HomeMy Public PortalAbout6028 CAMELLIA AVE_Building__ APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES. BUILDING AND SAFETY .
WORKER'S COMPENSATION DECLARATION
FOR TO ML IM BtXLDNa APDRE e
W
I hereby MIM. W I Fuavra a tordfldari of oorEent to self kEure,
BUUZXW ADDRESS
or a cgwWjca of Wbri4erl C,omperwatlon Irwarwrce,or a certtliad P W
ooPy thered(80d.300a Lab-a) Loc-�L" _
Pbiloy No.- CoiT Y =9 OF Lor I I OF DCAnow ON LOT 011 T
Q C*tfW ODPY Is hereby f ankhed. NPJ1F433T CRO98 ST,
TRY❑ py r'AW wnh the oounty Wk kq rrpaoriori f'I �OC-K- uBe zor E MAP no.
YAP HOOK I PAFICEL
Date Apploen) 4 3s
SPECIAL COPDrnow .
CI*MF1CJ M Of EI�ON FROM MORIQ?RRS'. 1^ 17a . I Y no
COMPENSATION*lMXU *Ct wnrrw woo Fr.OF.✓'cHoc L?
(fhiae0ction need not be cd n*W K the petnift Is for one hundred T Pie mrrE
($100) be)
1 cwttfy thid h'tie perfrreroal work for vhbFOils p.rmt LINDA
Y Mewed.Dell not_ampioy am person In any manner so r to on
bsoorrfe sub}eot to ttw Wbri"Compar"Jgn LEDs. awgt3lFlcAron APT
Dam AP~ Cl'96 NC Q(� DIMt3L IMrB
ax!
NOTICE TO APRJCA T.- tf, of er making this Certffldale of TEL NO. �� TOM
U-SETBACK FROM Deer
Exelnptlpn, you, should become sub}aot to the WorM 1 aET BACK YARD F PROPL� Wt
DTH
FF;
Compwraon provisions of the Labor Code,You must forttrwfth` I �iDs .
oompy w tth such provision or U*pwmlt etre"be deemed revoked Ly-l-n0. PL.
LICENSED CONTRACTORS DECLARATION Crrr Ua� P of 23
El
1 hereby aM rm that I am PoKwed under provYions of Chapter 9 ea FL t31�• na OF MWVM NO.OF r-AAU LES et I YAP ANT
(oornmerok>b with Section 7000)of DtvWon 3 of the Bu realm and D NEW Bei , r� 07 491.94
ProleeaiDne Code,and my lc6nes ie kr iul kxtks and effect
Uc.erre Number Lim a� coo
I 1 ITE M3
-Contractor Dari ALTM ❑ # SS
. I�r�,vla "❑ T1�TAi. 4� 1 _�,,�•�
❑ I ern.»rr>pc under sea # �/ 7 C�EM 491.94
EL a for this ration uer o f �FA DG
d��L ❑ LDMA PIC a [ ,�
Signature LDYAPWM,# *. F1LC:T 1
❑ I, as owner of the property, or my empivyeert wrtfh w�pee r ► 1 104
{�',h�/
their sob comperEailorr wrt31 do the work and the etruotun M 17s11�taArt 1 . O■
not Inlerided or offered for sale (SeMon 7044, Bualnew and 1 ITE )
C'd�') wle_L DA rinll�ER�r�n OOOUPRIM'T FWOkaAtiAZAROdIA '• L✓ ,
OR A��COWMM w A ■mAraaAi sajAL i «+qr HAN T TAL 1419.L
I, o owner of the property, am c-knt*y oDrftac*V vtth THs AYaMe�t9 oN Tee K%zARnoue raswis erorww>om eucar FNIAL BY >
60;e ed oontr.otors to oonetnrat_the pro}eo(.{Seddon 7044,. yes❑ " no❑ �'ti 141 .C
Buindes and Probeebn Coda)
wu M erraOm uer�Tre suLoew sr rt.Amus Wrr dR rUnm E.DM C .1717
o�r+TRvnusEA roe+conerw.iona+dRrooprKr*NMrarrresami
CONIMUCTION IZIMMO AOE7#CY coffer As QuAurr rAr�rr DwrwcT lecaobt R mraffn no od�RaeTKM OADMJNW
I hereby affirm thaf then Y.a eonon-don$endfng egan y for rs❑ No❑ rr r-i
the pkforrnnoe oFthe workfor whldh thk permit is knu d{Sec+7p READ TI;HAZAFO"WRfaALB*00FMMUXM cua AND ni @OAQW � �1 2/ 4/K
Op• 3097,Ctv.a). "'O000e° ZJLOHAPr"NDUMPAND MY!RLM MOTX r. ,00uaR`01�'rnouor+L"-OCO+dEFPGW 11. 1 b2 1 Aft 9:41
d L.wider.Name 30 a MffMW a FKPOWM ARO Ron o PAM A PMWT RACY TM WOCMM
Lander's Addr ew
a�
I awtHy that I�nad this appkatkm and a"that the
thfortnadlon Is correct. I agree to oDrn* with all P rPff �t
ordkEnoee and SUM WM reiatklg to buk&v oonetrtrcftr ° qN
t,er.by wrttrorta r.pre..rrtaiivfo of this county to«viMOUAr2 FFA 7� A b
the for purPS _
F - I,vton F� rovL F�
SEE REVEFM KM DQPLAMATORY LAMOUAOE