HomeMy Public PortalAbout4817-4819 CAMELLIA AVE_Miscellaneous__ .WORKERS'COMPENSATION DECLARATION 76M444 MISCELLANEOUS APPLICATION
of Workers'Compensation Insurance,or
ICE 875 (2-80),he=el;y_affirr�t [hat I have certificate of consent to :elf COUNTY OF LOS.ANGELES BUILDING AND SAFETY DIVISION - 1
' insure.,or'a.cexi.Rrea[e
a"Certified copy thereof(Sec. 3800. Lab. C.) _
Policy No. Company FOR APPLICANT TO FILL IN woow ss Q
❑ Certified copy is hereby furnished. + ADORE IrvG e, 8.,� _ i9 �Qm e�I r Q q Aye, Locpury
wODR'SS "£ H
❑ Certified copy is filed with the county building inspection NEAREST
department. Loewury "--'t��� - ci 4 CROSS 5T.
D3Ie Applicant NEAREST 1 L• CL
� DISTRICT NO. GRO P TYPE PRO
SSE0 BY
NEAREST. LQ'W�f' A�f�SW 1 CONST: '
CERTIFICATE OF EXEMPTION FROM WORKERS'. LEGAL - '� -
COMPENSATION INSURANCE OESCRIPTIOry Lor NO. BLOCK Cb wa
MpP (e..CLE) STATE,MAJOR SECOND LOCAL a
NO. OF BLDGE.
by t sectionperm need not be completed if the work involved TRACT NOW ON LOT �" USE ZONE SPECIAL CONDITIONS Q
by the permit is for one hundred dollars ($100) of less.) ( / U
(9S X I�O USE OF
512E OF LOT EXISTING BLDG. O
certify that in the performance of the work for which this -
permit is issued, I shall not employ any person in any manner OWNER jj_06'16of11 Uc all owe , Bi'oW h - F
so as to become subject to the Workers' Compensation Laws.' MAIL ,A // `OCCUPANCY GROUPLU
U
.ADDRESS 4cSIp3 0 Dorado Or.; � iL
Date Applicant - W
/
NOTICE TO APPLICANT: If, after making this Certificate of cirr LQ y eh-ne i CO— No. ^j}L�--S�3 -X44 OCCUPANT LOAD
'Exemption, you should become subject to the Workers'
Compensation provisions of the'Labor Code,"you must forth- - APPLICATION FOR EXIT HARDWARE:
with comply with Such provision$ or this permit shall be, TRAILER USE GEOLOGY.INSPECTION
deemedrevoked. ❑ ❑ NO Spec. Knowl, ❑
,LICENSED CONTRACTORS DECLARATION
occUFgNCY INSPECTION - Panic Devices ❑
Iherebv affirm.that I am,licensed under provisions of Chapter SAFETY PERMIT q (LIST ITEMS BELOW) NO, OF ..ITS
9 (commencing with Section,7000) of Division 3 of the Busi-
ness and Professions Code, and my license is in full force and 11 -
effect. �'C Y0eP1001 OYC PARKING.
' • _ SPACES REO'D O PROVIp ED
License Number Lic.Class �0.�8 O
LIMITED TIME USE
Contractor' Date o.TE DATE
❑ I am exempt from the licensing requirements as I am a
licensed architect or a registered professionalengineerSIZE OP•' rvo. OF INSPECTOR'S -
'acting in my professional capacity.(Section 7051,'Bus- EX 15 11 NG BLDG. STORIES SIGNATURE
mess and Professions Code), IFINAL APPROVAL.
PRESENT USE of BUILDING -
Lie.or Reg.No. Date -
HOME OWNER-BUILDER DECLARATION. NO. OF EXISTING BUILDINGS n.rn q Cn
ON LOT.AND USE �. ;R G L.A J rt
I hereby affirm that-.I am exempt from the Contractor's F `•� #•! • 5 0
.License.Law for the following reason (Section 7031.5, Busi- 1 1
NO. PARKING
ness and Professions Code): _ z • S 0,'5.0
SPACES PROVIDED (/ 1
❑ I, as owner of the property, will do the work and the. �8 0.,5.0 U
structure is not intended or offered for sale (Section /(/J " ,
7044, Business and Professions Code). 'PROPOSED USE of BUILDING - 0.6`Z'S'—8'4
CONSTRUCTION LENDING AGENCY _ V�
I hereby affirm that there is a construction lending agency,
for the performance of the work for which this permit is
issued (Sec. 3097,Civ.C.). -
Lender's Name PROPOSE WMAX. OCC.
Lender's Address PERMIT FEE ��
I certify that I have read this application and state that the
above information is correct. I agree to comply with all County ISSUANCE FEE ^,\
ordinances and State laws relating to building construction, T07AL.FEE
and he by authorize representatives of this County to enter
uyo tl above-m entione operty for inspection purposes. SEE REVERSE P EXPLANATORY LANGUAGE
Ts Signature of Permittee Date