HomeMy Public PortalAbout6155 CAMELLIA AVE_Miscellaneous__ WORKERS'COMI.PEN,SXTION DECLARATION ce s a(��o) M ISC E L.LA N�O US 'A PPLICAT f01�
1
hereby affirm that I fhave
Workers'
a eertlflcate ti concent to ,elf COUNTY OF LOS ANGtLES BUILDING AND SAFETY DJVBIO
insure, or ■ certificate of Worker'Compensation Insurance,or
e certltled copy thereof(Sec. 3800,Lab.C.)
PQllcy No.— 'GoInpany �uILDIRa 's
• FOR APPLICANTTO FILL IN woDR[a■ -
❑ Cert ifled Copy Is heroby furnished. BUILDING LOCALITY -
ADDR[■■ ( .
�. Gertifled copy is filed with the county building Inspectlon N[AR[aT
dOpRrtmart. LOCALITY 1 - CR0 k 5T.
Date• Appticant - N[AR[/T - tDISTR T,p/�p Ou ■7CRO■a■T. CON/T.CERTIFIdATE OF EXEMPTION FROM.WORKERSL[OAL
COMPENSATION INSURANC=E b[/CRIrTION LOT NO, _ *LOCK P' rl HIGHWAY
. �( S(ClwaLi) _STATIC MAJOR /s{ ND LOCAL
/��+bI,i�g� �I,, Im NOW O BLDG/. ^
1+•�+ wy1wII need not b0 CbIIlI)leted if t110 �VO C� WYVITOd TRACT � NOW ON LOT U ZON[ ■r[CI]�L CONDITIONS (y,
by die permit is for one hundred dollm,,(fl OO) or-less.)
U/[ OV,
aIz[ or LOT ' KXISTING BLDG.
I certify that in the,performance of the work foi which this O
permit As Issued;I aball not employ any person in any manner OWN[ `." t
so as to become subject to the Worker' Comperuatlon Lawn. MAIL OCCUPANCY GROUP;-: �` W
AD DR[S■ 6.1 a
Date Applicant (�]
NOTICE TO APPLICANT- - ` T[L G Z
ANT-"If, after tnaking�this Certificate of CITY I Me. 'O 7 OCCUPANT LOAD
Exemption, you should become subject to the Worker'.
Compffinsatlon provisions of the Labor Code,you:must forth- APP4IGATION FOR EX IT HARDWARE:
with comply with such provisions or this pwmtt shaIl be TRAIL[R U/[� G[OLOGY INSr[CTION Q NaSp@c. Know]. ❑
deemed revoked. , Panic i)BVICBS ,❑
LICENSED CONTRACTORS DECLARATION OCNNSP
CurACY I [CT4oN
I hereby affirm that I am licensed folder provisions of Chapter ■AF[TY PtRMIT (LUT IT[M■ BELOW)
v, 9 (commencing with Sectlon'7000) of Division 3 of the Busl- No. or sum
neas and Professions Code, and my llcenfe)j 1n 1`0 force and PARKING.
effect. It[o'D rROVID[D .
I.Acenw Nu bar_ Lir-Clis■ LIMITED TIME USE
Contractor Dace DAT/ DAT/
Pwbia l Tol
I am exempt from the licensing requirements as I Our■
licensed architect or ■ registered professional .enginaar aIz[ or No.oP IN [cTOR's
acting Ln my prbfesaional capacity (Section 7051, Bus- KXI/TING BLDG. ■TORI[a NwruJe[
Inas a4d Profeadons Code).. rR[■[NT US[ DP 014ILDING RINAIA APPROV./+L• .
LAC.or Reg.No. Data
WX
HOME OWNER-BUILDER DECLARATION No.OF AMID USG ■uNDINGs
ON Lor AND us[
I hereby affirm that•I am exempt from the Contractor's
License LAw for the following reason (Section 7031,5;dBull- NO. PARKING
Hess and Profasow Code): ■PAC[/PROVIq[q
. ❑ I, as ownat of the property, 6 J 2
� party, will do the work and the � -. • • ?_
structure Is not Intended or offgred fpr aaiv (Section • •. '
7044,Business and Prbfesclons Code). PROPOSED U/[ OF BUILDING r
CONSTRUCTION LENDING AGENCY .} B-2 8.rg 6 '
I hereby affirm that there is a construction lending agency
_for the performance of the work for w.Wch this permit L
laaued(Sec. 3097,Ctv.C.).
Lender's Names
Lender's Addreu
PERMIT Fes}
I certify that I have read this appllcatfon and state that the -
above Information Is correct.I agree to comply with all County IfiBUANCei"Fe[
ordinan and State laws relating to bulldW construction,
670 -0
and by auth a represents ves of this County to an 'IT
TOTAL Fae'.
upo a ■b v entloned ro ty-for Inspection purposes. SEE-REVERSE FOR EXPLANATORY L ANGIYAGE
gnaturo ttee Date