HomeMy Public PortalAbout5538 PERSIMMON AVE_Building__ (2) •• _,.s ' WORKERS'COMPE�N66TION;DECLARATION
4"+,if, ,, rm that I have r certificate of consent to self APPLICATION FOP' BUILDING PERMIT
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insure, ,t c��tificate of Workers'Compensation Insurance,
or a certitild copy thereof(Sec. 3800, Lab. C..) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. CompanyBUILDING
°
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN t ADDRESS ,1 0735Jv1 O
Certified copy is filed with the county building inspec- BUILDING
tion department. I ADDRESS ,;F: �
Date Applicantk=�Wo
,. O CIT �e �r ZIP �/ LOCALITY
ERTIFICATE OF EXEMPT FRERS' NO.OF BLDGS. NEAREST
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT :CROSS ST.
(This section need not be completed if the permit is for one ASSESSOR
hundred dollars($100)or less.) TEL.TRACT BLOCK LOT NO. �/ MAP BOOK PAGE PARCEL
OWNER �� +�} O NO.1 4 3 6 USE ONE MAP
I certify that in the performance of the work for which this NO.
permit Is issued, I shall not employ any person in any manner �� � � �. Q� 1 SPECIAL
so as to become subject to the Workers'Compensation Laws. ADDRESS ^'1 CONDITIONS V
Date Applicant CITY E' ZIP
NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL. DISTRIENGINEER NO. CONST.OUP TYPE FIRE PR SSED BY O
ZONE
H
Exemption, you should become subject to the Workers' � � V
Compensation provisions of the Labor Code, you must forth- ADDRESS �c Ltl
with comply with such provisions or this permit shall be Q-'
TEL. `STATISTICAL CLASSIFICATION APT. CONDO. N
deemed revoked. CONTRACTOR/�. w�J O. Z
LICENSED CONTRACTORS DECLARATION _ f rr LIC, CLASS NO. DWELL. UNITS
-
V,
hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS�ZS W 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 141 BK VALIDATION
2 SQ. F �/ NO.OF NO.OF CHECK {:
License Number a�/ 33 Lic.Class ��-r SIZE d STORIES ® FAMILIES ONE
VALU ION
C,���u � DESCRIPTION OF WORK NEW ❑
G❑ontractor to ADD $3
I am exempt under Sec. -e 994.9A
ALTER 10 �f•
B.BP.C. for this reaFon REPAIR $ # 0 0 0 0 2 3
USE OF ��
Date- DEMOL ❑
EXISTING BLDG. I /-� �1,
Signature APPLPRINTT . (%',T t�NO.S/kr 73 0 FINAL V G I ° 2 9 3 9 0
NE - UILD ECLARATION ff-- . DATE ° ° 2 9 3,9 0 0
I hereby a .it that I am ex pt from the Contractor's License ADDRESS Z r "L/ -J.Q ( FIN 0627-88
Law for t following reason (Section 7031.5, Business and
Professions Code): PRESENT
❑ BUILDING
1, as owner of the property, or myemployees with I ADDRESS
wages as their sole compensation,will do the work and LOCALITY 4
the structure is not intended or offered for sale(Section r
7044, Business and Professions Code). MOVING TEL. oil)
❑ I,as owner of the property, am exclusively contracting CONTRACTOR NO. 9 0 35.2 A
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code). # 0 0 0 0 0,1
REQUIRED TOTAL SET BA K 1 - 35625
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. ° 0 356250
=
(Sec. 3097, Civ. C.). SIDE
Lender's Name ,
P.L. 08.04—88
� LDMA'Ref.p
Lender's Address P.C. Fee$ L Permit Fee
I certify that I have read this application and state that the Issuance Fee L kLD P/C a
above information is correct. I agree to comply with all County Investigation Fee
? ordinances and State laws relating to building construction, Total Fee
3 and hereby authorize representatives of this County to enter u Perm. N
6 u t the above-menti ned pr p rty for inspection p rp ses.
SEE REVERSE FOR EXPLANATORY LANGUAGE '
D
ature pplicant or Agent Date