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HomeMy Public PortalAbout5712 CAMELLIA AVE_Miscellaneous__ � =L1C WO COMPENSATION DECLARATION 71a CE876 (11-84) MISCELLANEOUS APPLICATION CE 8 (� I hereby have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION fnalre or a f WOrkeTe Compensation Insurance,or s certffled copy ereof(Sec. 3800,Lab.C.). Policy No. Company FOR APPLICANT TO FILL IN BUILDINGADDRKSS ^ /► ❑ Certified Copy is hereby furnished. 'v BUILDING � � � r/ / ' LOCALITY 7, ADDRIS/ G LL- ❑ department.rtifW copy 12 filed with the county building inspection LOCALITY � f! C C CRO■■ ■7. O N■ARt■T l�J © DISTRICT NO, 6 OUP TYrt r C<■1■D ■Y Date Applicant aRofs ■T. -� CONST CERTIFICATE OF EXEMPTION FROM WORKERS' Lt GAL / COMPENSATION INSURANCE DR,CRIPTION LOT NO. ■LOCK YAP HMHRAY ■TATA: MAJOR ■1COND LOCAL No. 1.1.C L/) l+�"� NO. OF BLDG/. Section need not be o`o- ted If the work involred TRACT NOW ON LOT U■t ZONt ■P■CUL CONDITIONS by the permit is for one hundred dollars (;100) or len.) SK o,• /Izs OF LOT ....TING BLDG. I arrttPy that in the Perfomnanco of the work for which this permit L issued, I It not employ any person}n any manner o■,RUR so as to become subjee ct to the Workers' Compensation LaWL MAILAD OCCUPANCY GROUP � o ORB/■ Date Applicant C NOTICE TO APPLICANT: If, after makJng this Certificate of crrY NoL 70 OCCUPANT LOAD y Exemption, you should become subject to the .Workers' z Compensation provisions of the Labor Code,you mutt forth- APPLICATION FOR EXIT HARDWARE: with comply with such provisions or this permit shall boEl deemed revoked. TRAIL■:R USX ❑ 6BOL06Y INfPtC7IOM ❑ NO Spec. Know]. IPanic Devices A LICENSED CONTRACTORS DECLARATION occuPANcY IN1PzaTION [:] I hereby affirm that I am licensed under ns of Chapter 9 (commencing with Section 7000) of D On 3 of the Buss- ■AFLTY PCRYf[ L] (LIST rrtY■ EKLOW) NO. OF t7CITS mss and Prof"&ns Code, an m L in full force and eff6ct. TePtArrPARKING RRq'D p.OVID■D \ RPACK■ License Number Class \ LIMITED TIME USE Contractor Date T` DAT■ DAT: ❑ I am exempt from the licensing requirements as I am a OY1 TDI licensed architect or a registered �'profbssional engineer D:s of o. oP INSPtcT ■ acting in my profesdonal Capacity ,{ (Section 7051, Bus- 1xISTING BLDG. TORIC■ ■I6 NA t inessand ProfeasionsCode). FINAL APPROVAL Lic,or Reg.No. Date PRsstNT u■■ o� ■UILDIn6 HOME OWNER-BULLDER DECLARATION NO.Or KXISTING BUILDINGS ON LOT AND U/[ I hereby affirm that I am exempt from the Contractor's .�J(]] L It c License Ldw for the following reason (Section 7031.5, Buil- nen usf �� nen and Professions Code): O.PARKING 1 I I, as owner of the property, will re 1PACB■ PROVIDBD CARthe work and the TC17AL 234 - 45 structure L not intended or offered for Bale (Section 7044,Business and Professions Code). {( y 234-. 5 CONSTRUCTION LENDINAGENCY PROPOS<D USK OF BUILDING 03 I hereby affirm that there L a copAruction lending agency L ffRRHH�•• for the performance of the wo for which this permit is fuued(Sec, 3097,C1v.C.). � r1 Ufc?4 Lender's Name 4710 1 F11 D 1 ` PR OP O/■D MAX. OCC. Lender's Address I t I have read this application and state that the PERMIT F6E above' o tionis co eet I agree to comply with all County IaeuwnCK FKK �p. or cc and Sta to buildh* construction, and a an tho r attves of this County to enter TOTAL F[[ 3 up above-m o perty for Pu osea SEE REVERSE FOR EXPLANATORY LANGUAGE of P ee ate