HomeMy Public PortalAbout5138 CAMELLIA AVE_Building__ iW
WORKERS' C0MPETJSATION DECLARATION
affir hat I have a certificate ns Compensation s to self AP P L I CAT.I O N F.O R� BUILDING P E RM I T
Insure, or a cSate of Workers' Comperutrtlon Insurance,
or a certified ropy thereof (Sec 3800, tab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
BUILDING
❑ Certifled copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS
ElCertified copy Is filed with the county building Inspec-
tion department.
Date Applicant CITY OF P LOCALITY G
BLDGS. NEAREST
CERTIFICATE OF-D(EM31lON FROM WORKERS' SIZE OF LOT NOW ON LOTCRO55
W1 /
CCPEl1SAT1ON INSURANCE
ASSESSOR
(This section need not be coal Ieted If the permit Is for one TRACT BLOCK LOT NO. MAP BOOK PAGE PARCH
j hundred dollars ($WO),or less.
OWNER NO. no � L75E'ZOPE. MAP
i I certify that In the performance of the work for which this
ONS
f permit Is Issued; I shall not employ any penson In any manner ADDRESS (TI
to as to become subled to.the Work CbmpensatIon= J O
CITY C/ I zIP
Date Applicant ARS T� DISTRICT GROUP TYPE RE PROCESSED BY O
NOTICE O I If, after mI
this Certificate of ENG1N� NO. T.`
Exemption, you should beconlo' to the WorkenaCompensation provisions of the Labore, you must forth- ADDRESS �� ✓ '
with comply with such provlslorls or. ,this permit shall be TEL FATJSTICAL gASSJF7GeTpt1 spT. OpNDO,
deemed revoked. a CONTRACTOR NO. Z
LICENSED CONTRACTORS DECIARATIQN. LIC CLASS NO. UNITS
I hereby affirm that I'am licensed under proylslons of Chapter ADDRESS ADDRLSS NO.
(commencing with Sectlon 7000)of.Dlvlslon 3 of the Buslnew LIC SEWER MAP
and Professions Code,-and my license Is la full force and effect. CITY CLASS BK. PG. VALMATION
SQ. No. OF NO. OF Cl-sECX
License Number LIc Clash Sig STORIES FAMJUES ONE ,
VALUATION
Contractor Date DESCRJPTI ON OF WORK NEW ❑
❑I am exempt under SeADD El
c
- _ _ ALTER ❑ ,
B.BP.C. for this reason REPAIR ❑ ;
Dare:
USEOF
EJOSTING BLDt,. DEMOL ❑
Signature APPLICANT - T� 0INAL t
CtWNER-BUILDER DECLARATION
I No. DATE
I hereby afflrm that I am exempt from the Conirodoes License -
Law for the following'reason (Sgdlon 7031.5, Business and ADDRESS FI 3337 .01
Professions Code): j�
El1, as owner of the property, or my employees with ADDRESS—
Wages as their sole compensation,will do the work and LOCALITY - pool '. `l`_, `� `l ;.• '{ t,` �
the structure is not Intended or offered for sale(Section '11f-16.13
7044, Business and Professlons Code.). MOV1NG TB-
I, as owner of the property, am exclusively contracting CONTRACTOR NO.
with licensed contractors.to constructthe-project (Sea ADDRESS -
tion 7044, Busingss and Professions Code.)
R! U TOTCONSTRUCTION LENDING AGENCY SET YARD — t, �L, I 1 •I
I hereby affirm that there Is a construction lendinfl agency for FRONT - 'r�ITIIL 1L. 6
the performwnce of the work for which this permit. Is Issued P.L.
(Sec 3097, Civ. C.). . SIDE. . 1175.IS
P.L
Lenders Name
#�� 17
Lendef's Address _ P.0 Fee Permit Fee KJ +
o
I certify that I have read this application and state that the 1 Q -um P/C I..
O abovq Informatlbn is correct. I agree to comply with all County _ Invearlgat]on Fee
4R ordinonces and State laws rolaNrt9 to-building construction, Total Fee c LDMA Perm
and hereby author" representatives of this County to enter 47`5' `5
upon th above-mbntlbned pr for Inspec'tlon purposes.
SU RtllIIIIIIIIIS1111 POR EMANATOI.tY LANGUAGE
Appllcant dF&eiit Date '