HomeMy Public PortalAbout5827 CAMELLIA AVE_Miscellaneous__ �WOIaCCRS'COMPENSATION DECLARATION
CE 875 (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 DIVISION
insure or a certificate of Workers'Compensation Insurance,or
a cdrl�fied copy thereof(Sec.3800,Lab.C.).
Policy No. Company FOR APPLICANT TO FILL IN BUILDING 7
ADDRESS
Certified copy is hereby furnished_ BUILDING wA LQCALrry
ADDRESS 10
ent. is flied with the county building inspection LOCALITY !'�_, /1?�� ��c� REM[/T
VVG .7 CROSS /T.
Applicant NEARESTDISTRICT MO 6 OUP TYPE PROCESLED ■Y
CRO■S ■T. CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSA'T'ION INSURANCE DESCRIPTION LOT NO. I.L.C. Yw HIGHWAY
RO. (CMCL/) STAT[ MAJOR SL'COND LOCAL
//��,��'�
NO. OF BLDGS.
(This section need not be Comppleted if the work involved TRACT NOW ON LOT USE ZONE ■r[QIAL CONDITIONS
by the permit is for one hundred dogs ($100) or lees.) USE of
LIZ[ OF LOT Ex IDTING BLDG. /
I certify that in the performance of the work for which this o
permit is issued, I shall not am Y P� In any manner OWNER m l
so u to become subject to themp ., Co tion laws. MAIL 2OCCUPANCY GROUP
ADDRESS
Date 0 Applicant TEL
NOTI TO APPLICANT: If, after making this Cortiflcate of CrrY No. le
`Y OCCUPANT LOAD D_
Exemption, you should become subject to the Workers APPLICATION FOR EXIT HARDWARE: K
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be ❑ ❑ No Spec. Know[.
deemed revoked. TRAILER U/E 6[O LOGY INSPECTION
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices
I hereby affirm that I am licensed under provisions of Chapter
9 (commencing with Section 7000) of Division 3 of the Busi SAFETY PERMIT ❑ (LIST ITEM/ BELOW)
NO. OF Exrt■
mess and Professions Code, and my license L In fall force and
effact. av PARKING REO,D PROVIDED
■PAC[1
License Number Lia Class LIMITED TIME USE
Co ntractor Date DAT. DA r'/
PwDYI rDl
I am exempt from the licensing ng requirements as I aa
licensed architect or a registered professional engineer SIZE OF No. oP IN■PECrOR•■
acting In my professional capacity (Section 7051, But Ex ISTING BLDG.
STORIES BIG ATURE
inm and Professions Code). FINAL APPROVAL
PRESENT ULE OF BUILD INC / f
Lic.or Reg.No. Date _
HOME OWNER-BUILDER DECLARATION NO. OF KXILTING BUILDINGS ■,�
ON LOT AND USE
I hereby Affirm that I am exempt from the Contractor's 1 ITM
License Law for the following reason (Section 7031.5,.Buri- TUAL 80.51131
ness o(anions Code): NO. PARKING
as owner of the property, will do the work and the /PwaE/ PROVIDED CWCt 80.50
structure Is not Intended or offered for sale (Section /
7044,Business and Professions Code). ----- ... .00
CONSTRUCTION LENDING AGENCY PROPOSED u/E of BUILDING
I hereby affirm that there is a construction lending agency 0DW-W01 5/3DM
for the performance of the work for which this permit is
issued(Sea 3097,Civ.C.). 3%7 1 AM 832
Lender's Name
PROPOSED MAX. OCC.
Lender's Address
PERMIT FEE
I cez- fy that I have reed this application and state that the 7 J
above information is correct I agree to comply with all County IeeUANCa FSE 6
ordinances and State laws relating to building construction,
and here autho a representatives of this County to enter TOTAL FEE Q D
upon VO-m oned property for insp on purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
tignature of Permittee Data