HomeMy Public PortalAbout5208 CAMELLIA AVE_Building__ APPLICATION FOR BL" ���G P MLT
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4 COUNTY'OF LOS AN6ELZSM48,A4D-SAFETY "-
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN '
I hereby afflrm re
that I he , a certfld cate convent to soft �L SS Y`
or a cerfiftcate.d Vlbfkefs' CompwWtbn kmurarlce,or a
copy.,tibere-of(Sea 3800,Lab.C.) Crry zip!
Pd loy No. ComPQrry r-e-P- - C A,
SIZE LOT .OF BLD03 NOW ON LOT .
❑ Ceftfled copy b hereby fumlahed. QST CP109.9
❑ Cartlf i copy.b filed wttl the pormty buDc ing Yivpectbn TRACT BLOCK LOT 40.
depalt—t USE ZONE MAP NO
Date Appflcent MAP�°°"��00 o `'moo/¢
SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WOF#KERS' ra NO.
COMPENSATION INSURANCE
f-•C H c_.t. 'lit 6 3 Wm-itN 1000 Fr.OF ScHox? vl=s NO
(This section need not¢e corrq+eted H the perTrdt b for one hundred S- i� DVnT6CT pgpOp TYPE CONST. FFiE ZOiE PROCE88ED BY
.. idlers ($100)or lees-1 ZIP CITY Jl moi` ZIPI owtwhish
� .
ffy that In the Performance of the work for whish thla permft �\ e k `-C
16 l9wwl, 1 shell not employ arty person In airy manner so as to
become &ti}ct to the Wor'kere'-C-o�mpar�atbn Lam.' A TECT OR ENd EFA TEL.Na
Date_ AppilCelrt ^D .�t_,� AmRESS 111,UNrrs ,SPT Corpo
NOTICE TO APP",W H, after making this CerHflimte of REODUPED TOIL SEfBAC,X FROM E IST
ExernOW, You should becorne subtect •to the Voofsl ra': CONTRACTQR Ta NO: SET BAG!( I&J-D "ffy PROP LAE WOTH
Compeneatfon provtslons of the Labor. Code, you rmbt brt r*tth
FRONT
corr0y with such provolone or this permit shell be deemed revoked.
ADDRESS DC.NO. PL
LICENSED CONTRACTORS QECLA11ATION %DE
23
CFFY LIC.CLASS PL
I hereby affirm that I am licensed underprovbl s d Chapter 11 SEWER MAP .T
(comrrlendng with Section 7000)of Dlvbjon 3 of the BLAr*eas and 9a Fr.S= No.OF S N0.OF FAA4-E8 NEW PO 330360.71
Profeaslorm Code,and f1Ty.11cenee is In foil force and effect '
Lk ones Number Lb.clew DEScaPPTION OF F. ADD ' mu-I�ON -1 ITEMS
Contractor Date /" / ,a�T R ❑ TOTAL 960 7 1 oC
0 I am exempt render sec. • '+1F+J /(/P.t.�— R�PAI R El $ 9a� D�D I�} 1
f BAP.C.for this reason DEMOL ❑ CDMA P/C f
0 C3
Data URM El .
tura �0
t
I (PWT) No. LDMn Perm 6/9`
I; BD owner d the prop", or rrry employees with.wvQoe as Z
r
r their sole cornpenea5w, wd0 do the work and the structure Is
not InterKM or dieted for sale (Section 7044, BuNnees and Fl►1u Dae `i9
Profeasiorm Code.) w+L n-e APDL OR FUTURE MAXNo oca"Arr FIAIDLE A�zARDo�rs MaffWL
❑ I, as owner of the prope+iY, am exclusively oontwU with A MORUr1E ONTWA a A HAzAFoorm wArEFm To o i cram TKw n-e 1
A600 r SPECK ON TFIE HLVI�RDOl18 AMS�l'La 1410N GLIDE? FINAL.BY•ticerised corrtrsctore, to conetnuct the protect (sectiDn 7044, vEe❑ No❑ � ACCT.i
BuWrxeae and Pmfeaslona Code.) '}�}}�Cy7 �J'� p']
wlL THE NTE? UeE OF THE RI■il.a'a BY TRE OR FUTURE O LONG .7 71h7 IM.O
REQUIRE A PETM'T FOR COISTFiJCTON-0R�FROM THE 60UTH
CONSTRUCTION LENDING AGENCY �T AF'O1"uTM..WQElAEW 01Q1T�T MCAC&�sm�TTMO� T FOR 7 ITEMS
to rice.pw
hereby affirm that tiTere o e oonstrudbn Verldkng eperxy for Yes❑ No 1:1
r j e
N the performmroe of the worts for welch this permit Is baued(sec -TOTAL 1•x+03.46
CD I HALE READ TFE FVZAfDCkM MAFAALe rFOPwmoN a10e Alii THE eCI O PET#fTT►1.3
a 3097,CN.C.) a-Eaa.ler. lrD�QUl�D MY RECPLXlavrrs UNDER THE Los AHaaEe COl1fTV COOS ►{�/y/ CJy
Lefldere Name TITLE Z CHAPTER BECTKM 220.100 TH 0U()H 2-2Q 146 CONGER04M HVZAFOOUe CHECK 1503.46
M/U�RAL�REFORTNO AND FOR OaTAlfq A PEFMT FROM THE BCAd►O.
Lenders Bees ■00
- CVAW a err
5� I certtfy that I have need this appllbaticn and stats under penetty
d per)ury that tie above lnformatbn o correctI epee to cornoy P.C.FEE .y PEF T F'EV.}%3. -OW1 1/ 4/9-6with all county ordinances and State lave re}�na tD bulking J
oDrabixtIon, and hereby autlortze reoreeentatvee of this Canty 0UANCE FEE
two E,nt/e�r upon mB abo a mentonBd prpperty for 1r0Pea5on prrppoeea. l27- 80 409r 1 AM10:49
o /�C�.• LCL. NVESTKimoN FEF TQP1 J O
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r ~ Q ,(,� SEE REVERSE FOR EXPLANATORY LANGUAGE