HomeMy Public PortalAbout5144 CAMELLIA AVE_Miscellaneous__ wQR ERs'COMPENSATION DECLARATION 76cE ere(11-84) M ISCELIVANJEOUS APPLICATION
I hereby aM that I have a certificate of consent to self
insure or a certificate of Workers Compensation Insurance,or COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
a cer�copy thereof(Sec. 3800,Lab.C.).
Policy No. Company FOR APPLICANT TO FILL IN BUILDING
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Certified copy Is hereby furnished- BUILDINo LOCALITY ,
J
Certified copy is fliedADDR[f■6d with the county building inspection LOCALITY �'R-� X[ARKsT
department. r aR0/■ sT.
Date Applicant HKAR[eT DIVRICT NO. a UP. TYP[ PROC[S■[D ■Y
CROSS ■T. {,� J> CONwT' /
CERTIFICATE OF EXEMPTION FROM WORKERS' L[oAL J 0 v
COMPENSATION INSURANCE D[S( IPTION
LOT NO. ■LOCK MAP H"HAAY
NO. (.IRCLS) TAT[ YAJOR •[GOND LOCAL
NO. OF BLDG■.
(Thh section need not be compb�ed if the work Lnvolred TRACT NO
OX LOT US[ TDN[ eP[CUL CONDITIONS
by the permit is for one hundred dollm ($100) or Leta.) USK OF
BIZ[OF LOT XrISTINT BLDG.
I certify that in the performance of the work for which this
shall 11 0
permit L issued, I not employ any person in any manner orN[w ce
so as to'become subject to the Workers' Compensation Laws. OCCUPANCY GROUP
MAIL _ o
Date Applicant ADDR[■ T �y
T[L. L7
NOTICE TO APPLICANT: If, after making this Certificate of CITY No. 7 OCCUPANT LOAD
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code,you must forth—
with comply with such provisions or this permit shall be TRAILaR Us[ ❑ GKOLOGY IXeP[c-rloN ❑ No Spec. Knowl. E]
deemed revoked
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSP[CTION ❑ Panic Devices
I hereby affirm that I am licensed under DpLrri vizions of Chapter ■AF[TY P[RYIT E] (LIST rr[Y■ 1t L01•)
9 (commencing with Section 7000) of Division 3 of the Bu
ivi
NO. OF [xlTe
new and Professions Code, and my Ilmnse Is in ftrll force and Q J crm ,/ r
effect. i ,C G(ex i /OTz, s-i PARKING R[q'D PROVID[D
License dumber Lic. Class s � -BN! ■Pwa[■ IID
��D. �e Jlkc�rn LIMITED TIME USE
Contractor Date DATZ DAT=
ElI am exempt from the licensing requirements as I am a l�_Plvt Q- Q GA J I RDYI TDI
licensed architect or a registered profbssional engineer ■a[OFNo. of INSP[cTo R's
acting in my professional capacity (Section 7051, Bus- [x IST I Na BLDG• ITOR I[S ■I6!(A7UR[
Ineaaand Professions Cade). FINAL APPROVAL L
PR[S[NT US[ OF BUILD IN6
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION Mo. OF KXISTING BUILDINGS if
ON LOT AND USX
I hereby affirm that I am exempt from the Contractor's 4'CT'a
License Law for the following reason (Section 7031.5, Buti- 154.7,
K
Professions Code): NO. PARKING
I
s owner of the ro SPAC[S rROVID[Dp arty, will do the wor;c and the Icture is not intended or offered for tale (Sectionc c-4,Business and Professions Code). TOTk 15 o 7''f—�s
CONSTRUCTION LENDING AGENCY PPIOPOS[D US[ OF BUILDING `•I tl-�r\ 154.�•-i
I hereby affirm that there is a construction lending agency �}{ {{� .LTJ
for the performance of the work for which this permit Is
Issued(Sea 3097,Civ.C.).
Lender's Name PROPo■[D YAx. oac. agrin- Of13
Lender's Address
I cmtiiy that I have read this application and state that the PERMIT F[t �4 1 AM ��ti
above informatf n Is correct I agree to comply with all County IasUANC¢ Rs¢
ordinances and State laws relating to build construction,
and by authorize representatfvoa of this Gouty to enter TOTAL FUR
upon ve-mentio p Pty for inspection perp SEE REVERSE FOR EXPLANATORY LANGUAGE
Ignature of Permittee Data