HomeMy Public PortalAbout4834 CAMELLIA AVE_Building__ COUNTY OF LOS ANGELES BUILDING_ AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS X1673 ® u�
BUI R / 6 J 4
I hereby affirm that I hese a certificate of consent to ,If insure, CdI 1"6 L L 1
or a certificate of Workers'Compensation Insurance,or a certified CI - ZIP
— �—._ LOCALITY
Company �J SIZE OF LOT NO.OF RLDGS.NOW ON LOT ,
❑ Cert led copy is hereby furnished. 41 I NEAREST CROSS ST. � �'
L C:ertuied copy is filed With the c0 I uilding inspection TRACT BLOCK LOT NO.
USEZONE MAP NO.
a I.
� ASSESSOR MAP BOO PAGE PARCEL
Data la[/_�OA licant ��V'7 SPECIAL CONDITIONS
PP 9 �
`r OWNER TEL.
CERTIFICATE OF EXEMPTION FR WORKERS' [J,} SO y` '�G9d .YES NO
COMPENSATION INSU E WITHIN tOW FT OF SCHOOL?
ADDflE55
(This section need not be Completed if the permit i5 for one hundred �() e, DISTRICT GROUP TYPECONST' FIRE ZONE PROCESSED BY
dollars($100)or less.) CITY .ZIP
I certify that In the performance of the work for which this permit 5, D 12.—?,
i4 issued, I shall not employ anyperson in any manner So as to ARCHITECT OR ENGINEER TEL NO.
become Subject to the Workers'COmpensation Laws, STATISTICAL CLASSIFICATION APT CONDO
Date Applicant ADDRESS CLASSNO..—_N_DWELLUNITS
NOTICE TO APPLICANT: If, After making this Certificate of REQUIREDTOTAL SETBACK FROM EXIST
Exemption, f C TRA TO - ALT
p you ShOUId become subject [0 the Workers' � Q� �y'32� SACKJYALRDHWY PROP LINE WIDTH
Compensation provisions of the Labor Code, you must forthwith C J LFRONIT
comply with Such provisions or this permit shall be deemed revoked. AD RE9_0 Y �4 IC.�.� >-
LICENSED CONTRACTORS DECLARATION- Cm c � LIC.CLASS L� C)
I hereby affirm that I am licensed under provisions of Chapter 9 �/ _ 7 SEWER MAP V
(commencing with Section 7000)of Division 3 of the Business and S IZ NO.OF ST ES NO.OF MILIES fY
Professions Code,and m license' m full forceantl e{fg�C(`,'.� NEW BK PG V
License Number LIC.CIa59 — ` DESCRIPTION OF RK ADD ❑ VALUATION
D W
Contmct VC, nat._T'.Z ` u' ALTER ❑ $
p n r...
Z
r7 �II I ' t-0 -2.7 dY SIT �iOJ9[ REPAIR ❑ �L4!,s
E3Iam exempt under Sec. $
B.BP.C.for this reason DEMOL El 61
LDMA PIcp 1 IT`y
Date: USE OF EXISTING BLDG. ('� URM. ❑ TOTAL
Signature APPLICANT(PRINT) r I TEL.NO. - LDMA Penn 8 I�)'AL 105 ® 2c
❑ I, as owner of the property, or my.employees with'wages as O CLFhCKi135.2=
their sole compensation, will do the work and the structure is ADDRESS f ' r'1
not intended or offered for sale (Section 7044, Business and FINAL DATA 4O CHANGE
Professions Code.) WILLTHEAPPLICANTOR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL
OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN Q
❑ I, as owner of the property, am exclusively contracting with WILL
AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY
licensed contractors to construct the project.(Section 7044, VES❑ NO ( 2:`/9J
❑ 'u/ tl /IJ
Business and Professions Code.) i 99v(
WILL THE INTENDED USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING y.J{J j 1AN
OCCUPANT DUAL EAPERM EFORCANSTRUT(SCAOMO)SEI PMMI TING HECOUTH /� /y 9'i�
CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MgNAGEMENT DISTRICT ISCAOMDI SEE PEnMITTING CHECKLIST »�Yb.•�I'/
FOR GUIDELINES: V
I hereby affirm that there is a construction lending agency for YES❑ No❑
the performance ofthe work for which this permit is issued(Sec. HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD
.3097,CIV.(i.). PERMITTING CHECKLIST I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES '
COUNTY CODE,TITLE 2.CHAPTER 220 SECTIONS 2.20.100 THROUGH 2.MAQ CONCERNING
3 Lender's Name HAZARDOUS MATERIALSREPORTINGAND FOR OBTAINING A PERMIT FROM THESCAOMD.
Lender's Address
o I certify that I have read this application and State that the above
R
information *Scoarws
agree to Comply with all COualy PC.FEE PERMIT FEE
a ordinances erelating to building construction,and
¢. hereby authotative5 of this County[o enter upon - ISSUANCE FEEthe above-meerty for inspection rpo$P�s. �1
m � ,11— LO INVESTIGATION FEE TOTAL FEE
SEE REVERSE FOR EXPLANATORY LANGUAGE•