LOT L'� I��L.% NOW ON LOT CROSS ST. �� (TMis section need not be completed If the permit is for.one TRACT BLOCK LOT NO. ASSESSOR kindred dollars($100)or less.) y �! MAP BOOK p / + PAGE PARCEL OWNER �� j �{'0�1i 1-60 L. �7 �>r� USE ONE NO L�(JJ I certify that in the performance of the work for which this . >' Pe it is issued,I shall not employ 'person in any manner ADDRESS �]��1' f.C{es/r"��"v CONDITIONS so p i become subject to the Workers'Compensation Laws. -9 CITY. dP'1�p�1��" 01-4ZIP �f [ L of Applicant ARCHITECT OR TEL. 'NOTICE'TO APPLICANT: If, after making this Certificate of ENGINEER NO. DISTRICT GROUP TYPE FIRE PROCE ED BY Exemption, you should become subject to the Workers' �� CONST. ZONE M Compensatioprovisions of the Labor Code, you must forth- ADDRESS / r_ with comply with such provisions or this permit shall be- deemed revoked. CONTRACTOR �V.T NO. STATISTICAL CLASSIFICATION APT. CO O. • LICENSED CONTRACTORS DECLARATION LIC, CLASS NO. DWELL. UNITS L hereby affirm that I am licensed under provisions of Chapter 9 :ADDRESS F— NO. (commencing with Section.7000)of Division 3 of the Business and - LIC SEWER MAP Professions Code, and my license is in full force and'e.Wect. ' CITY CLASS BK PG VALIDATION SQ.FT.��// -� NO.OF IVO.OF CHECK t License Number Lic.Class— SIZE 7 � STORIES FAMILIES ONE VALUATION Contractor Date DESCRIPTION OFWOORRKK,'p NEW 19. $ o f L. 7 1�+ C• �i�l ADD ❑ D ❑I am exempt under Sec. ..,�, ALTER ❑ B.BP.C. for this reason c-_ REPAIR ❑� $ USE OF Date: EXISTING BLDG. DEMOL ❑ Signature APPLICANT TEL. l� %� OWNER-BUILDER DECLARATION PRINT NO. DA / i Com/ -% I hereby affirm that I am exempt from the Contractor's License ADDRESS FIN, � ��7 9 6 A Law for the following reason (Section 7031.5, Business and Professions Code): BUILDING B # 1 0 0 0 0 0 I, as owner of the property, ormy employees with _ _ ADDRESS wages as their sole compensation,will do the work and o 0 8 7.3 8 the structure is not intended or offered for sale(Section "LOCALITY 7044, Business and Professions Code). MOVING TEL. 0 0 0 8 7,j 8 �❑ 1,as owner of the property,am exclusively contracting CONTRACTOR NO. . with licensed contractors to construct the project (Sec- ADDRESS O 8 2 b'-8 5 tion 7044, Business and Professions Code). ` 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. e Lender's Name / " �� DMA Ref. # P.C.Fee-$ Permit Fee Lender's Address I certify that I have read this application and state that the - Issuance Fee S ld DMA P/C# s above information is correct. I agree to comply with all County _; Investigation Fee Q $ Ord in ces and State,J,aws relating to building construction, Total Fee r tU' LDMA Perm. # U and reby au or'f�epresentctives of this County to enter upro the ab �nt' ned property for inspection purposes. /� n+s9l4 SEE REVERSE FOR EXPLANATORY LANGUAGE i • 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 0109170041 PHONE: (626) 285-0488 EXT: LEGAL IDi . OF CONSTG SS: TR: 13613 LT: 158 SQ. FT STORIES TYPE 5509 PERSIMMON AV STRUCTURE: 2600 VN TEMP CA 917802806 ASSESSOR INFORMATION NUB : NEAREST CROSS STREET: DAINES 8573-002-021 THOMAS PAGE: 597 GRID: C3 LOCALITY: TEMPLE CITY, C TENANT: T B G S SID USE ZONE: 0 SS S EXIST OCC GRP: 09/17/01 VG 03/16/02 . OWNER: TEL. NO: BLDGS. NOW ON LOT: VALUATION: FIPPL DATE FINAL BY: CODE: RASMUSSEN JAMES A;CECILIA A (626) 448-5605- 4,000 1 /("gocr 5509 PERSIMMON AV TEMP 917802806 ES PAID DESCRIPTION OOR T/O!EXIST ROOF, RESHEAT AND INSTALL COMP SHINGLES FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: APPLICANT: TEL. 0: SAME AS OWNER - AN BLDG PERMIT ISSUANCE 27.75 AC STRONG NOTION RESID--- , 4000.00 VAL 0.50 SPECIA CONDITIONS: B2 PERMIT W/,ENERGY_--_ -4000.00 VAL 127.38 �` :'�• TOTAL`'FEES 155.63 CONTRACTOR: TEL. N0: .`'� � ;ate � �t'/T•-� APPROVALS DATE INSPECTOR SIGNATURE SAME AS OWNERt LIC. NO r l LOCATION TBAC SOIUS ENGINEER APPROVAL ARCHITECT OR ENGINEER: TEL. N0: - �r 1-Ir11 - -�` �i 0 D I RE C 0 S LIC. NOe - S A '/ DER FLOOR /' RAISED FLOOR FRAMING P N0: SEWER MAP BOOK: PAGE: FIE 20NE: OMP,: ,; UNDERFLOOR INSULATION XX 3 .01' t.�li �, ,'ItiJ !;� . I y I' - ' - �'- FLOOR SHEATHING NO. OF FAMILIES: D L G S: 0 C SS• - - - - - -- - - NO 21 �. -\ -- — F' 1 -- --1 J ROOF1 S EA H NG 906-0HAZARDOUS , ! '� ii i ., ! f:, ySHEAR S AIR QUALITY: 1000 FEET MATERIALS " , NO NO NO `� j' ,;' i�c= FRAME INSPECTION REQUIRED TOTAL SETBACK 0 -�\�U: R S R R ERS SET BACK YARD: HWY: PROP LINE: WIDTH: � �_ `�� _—_ JL �. d FRONT PL- '�� ;eryic e ��/ � INSULATION/WEATHER STRIP SIDE PL- � _ _-�" :=s�a� INTERIOR EXTERIOR LATH RATED OOR . RATED WALL ASSEMBLIES— SH S T-BA CE IGS 0 REPORT ID: DPR261 ROUTE TO: BS0508 /71 1 e PPLICATON FOR BUILDING PERMIT COUNTY OF LOS ANGELES ASSESSOR DEPARTMENT OF COUNTY ENGINEER MAP BOOK PAGE PARCEL BUILDING AND SAFETY DIVISION BUILDING ADDRESS, r .S' COLEMAN W. JENKINS, SUPT OF BUILDING LOCALITY FOR APPLICANT TO FILL IN NEAREST Print orf a onl GROSS ST. �j/1.) ,A.3.�= DIS-�¢ICT NO. GR F TYPE r.T PROCESSEZD BY BUILDING ��• CONST. ADDRESS sj,j o 2 // —&rS*rM/�B'--( r _ C� � r� / STATISTICAL CLASSIFICATION s5f=WER MAP LOT NO. a7 C% BLOCKCLASS NO. <�—DWELL.UNITS • BK� PGe_r TRACT f•3 lJ USE ZONE MAP i� NO.OF SLOGS. NO. SIZE OF LOT .120 Je 6 d NOWrON LOT i SPECIAL USE OF I EXISTING BLDG. , .r10,C 4 T j CONDITIONS IL'rCs Ic.�iC��ID�NO OWNER' �L6� BLDG.SETBACK FROM ADDRESS ere M� FRONT PROP.LINE OF Z R!!t;-I A—a!�' (STREET) � � C7� �'�'; � �- _ TYPE OF EXISTING SETBACK HIGHWAY + YARD - TOTAL i• CITY . ',F'w 1v HAGHWAY WIDTH FROM C.L. ARCHITECT OR TEL. Ly^ 41 I � + :�G� _ I ENGINEER NO. • •I BLDG.SETBACK FROM ADDRESSSIDE PROP.LINE.OF (STREET) i �-/- TEL. TYPE OF EXISTING SETBACK HIGHWAY + YARD = TOTAL '> CONTRACTOR i(�/yr��„ NO. HIGHWAYI WIDTH FROM C.L. LIC. + _ ADDRESS (/]L.Q/, NO. LIC. CITY CLASS q CORNER CUTOFF YES ❑ NO ❑ CONSTRUCTION LENDER BRANCH f �r�� .�� _ SEE REVERSES E FOR SPECIAL APP- V S ADDRESS ,I.Gr�1®« C d e� SIZE FT.S-// O- STORIES NO OF IEs NEW ❑ l USE OF ADD v'eL ` STRUCTURE _ ALTER ❑ f •„ �'c., 4 �r�'J% REPAIR❑ 4'l-(-ice i 1 SIGNATURE OF c - 2, 111wct APPLICANT l4 _ DEMOL ❑ V . VALUATIONS ] f,;r a1 £— PPROVALS DATE INS" CTOR'S SIG ATURE P.C. PMT. S¢�.1 FOUNDATION: LOCATIONEES FEES FORMS, MATERIALS FRAME: FIRE STOPS, I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION BRACING BOLTS AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY FURNACE: LOCATION, ,I WITH ALL ORDINANCES AND LAWS REGULATING BUILDING CON- GAS VENT, DUCTS STRUCTION. 1 CERTIFY THAT IN DOING THE WORK AUTHORIZED HEREBY 1 WILL NOT EMPLOY ANY PERSON IN VIOLATION OF THE LATH, INT. LABOR CODE OF THE STATE OF -CALIFORNIA IN RELATING TO WORKMEN'S COMPENSATIOy INSURANCE. i LATH, EXT. SIGNATURE OF �� HOUSE NUMBER COR- ' PERMITTEE r RECT AND POSTED ADDRESS FINAL �j JOHN F. LEWIS. WINCIPAL STRICT A ENG N PLAN CHECK VALIDATION CK. M.D. CASH _ PERMIT VALIDATION cic� M.o CASH r Lri1r0 7 ? *i ce tui R 27 55.50- . r