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Home My Public Portal About6027 CAMELLIA AVE_Building__ WORKERS' COMP2NSATION--DECLARATION Lll 97) � ��j %Lh,t, o dffirm car that I haver cert Come of consent r ce, q p p L I. �T I O�l FOR BUILDING P E RM I T InsJie, or¢,certlficnl#of Workers' Compensation Insurance, or a certified copy thereof (Sec. 3800, Lpb, C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company BURRING Certified dopy Is hereby fumished. FOR APPLICANT TO FILL-IN ,�p� 46 8 ❑ Cer'tified copy Is filed with the county buMinq Inspec- BUIUDING CXH�. ) , 11/Jr 949 N/Ta tion departtment. ADDRLSS AIL !�, ' Y ` . Date X 1 Appllcan CITY (�/ `ZIP IACAJ Y IRTIFI TE EXEMPTION SIZE Of LOT f0D ` X� � MOw QST COMPENSATION INSURAN (This section need not be cam leted If the permit is for one TRACT BLOCK . ASSESS hundred dollars (;100.)or less. MAP PARCEi llSE ZGtNE I certify that In the performance of the work for which this O'r� ►10. — �P � permit Is Issued, I shall not employ anyPQf 1O n Ih any manner ADDRESS 4 � 4 L Q so as to become subject bject to the Workers Compe{ lon Laws. ADDRESS .rJ' zj Date Applicant r �r NOTICE TO APPLICANT. If, after making this Certificate ofmlitiff �. , NO, }OR DISTRICT TYPE RRf BY Exemption, you should become subject to .the Workeri Q CONST ZONE I .. Compensation provisions of the Labor Code, you must forth- ADORES 4 �( 10 �[ with comply with such provisions or this permit shall be - deemed revoked. COtJIRACTOR '. STATISTICAL CLASSIFICATION AFT. COttDO. Z LICENSED CONTRACTORS DECLARATION Ltc CLASS NO.1_DWELL UNITS I hereby afflrrn that I am licensed under provisions of Chapter 9 ADDRESS NO. M1 (commend! with Sectlon 7000 of Dtvislon 3 of the Business and Y_ 'rr SEWER req ) . 1 '' ;,� :- �' ,.y-�. Profenions Code,'and my license is In full force and effect. CITY Cut& BK. �-PG. 13�• VALOATION t sa SIZESTORE NO.OFFS- / License Number Lir.Clara VALUATION 2 OF WORK N�" �y j tractor Date DFSORIFTKkJ�W GfV�/ O VJE ADD , I am exempt under Sec ALTER , . A.3P.C. for this reason REPAIR $ Date: fX�isT-InNG BLDG. P-L DEMOL OF 0 4 9.2 Signature OWNER-BUILDER DECLARATION PRI /Iv^.�I� 1/ NO. - RN� I 008,78 2 1 hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and ADDRESS 1-!/B - 6,3a78'0 Professlons Code): 1, as owner of the o y employ*" BUILDING ' `: .] 0 9,'� 6"8 8 property, or m em I with ADDRESS wages as their sole compensation,will do the work and the structure Is not Intended or offered for sale(Section LOCALITY 7044, Business and Professions Code). MOVING TEL a I, as owner of the property, am exclusively contrccding �_ -- _ t �T.T No. . - .( JL with Iltensed contractor to construct the project (Sec- "ADDREW ,�' tion 7044, Business and Professlons Code} , ` 7 76 .00 CONSTRUCTION LENDING AGENCY YTOTA = 1 I1E]iS I hereby affirm that there Is'a construction lending agency for FRW ;the performance of the work for which thh permit is Issued TOTAL 762 - 00 (Sec. 3097, Cly.C.). PDE 76 .al Lender's Name DECK LDMA Ref. # .00 Lenders Addtesa P.C. Fee + Perms Fee ' I.certify that I have reo this appllcatlpn and state that the IssuarxaTee LDMA P/C# Q above InfomxHion Is correct. I agree to cpmpfy with all County . lms�noanon /1 , �-( Q1 1.{ V33 $ ordinances and State laws relating to bulldlnQ constructlon, Total Ire• O( , CO) LDMA Perm. # Q and hereby authorize representatives of this County to enter 7198 1 AM 10:O8 u the abo loved property for Inspectlo purposes. ' ly I 1111111111 111111 W i FOR KXPLAltIATORY LANOUAGN WORKERS'COMPtNSAT10N DECLARATION 1, hereby-dfflrm that I have a certfflcate of consent,to self •' Irleuie, or a certlficati of Workirs' Compehsatlon,IhWmnce, APP UC T_ 10 I, FlO R BUILI I NG PERMIT or a certiNed copy"tFlereof (Sec. 3800, ) COUNTY OF LOS ANqELES BUILDING,AND SAFETY %llcy NO.' Company _-._ , Ceeffled copy Is hereby furnished. FOR APPLICANT TO FI IN WILDING ADDR�ss D Certified copy Is filed with the county building lnspec- BUILDING tion department. ADDRESS 10.2 Date -Apolic.S CTTY nPl LOG1111Y Of EXFINPTION ! •bF ;%'c NEAREST IF _ XTEM I INSU SIZE OF Qb MOW ON LOT ST. SAT(This sectlon need not be corn leted If the permit I*for one �4 �� = ASSESSORhundred dollars ($100)or less. TRAi7T BLOOC LOT NO. /NAP BOOK PAGE PARCH ZONE I certify thai In the performance of the work for which thla � permit is tesued, I shall not erhplby any person In any mbnr»r A so-a}ro become subject to the Workers Compensation Laws FWRESS ~ _ OOt• CM Q NOTICE TO APPLK:ANTDate �„after making this�Certiftcate of It), ARlS7IRECT OR A* pISTRICT pROUp. TYPE OotzT. zQNE aY t Exemption{ you should become subject to the Work--!- 91+, CompenKdlon provislons,of the Labor Code, you must forth- A 4 1 X l R S _57 0i �1 - with comply with.such provisions or this perTnft,shall b!, t � �� Tg STATISTICAL CLASSIFICATK)t4 APT. CONDO. C!1'I deemed evoked. CCKlTRiKCTOR - z LKINSID CONTRACTORS DECLARATION Ly- CLASS NO. DWHL• iJNITS I hereby'a#Irm that 1 am IIceneed under provIalans'of Chapter 9 ADDRESS NO. commendnp with Seaton 7000)of DfvWon 3 of the Busingw and t `� ti`' S �- ;•k..'..l. SEWER MAP Ions Code, and my Ilcense Is In full fora aril effect. CITY CLASSt B PG. VALIDATION S4 FT'. NO.OF NO.Or {1iEp� Clause Number Llc Ck*ss' Sm ISS I Ota O f19,t� E{ DOMPTION OF WORK V VALUATION gap #�o'oa o e 21 Contractor date ADD : ,•— iI - 63a05 1 am exempt underNOW 7'QW11/ HO(/Sec. , ALTER 6.3 3 0 5 6 BAP.C. for this rectson kVA1R USE OP j�hT1 Q'9 1 b�8 8 Dote' Exinw BLDO. Dia AP9UCA,tlr PAAL Signature .OWNER-BUILDER DECLARATION. PRI —J 4. DATIll I hereby.affirm thqt I am exempt from the.Cbntroctora License ADDRESSN CJ FKAX, Law far the following reason (Section 7031.5, Businea and Profeselons Code): BUILDING �f I, as owner of the property, or my employees with ADD 1 ._ _ ." 'gym wgges as their sale compensation,will do the work and � �' •1 � the structure Is not Intended or offered for sale(Section _ t +;'y. 7041, Businees and Professions Code). MOVING til t J1. I, as owner of the property, am exclusively controttiny _ -. _ r-� 4•i\�'• 1 ti `�i;1 ACCT $ • with,II eased-contractors to corutruct the project (Sec- ADDRESS f t \'1 { 7 755.25 tion 7041, buslnees and Professions Code} . SEErBACX CONSTRUCTION LENDING AGENCY YARD FiV�YTOTLiPE i •i I 1 ITM I hereby affirm that there Is a conwuctlon lending agency for HZONT �t i the.performance of the work for which this permit Is issued I,\� ';!1 r t OVL 755.25 (Sec. 3097, Civ. C.). SI OEM M e Lendrs Name � - 5 COMA Ref. t OWE Lenders Address P.0 Fee i 33 101 1t Fee I certify that I have read.this application and.xtate that the lauarKe Fee s CDMA P/C ! above Informalion is correct. I agree to comply �a, with all County inveoFee IAJIRJ IARJ1 U V1919eordinances and Slate laws relating tobuilding cor,strvctlon, Taal F... "L5S ' LDMA Pa... * 7199 1 AI'i1Q:nrtia and hereby outhorLse representatives of this County to enter I u the a oned property for Inspection purposes. t�11Nf�f#PO!DMANATORY LAN¢UAW of Appl Date