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Home My Public Portal About5008 CAMELLIA AVE_Building__ if WORKERS' COMPENSATION DECLARATION hereby affirm that I have a certificate of consent to self APPLICATION F UILDING PERMIT LS • insurA�'or a certificate of Workers'Com pensiion Insurance, or �% o certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANG ES !�. BUILDING AND SAFETY Policy No. Company Certified copy is hereby furnishe�j, FOR APPLICANT TO FILL IN ADDRESS �r5 El Certified copy is filed with the county building spec- BUILDING _S -a f�a� tion department- ADDRESS J L // LOCALITY /�� ,y ( NEAREST y� Date Applicant CITY C A•P a �2y 1 ZIp %1!I�O-± d CROSS ST. -V CERTIFICATE OF EXEMPTION FROM WORKERS' // NO. OF BLDGS. P 4^4 f' ASSESSOR COMPENSATION INSURANCE SIZE OF LOT(pU I NOW ON LOT C•.^ MAP BOOK PAGE PARCEL (This section need not be completed if the permit is for one '`( / US ONE j MAP D TRACT/5 j G BLOCK LOT NO. / O. hundred dollars ($100) or less.) Y TEL. q FECAL CL 0 I certify that in the performance of the work for which this OWNER %'P G(,/pN� NOd J�d� CONDITIONS - permit is issued, I shall not employ any person in any manner [^ /� DIS RIOT GROUP TYPE FIRE OC ED BY U so as to become subject to the Workers'Compensation Laws. ADDRESS V V a� L.rD hs L��// 2 -` CONST. OTY � Cir, /J ` /� q Date Applicant `-/` C1� ZIP / STATISTICAL CLASSIFI ATION APL C NDO. l� NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT R TEL. ty ENGINEER NO. CLASS NO. DWELL. UNITS_ B. Exemption, you should become subject to the Workers' N Compensation provisions of the Labor Code, you must forth- ADDRESS SEWER MAP g with comply with such provisions or this permit shall be JJ� //// //�/ _ deemed revoked. CONTRACTOW19J(A?Ar,&^ 6A Cp,,/� NO�S��/ y BK. PG, VALIDATION LICENSED CONTRACTORS DECLARATION �j / / L' I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS)� (�l0 i'~A X, / IC-'3�i'ra G 7 VALUATION (commencing with Section 7000)of Division 3 of the Business and /� Professions Code, and my license is in full force and effect. CITY 2S2 CLASS SQ. FT�J p NO. OF NO. OF CHECK License Number Lic.Class SIZE SO STORIES FAMILIES ONE Contractor Date DESCRIPTION OF WORK NEW S am exempt from the licensing requirements as I am a ADD licensed architect or a registered professional engineer ALTER FINAL acting in my professional capacity (Section 7051, REPAIR DATE ,S'z� -�r Business and Professions Code). USE OF FINAL EXISTING BLDG. DEMOL B U'�"✓ Lie.or Reg. No. _Date APPLICANT TEL OWNER-BUILDER DECLARATION PRINT Pl •?J 79d�y I hereby affirm that I am exempt from the Contractors License p�J e[ Low for the following reason (Section 7031.5, Business and ADDRESSJp/ (aFf'��/// ?�A /� •^1� Professions Code): _ P NT ❑ I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and the structure is not intended or offered for sale(Section LOCALITY - 7044, Business and Professions Code). MOVING TEL. 1, as owner of the property, am exclusively contracting CONTRACTOR with licensed contractors to construct the project (Sec- , ADDRESS :22 4 9,8 A tion 7044, Business and Professions Code), REQUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH # 0 0 0 o e 1 1 hereby affirm that there is a construction lending agency for FRONT -i the performance of the work for which this permit is issued P.L. Z ^ 2 1 4 0 0 (Sec. 3097, Civ. C.). SIDE P.L. d z7 e - 21 4005 Lender's Name J P. . e S Permit Fee Q / -- 1 D07-80 Lender's Address w I certify that I hove read this application.and state that the Issuance Fee aabove information is correct. I agree to comply with all County Investigation Fee Zzz S ordinances and State lows relating to building construction, Total Fee and hereby authorize representatives of this County to enter a upon the above-mentioned property for inspection purposes. , a SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Dole ®s WORKERS' COMPENSATION DECLARATION hereby affirm that I havecertificate of consent to self APPLICATION FOR BUILDING PERMIT insure, ora <e fficate'cyf Workers' Compensation Insurance, or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS ❑ Certified copy is filed with the county building inspec- BUILDING . tion department. - ADDRESS f Date Applicant Cm ZIP en _ . OF LOT OCALI NEAREST Y CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF.LOT w ON LOT CROSS ST. COMPENSATION INSURANCE ASSESSOR i6 (This hundred dollars ($100) or less.)section negd not be completed if the permit is For one TRACT BLOCK LOT NO. MAP BOOK 8 PAGE PARCEL OWNER ` IVO. USE ZONE NO I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner ADDRESS �� SPECIAL CONDITIONS so as to become subject to the Workers'Com ensation Laws. /7 Q DateL I _ CITY (�! ZIP Applicant �/p r�.IA.X�YI, ARCHITECT OR - TEL. DISTRICT GROUP TYPE FIRE P ESSED BY Q NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. Exemption, you should become subject to the Workers' y CONST.,/ NE w Compensation provisions of the Labor Code, you must forth- ADDRESS �/O • o_ N with comply with such provisions or this permit shall be �7 TEL. STATISTICAL CLASSIFICATION APT, CONDO. Z deemed revoked. CONTRACTOR ///JY1 I NO 2 6 LICENSED CONTRACTORS DECLARATION �I o-4j l� L , - LIC g CLASS NO.�DWF1L UNITS — I I hereby affirm that I am licensed under provisions of Chapter 9 NO (commencing with Section 7000)of Division 3 of the Business LIC. SEWER MAP and Professions Code,and my license is in full force and effect. CITY PSS. CLASS G�3 _ BK PG VALIDATION SQ. FT. NO. OF NO. OF CHECK License Number� '�� LLi c. Class G-3 SIZE STORIES FAMILIES ONE �� VALUATION t Contractor 11 rPL AA14-!� Date 9-2. %Z' DESCRIPTION OF WORK NEW ❑ _ ADD ALTER ❑ f PON.❑ am exempt under Sec. D LJba� .f^ _ B.BP.C. for this reason syn ❑ `^ �Mry REPAIR E] S Date' USE OF ,L�� II EXISTING BLDG. DEMOL ❑ Sinnnn1Tr.,_i I t; APPLICANT - _ _TEL. FINAL _ - (PRINT" _6ati }NO. i OWNER-BUILDER DECLARATION DATE , . I hereby affirm that I am exempt from the Contractor's License l iF 3701 i Law for the following reason (Section 7031.5, Business and ADDRESS CJj ( �. FINALr _ _y=. Professions Code): PRESENT -r ByEl I, as owner of the property, or my employees with BUILDING ADDRESS ' / ,-} i t`.HL 173 - 93 wages as their sole compensation,will do the work and the structure is not intended or offered for sale(Section LOCALITY b /' t 7044, Business and Professions Code.) MOVING TEL. Opp' l0"/iZ—'op tt_'_.. L(?C ARjt _ , El I, as owner of the property, am exclusively contracting CONTRACTOR NO. , with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code.) REQUIRED TOTAL SETB(,CK FROM EXIST. CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP;LINE WIDTH ''- I hereby affirm that there is a construction lending agency for FRONT c-;� u;-,-,-- the performance of the work for which this permit is issued P.t. 51 DO RIL slat (Sec. 3097, Civ. C.). SIDE ; P,I, r Lender's Name. / Q LDMA Ref. # Permit Fee Lender's Address I certify that I have read this application and state that the Issuance Fee /�'� LDMA P/C# 8 above information is correct. I agree to comply with all County Investigation Fee // e ordinances and State laws relating to building construction, Total Fee / LDMA Perm. # a and hereby aut or' representatives of this County to enter m on the abo - ti ed property for inspection purposes. a SEE REVERSE FOR EXPLANATORY LANGUAGE _ gnature of Applicant or Agent Date