HomeMy Public PortalAbout5315 CAMELLIA AVE_Miscellaneous__ woRxEP,s'coMPE4)ISATIONDECLARAT1oN
CE 876 (11-84) MISCELLANEOUS APPLICATION
CE 876
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISIO
Ensure or a certificate of Workers'Compenantion Insu=ce,or
a cart�t7ed copy thereof(Sec. 3800,Lab.C.).
Policy No. Company r FOR APPLICANTTO FILL IN ■ G
ADDRKSDR[/■
Certiflod copy Is hereby furnished. -
■uILDIHG
ADDR[■ LOQALITY
FICertified Copy is filed with the county building inspection LOCALITYH[AR[/T
department, CROSS /T.
Date rApplicant H[AR[■T DISTRICT HO OR ► Y►[ ►ROC
[■S[ Y
• CRO// ■T. CON
CERTTFIGATE OF EXEMPTION FROM WORKERS' L[ST.
COMPENSATION INSURANCE D[SCRI►TION LOT N ■LOCK LL�� X,o XRAY
wo. —G(CICL.S) /TAT[ MAJOR ■[QOHD LO L
(+TLi+ section need not beCOIDpleted If the work inyoh- d TRACT �. NOW OH LOT U/[ ZON[ ■►[CIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) 4 u•s[R ►
6 KIS
IN ■LD 6. CD
I certffy that in the performance of the work for which this /IZ[ OF LOT o
permit Is Isaaed,I shall not employ any person in any manner o.N[RNAEL
so as to become subject to the Workers' Componaation Laws
MAIL QCCVPA &Y GRQUP ,;
AODR[SS
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of CITY Mo� OCCUPANT LOAD
Exemption, you should become subject to the Workers PLICATION FOR EXIT HARDWARE:
Compensation provisions of the Labor Code,you must forth
with comply with such provisions or this permit shall be TRAIL[R U■[ ❑ G[OLOGY INS►[CTION ❑ No Spec. Know].
deemed revoked-
LICENSED
evokedLICENSED CONTRACTORS DECLARATION oCCUPANCY INS►[CTIOn Panic Devices
I hereby affirm that I am licensed under provisions Of Chapter sAP[TY ►[RYIT LIST IT[YS ■[LO7)
9 (commencing with Section 7000) of Division 3 of the Bull- No. Or [NITS
mss and Professions Code,and my license is in full force and
' PARKING R[p'D ►ROVID[D
PARKI1
License
� NumLi.c' Clao CA d6 iudg LIMITED TIME USE
Contractor WI Late DAT■ DAT=
I am exempt from the licensing requhm
roents as I am a Fwom, TO.
licensed architect or a registered professional engineer 61X[ OF NO. OF IN/F TOR'■
fitting in my professional capacity (Section 7051, Bur [XISTIHG BLDG. sT ORI[/ ■1 ATUR[
inewand Professions Code)• FINAL APPROVAL
Lic.or Reg.No. Data FR[/[NT US[ OF BUILDING
HOME OWNER-BUILDER DECLARATION NO. OF [XI/TING ■UILDINGe
' ON LOT AND U/[
I hereby affirm that I am exempt from the Contractor's -2937.4
License Law for the following reason (Section 7031.5, Buri- #•• . • • 3
mss,and Professions Code): NO. PARKING
❑ I, as owner of the prowill do the work and the
perry, /FAC[/ ►ROVID[D
structure is not intended or offered for sale (Section
7044,Buainem and Professions Code).
CONSTRUCTION LENDING AGENCY PROPOSED U/s OF BUILDING +'j \ .'• ` ', 8'�`5
I hereby affirm that there is a construction lending agency ti 8 8
for the performance of the work for which this permit L
sawed(Sea 3097,Civ.a).
Lender's Name
PR OPO■[D MAX. OCC.Lender's Address :1 9 3 9,'9 A
I certify that I have read thisapplication
FHH application and state that the 0 # 0,0 •.• 3 0
above Information Is correct I agree to comply with all Coynty ISSUANCE FEE
ordinances and state laws relating to building construction, I •,/ 8 a 5 0
and hereby authorize Iepresentattves Of this County to enter TOTAL FEE 8'a 5 0 6
upon a above m on property for inspection purposes. ` '
(✓(/1/,. L L� SEE REVERSE FOR EXPLANATORY LANGUAGE g- 0 41 rJ I;8 8
Signitufe of Permittee Data / ����