HomeMy Public PortalAbout5821 CAMELLIA AVE_Building__ W/rOliXOS'COMWNS_ATION DECLARATION
'si�licfr b.fRrm that I hpve_�r tertlflcate of consent,to seff
'� tl`c�'oR;�rf,K.o sec 80o b rnCa;on IntUMr,Ce, / 8P.P L� �4 I O O R B lrI DING- PERMIT
.
( d COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No Cc,mpany� �n_ BUILDItvC
Certlfi*d•copy 1s hereby furnhhed. FOR APPLICANT TO F[LL IN r
Certified dopy is filed,wlth the County building Inspeo- BUILDING
tion deportment ADDRESS
II' Dat._A:Ere,8 Applicant CITY zip /7eV LOCA-r
CERT1riGATf C>F IDC n TION SROM. RS' NO.QF BLDGS•
' COMPENSATION INSURANCE' SIZE OF IAT NOW S7.
(This sedtion need riot'be comleted If the permit Is for bne ASVZOR
TRACT LOT'Np 721- PACE PARCEL
hur>dt•ed dollars_(;1-00)or Iessp
THIrl jr
11SE, -
I cWtlfy tbat In chi pKFofmgnu'gf.thework fot'whlch this
p*rmlt is Issued, I shall not employ any F"n In dtly mannerL.' SPECLAL
so.ato become sub�ecf to Workers Comp�rsatlon Laws. �►D+Ts p
Dari hlchnt ' - CITY T a
ZIP I _ = a
NOTK�'TO'APPUCANT� pftsf making 1hh Cirttficati of ARC�iRECT OR
9 S 8' DISTR1Ci CiR01� TYPE FRt. B1' - O
Exemption, you shoVCdbscdrhe'sub ect to the.Workers' 0W., -, .` FU-
Compefrsatlon provisions of the:Labor.Code, you must,forth- Am S(✓ �/ �y
with' comply -with such provisions or this permit shall bi R�a
4'
deemed revoked. _ TESTATI CLASSIFICATION APT. Cn
Z
LICVNSED CONTZNCTORS.DECLARATfON. - LIC CLASS NO.�D%q!L. UhiftT_ •--�
I hereby affirm that I am licensed udder provisions of,Chapfer 9 AD RESIS +�►
{commendnp with Sectiofi 7000)of DIvWgn 3 of the&txirrees and - LIG xN�hW
Professions Code, and rrry Ilcerr is In full fc",and effect:. CITY G' � VALVATION
SCS. NO.OF NO.,QF. ClIE(X BIL PCI.
9325'A
License Numbe*s95!LZ Llc�less��� VALUA
DESCRIIION of ► # ... 2 3
con . Date : .
ADD- d 67a96
❑ (am exempt ufrdqAqlze
ALTER
4o67.a95� .
B.ap.0 for rhts t•eason- •. �R
Doth: 115E OF.
EXISTING BLDG. filfroDCMOL p Q, a6-TEL
8$
slpndtunFWL4kL
- AJ�PL
a
' Q1NNEft-BUILDER DECf�4ltATION PRI No.�o DAT1.
I •by afWrn,thot I'dni exempt frorn4he Ccintrgdfar's Likens&
Law for tht following reason (Sectl(n'7031.5, Bdsiness and SS ADDRE
Pfofessfon�Cot>ke):- � -
BU I LDING
a I, as owner of ther'prpperty, or my employee. with -ADDRESS
wes as thelr sole c
adoFnpensatiori will do the work and
thio structure Is not Intended or of�ered for sale(Sectlon LOCALITY
70M,Business and Professions'Code). MOVING TF,L
tJO.
1,01 I1rc cf the prgpm"tc' am extlinivelycpntrattlnq with licensed tontrattors M cgnstrokt the proles (sec.
tldrl 7.044, Business and Professions Code). . t ADDRESS ' _ '� L�t`;_ '�.
TOTAL Elm WT . ,ti . . ,... �,�, , 1 9 6:9 9 A
COt�STRUCTIOtJ LENDING AGEIJCI Y� } PROP. UNE WIDTH
•f. .
I hereby affiYni that tbprb Is a cohatnJcHon lendlnfl agency for �ON7 W •_1. -�3 # o'o.o:o .0'1
the perfohrnance of-the work for which this permit Is Issued ( _ -
(Sec- 3097, Civ.'C'� SIDE 1 �', W
_ P.L J�, r.. •� I . t :- � I • 8,0 9,2 5
Lendefs Name , , } ;
LDMA Ret. 1 tiL.1rt »'0 8 09.'2 51
8 P.0 Fee b r7t Perm, Fee [ { ti
LenrAdd{esr
vL derttfy that J have read this gppIIg3tloo'and stcrie that the +sudnt•Fee / (� ,V O LDNA-P/� 2 a 8
above Information b correct. I agree to comply wfftt aIL County Investlpatkxi Fs*
$ ordina l!hg to building construction, Total Fee 7 ADAM Perm. i
SZ a outhorize cepreesn of thta.Cbunty to enter
the a tlo for Inspection purpos•L W y
y�
o 1h7 so RMW PM DMAMATONrY LAMgU 1W
Signature of�tppi br _ Date -- - ... - r ., _ i _ •- .. .,