HomeMy Public PortalAbout5826 CAMELLIA AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 76
CE 875(2-80) MISCELLANEOUS APPLICATION
I hereby affIrmcert thiIcat I have a ceCompte of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DMSION
Insure, or 1"aertiflcate of Workers'Compensation Insurance,or
■certified copy thereof(Sec. 3800,Lab.C.)
Policy No. Company FOR APPLICANT TO FI L IN IS I LD1 1.4
ADD RKIN■ C!
❑ Certifle¢copy L hereby furnished. BUILDING
❑
Certified copy Is filed with the county building Inspection
LOCALITY
ion NKA
department. LOCALITY CRO■f .T.
Date• Applicant NKARK■T DISTRICT N rur TYPK PRO KD AY
CROSS ■T. � CONST. '
CERTIFICATE OF EXEMPTION FROM WORKERS' LKGAL V
COMPENSATION INSURANCE DK/c RIrTIoN LOT No. I.L.C.
YAr HIDH�AY }
no. (cIRCL/) •TATs MAJOR ■CCO LOCAL' a
//��r�h{,�is� NO. Or BLDG■.
�a.ua� &eCtLOn need IIOt be COm sated it the R'OiY 1nVOlved TRACT IND.
ON LOT u/ ZONE KPKCIAL CONDITIONf .
by the permit L for,one hundred dollen ($100) or'les.) u■¢ or/TING BLDG. 2)
r✓ [[
I certify that In SIZK Or LOT KXI the performance of the work for which this .
permit is hued, I shall not`employ any person in anOy manner OWN 0
to as to become subject to the Worken'.Compenutlon Laws. ADDMAI OCCUPANCY
4 OCCUPANCY GROUP. _3 W
Date Applicant_ Z
TKL.
NOTICE TO APPLICANT: If, after making this Certificate of CITY No. OCCUPANT LOAD
Exemption, you should become subject to the Workers' APVtICATION FOR EXIT HARDWARE:
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit &hall be. TRAILKR UfK E] GKOL6aY INSPECTION Q No Spec. Knowl. ❑
deemed revoked.
LICENSED CONTRACTORS DkCLARATION
OccuPANCY INSPEC'noN Panic Devices ❑
I hereby affirm that I am licensed under provisions of Chapter ■AFKTY PK MIT 1 (LIST ITCMa■KLOW1 NO. Or CRIT■ ❑
9 (commencing with Section 7000) of Division 3 of the Busi-
nes& and Professions Code, and my license Is in full force and
effect. PARKING
( /PACKS RKQ'D E:= PROVID KD
License Number Lic.Clans-
- LIMITED TIME USE.
Contractor Data DAT/ DAT/
❑ I am exempt from the licensing requirements as I ams TROY l To.
licensed architect or a registered profeWonal engineer ■IZK or No. or INSPKCTOR'■
acting In my profe/alonal capacity (Section 7051, Bus- KXI/TING BLDG. ■TORIK■ NATURE
iness and Professions Code). PRKeKNT USK Or BUILDING FINAL APPROVAL
LIc.or Req.No. Data
NO. Or KX15TING BUILDINGS c}6 Jr A
HOME OWNER-BUILDER DECLARATION ON LOT AND UaK
I hereby affirm that, I ■m exempt from the Contractor's
# • •.• • 30
License Law for the following reason (Section 7031.5, Busl- I • - 8(150$(�Jr 0
nese and Professions Code): No. PARKING
SPACES PROVIDKD
❑ 1, as owner of the property, will do the work and the o • •`8 0 Jr 0
structure Is not Intended or offered for sale (Section
7044, Business and Profeaslons Code). {
rRoro/KD u/K or ■u1Lo1NG
CONSTRUCTION LENDING AGENCY
I hereby affirm that there Is ■ construction lending agency
for the performance of the work for which this permit Is
issued (Sec. 3097,Civ.C.).
Lender's Ntme
• rleoroeKD MAX. occ. '
Lender's Address PERMIT FEE
I certify that I have read this application and state that the /D
above Information is correct.I agree to comply with&H.County ISSUANCE FEE
ordinances and.State laws relating to building construction, TOTAL FEE V"s■nd hereby authorize representatives of this County to enter
u on the above-mentioned propert r Inspection purposes. BEE REVERSE FOR EXPLANATORY LANGUAGE
Signature o Permltt Data /`•/p
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