HomeMy Public PortalAbout5833 CAMELLIA AVE_Building__ �1NQRKERS'COWPIENSAT16WDECLARATION =
" insure, orate ilfl alts off�NorVicers�CocmPer�ua on�lnsurancelf r APPLICATION FORBUILDING PERMIT
R_ M_I T
or a certified copy the-r&61 ((Sec. 3800, Lab. C:) COUNTY OF LOS ANGELES BUILDING AND SAFE�Y
Pgiicy;Nq.M4efdSA477 C' Bn,panyJ rit Nn tLJ i- euILolrlG -
0- :Certified copy Is hereby.fumished. ' . FOR APPLICANT TO FILL IN ADDRESS
Certifle�copy'1i,filed with the County building Inspec- 6UILDING )
}Ion department: ' `' ADDRESS
Date Appllcant CITY ZIP 0 LOGALFTY
CERTIFICATE bF EXEAKPTION FROM WORKERS' NO. OF BLDGS. - NEAREST..- -
COMPENSATION'INSURANCE SIZE OF LOT NOW ON LOT ST.
(This 4actlon'need not be completed If the permit Is for one - TRACT I TOT NIO PAGE PARCH
hund*ed dollars ($100)or Igss.)
OWNER NO.Z$ ZONE
I,certt4y Is
In the per fprmance TEL
of.the work for which this i SPE
permtt Is Issued,'l&hall not employ any person°Ih any manner ` ^
sops to become'iubject to the 1Arorkers'Com'pensatlon Laws. '�'�� t CONIDffIOtJS a
CITY _. -4 ZIP D
Appflcaht ARCHITECT Oil Te- DISTRIET P TYPE FIRE BY- O
NOTICE 'TO•APPLICANT;'If;•affer• m6kInb''this Certificate of NEER NO
Exemptlor�, %you should becbme-subject to the Workers' �y /�Q �j CONtST ZONE
!Compensation provisions of the Labor Code, you must forth- ADDRESS ✓t v.D. /.
with-comply with 'such provisloris or .this permit shall, be -- - --
dpemed;revok4d•.,• , . . .. CONTRACTOR' NO. 2 STATISTICAL CLASSI TKx1 AFT.
LICENSED CONTRACTORS DECLARATION - LIC CLASS NO. DWELL UNITS
1 her.&�y,off Irm thQ� MAP
I am Ilcense�urt¢er proyWons of Chapter 9 ADL>RESS NO. 71 D
(comrr�endnq wjffi Sbcripn 700tl�of DlvWoa 3 of the Buslneas and - -- . LAr �2R
Plo'fesslonr.Codp, and my'llcense Is In full force and'effeci. CITY 1rs CLASS V J� BK - _ VALIDATION
License Numbef ">r / 1 p LIc.Cldas tom` ?� Lu STORIES FAAM11JESAM
trDESCRIPr}ON'OF WOW !L G! N
Conactor til L 1�-O�r�l�1T gbote�_ ADD ;
I am exempt under Sec L4+- s/ Q oil, ;
ALTER
B.&P.0 for a reason �L1 REPAIR ;LISE Of-'
- -
Date: EXISTING BLDG. � DEAhOL _ ;-- ;243 1.4_A
Signature '- APPLK-A.NT � NO. RNAL f ' # • o o • • 1
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from.the-ContractorsllcenseA 3��/ A R • o 7$0 0
Law for the following reosbm{Secttor5 7031.5, Business and -
Ptofessioni Code):-' _ PRESENT 7 Q O O
❑ BUILDING - _ • •'• '
I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and ' 3,27--86
the structure Is not Intended or offered for sale(Section. LOCALITY
7014, Business and Professions Code). MOVING' Tli —
I, as owner of the property, am-exclusively contractlng RACTDR �'
with licensed contractors to construct the project-(Sec-
tion 70+11, Business and Professions Code). ADDRESS
.-CONSTRUCTION LENDING AGENCY SET BACX YARD HWrY PROP. UNE WIDTIi -
I hereby affirm that there Is a construction Iendlng agency for FRONT
the performance of the work f which this permit It Issued P.L
(Sec. 3097, Clv. C_). SIDE
g P.L. -
Lendees Name Emmilliiiiiiiii
SO LDMA 12•f i
Lender's Address - P.C_ Fee i Permit F•• .. '
.1 certify that i have this application and stats that the Issuance F•• LDAti�P/C! -
above Information Is co . I agree to comply with all County Invs6gatlon Fee
ofdlnan_gm 9nd S14te qws relating to building wnstrvFtlon, Total Fee `� LDALA Perm. tl
and hereb authcrl ropr n vas of tills County to enter
upon vo-m tion for Inspection purposes.
fa RiVWM POR WgAt1ATORY LAWWA69
n
of t or Agent - - Date -