HomeMy Public PortalAbout5145 CAMELLIA AVE_Miscellaneous__ _WQRICEW_g0MPENSATION DECLARATION 76M"4
CE 878 (2-80) MISCELLANEOUS APP1,ICATION
I hereby affirm that I have a certificatelf C
of consent to IOU OF LOS ANGELES BUILDING AND SAF'E'TY DIVISION
tnzure;or a certiflcat&of Workers'Compensation Insurance,or
■certified copy thereof(Sec:3800,Lab. C.)
Policy No.—Company FOR APPLICANT TO FILL IN BUILDING �.�
❑ ADDRK■S
Clertlfied copy V hereby furnished.- BUILDING , ��T J Gf►7 �GL
T LOCALITY
❑ F ADORE/■ '
Cbrtifled,copy is flied with the county building inspection NKwREer
dop§rtmant. LOCALITY CRO// ■T.
Date Applicant NKARKST ` /� `' y/-C DISTRICT NO. G OUP TY K FROCKS/KD ■Y
CROS■ ■T. / go .DO S CON/T.+
CERTIFICATE OF EXEMPTION FROM WORKERS' L/GAL f /// J �/ IF
COMPENSATION INSURANCE DESCRIPTION I LOT NO. -LOCK yA► HIGHWAY STATE MAJOR SECOND LOCAL
((��r�hLi�s� >_d
NO. OF MLDGS.
Ho. (CIRCLE)
�aiiu SeCt10II-IIOOd not be completed if the work fIItOhOd TRACT NOW ON LOT USE ZONE ■P ECTAL CONDITIONS '
by the permit is for one hundred dollars ($100) or fess.) /f_�vu■E or
o
I certify thst In the performance of the work for which this SIZE OF LOT 14 117 KxISTING BLDG. Cr
perrptt to lssu6d, I shall not employ any perio❑ In any manner OWNER
Sdu'fwp// 0 jr ow o
so as to become subject to the Workers' Compenpatlon Laws. MAILOCCUPANCY GROUP [?�� W
DSte Applicant ADDRKss ��✓� CA,*1Sli 4A- p
NOTICE TO APPLICANT: If, after making this Certificate of CITY �m`� ei NOI ( ag7� ,Zb OCCUPANT LOAD ` Z
Exemption, you should become subjpct to the Workers'
Compensation provisions of tbe.Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE: '
_ with Comply with such provisions or this permit ahall beryeAILER U/E Q ascoLOhv IN/PSCTION 1 NDS c: Know El1,
deemed revoked El � t ❑
urANCY U49PUCrtora Panic DBViCBS
LICENSED CONTRACTORS DECLARATION oac ❑' _
I hereby affirm that I ash licensed under provisions ofChapter ■AFKTY PERMIT (LUT ITUM■ BELOW) NO. or EXITS
9 (commencing with Section 7000) of Division 3 of the Bali-
ness and Professions Code, and my ilcertse Is in full.force and B/}r 1XQ PARKING effect. RKa'D PRovIDEo
' SPwcRs
License Number Lic.Class LIMITED TIME USE
Contractor Data D AT. DAT i
I am exempt from the IlcerulnQ requtrements as I +m ■ ►"oy: TO[
licensed architect yr a registered professional engineer slzx Orrye, Or IN/PKCTOR'■
acting to my profeastonal capacity (Section 7051, Bus- KXISTING BLDG. 1 r� ■TORIE■ \• ■]ONATURK
tress and Professiotu Coda). PRESENT USE Or BUILDING ��s�lj � L _ STINAL APPROVAL
Lic.or Rek.No. Date
HOME OWNER-BUILDER DECLARATION N LOT AN AND UNG BUILDING/ I ` '
ONO-OK USE
I hereby pffh-m that, 1 am exempt front the Contractor's ACCT.It .
License Law for the following reason (Section 7031.5,ss liusi No. P/tRKINa7 �j,tf(i
Geand Professions Code): ■PACK■ PROVIDED
I, as owner of the property, will do the work and the 1 IT�j
structure Is not intended or offered for sale (Section _
7044, Business and Professions Code). PROPOSKD USK Or BUILDING TOTAL 93 - 1130
CONSTRUCTION LENDING AGENCY CHECIV, 9J•0
1 hereby affirm that there is a construction lending agency . I
for the performance of the work for vKhich this permit is
Issued (Sec. 3097,CtR.C.).
Lender's Names PROPOSKD MAX. OCC.
00 IG-ow 1 4/1:V91
Lender's Andreas PERMIT Fels, O " �,�1
I certify that I have read this application and state that the 64 4 1 AM 10:ID
above hAormatlon is correct. Iagreeto comply with all County ISSUANCE FEE
,
ordinances and State laws relating to butlding construction, TOTAL FEE 3•
and hereby authorize representatives of this County to enter
upon t ve- tion prop for inspection purpose. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date