HomeMy Public PortalAbout6120 CAMELLIA AVE_Building__ -------------
WORKERS' COMPENSATION DECLARATION
hereby affirm that I have Worker'certificate consent to ,elf APPLICATION FOR BUILDING PERMIT
Insure, or a 4ertificate of Work ' Compensns ation Insurance, '
or a certified copy thereof ($ec 3800, Lab. C) COUNTY OF LOS ANGELES BUILDING AND SAFM
Polley No. Company
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL JN.- BUp
ING
ElCertifled copy is filed with the county bullcling Inspec- BUILDING /.�
/tion department. �y �� e-
/�/ l S tC-
Datd 4ppllcbn„R� Com, / C! /�Ild K CITY L/' ZIP LOCALITY
NO. OF 13LDG& NEAREST
CERTIFICATE OF IDGMF ION FROM WORKERS' SIZE OF LOT G ?�p NOW ON LOT CROSS ST.
COMPENSATION INSURANCE ASSESSOR
(This section rived not be completed if the permit Is for one TRACT BLOCK LOT NO. Ak P BOOK PAGE PARCEL
.hundred dollar (;100)or less.) c Tg•
OWNER / 5 �� USE MAP
,I certify that In the performance of the work for which this SPECL4 L
permit 1341ssyed, 1 shall nbt employ any person in any manner ADDRESS
so as,to beconia subject to the.Workers'Co m pe nsat I o n.LoWs. . COtDffIONS O
CITY c ZIP 1 7�D
DatefG Appllcant�r' !C'�i ri�'15 ARCH OR TEs. °C
NOTICE.TO ICANT:. If, after making this .Certificate of BIOG EER - NO. DI I T ROUP ITYPE FIRE BY r
Exemption, you should.f? me sublect to the Workers T 4f
'Compensation provisions of the Labor Code, you must forth- ADDRESS uuCO` rrriii
with 4omply with such provisions or this permit shall be TEL STATISTICAL CLASSIRCATKDN Aim, CONDO. -
.deemed revoked. CONTRACTORsC NO. —
LICENSEq CONTRACTOIRS IDECLARATION UG CLASS NQ. UNITS
—
I hereby affirm that I am licensed under provisions of Chapter 9 ,ADDRESS NO.
(commending with Section 7000)of Division 3 of the Business
LIC SEWER MAP
and Prof [on;Code,and my license is In full force and effect. . _ CLASS BK .� f VALIDATION
SQ. FT. NO. OF NO. OFC}f CHECK
License Number I Ic. Clan SLZEr STORIES FAAAIUES ONE
- VALUATION.
Contractor Date DESCRIPTION CF WORK NEW ❑
ADD ❑
❑I ►
am exempt under Sec ALTER ❑
B.&P.C. for this reason REPAID 3
hr,rw; USE OF _ — --
EGSTING BLDG. DEM04 ❑
Slgnoturo APPLICANT TEL FINAL
OWNER-BUILDER DECLARATION ( NODATE l d L
I hereby affirm that 1'am exempt from the Contractors License
Law for the following reason (Spctlon 7031.5, Business and ADDRESS FI 1;
.Professions Code):' _
I, as owner of the property, or my employ" with ADDRESS ANT■
i
wages as their sole compensation,will do the work and
the structure Is not Intended or offered for sale(Section LOCALITY 3307 fir° r
A&CMNG TEL
' L ■ L�
7044, Buslneas and Professions Cbde:) T
❑ I, as owner of the property,am exclusively controctin9 9DNTRACTORS NO. 1 ITERS
with licensed contractors to corl>ttt'uct the project (Sec-
tion 7044, Business and Professions Code.) ADDRESS
TO
CONSTRUCTION (ENDING AGENCY3 - 25
YARD HVJY u FROM I ��i 53!25
1 hereby affirm that there Is a construction lendlrig.agency for FRONT
the performance of the work for'whloh this permit Is Issued P.L. � .Qct
(Sec 3097,'Civ. G).
P.L.
Lenders Name
LDMA Ref. t - -0401 1.0/10/89
Lenders Address P.C- FM Permlt Fee r 6.149 1 AMII:,72
I certify that I have read this application and stole that the isuancs FM LDMAfIC R
above Infornnatlon Is correct. I agree to comply with all County Investlgaflon Fee 1
ordinances and State laws relating to building construction, Total Fee 15 LDMA Perm
and hereby authorize representatives of this County to enter
=?a-mentionecl propertfor Inspection purposes,-
zk,�' °''~`'' ��a�DYa $e FAVIM FOR I)MANATO[Y LANGUAGE
Signature of Appllmnt or Agent Dav