HomeMy WebLinkAbout1028 FAREL AVE WORKERS'COMPENSAT�ON DECLARATION �' ���
I hereby affirm that I have a certificme of consent to self APPLICATION��FOR �BUILDING PERMIT
insure�or a certificate of Workers'Compensation Insuranca,
� or a[ertified copy ihereof(Sec.3800,Lab.C.) - �
COUNTY OF LAS ANGELES , BUILDING AND SAFETY
PolicyNo. Company BUItDiNG
� Certified copy is hereby furnished. F�R APPLICANT TO FILL IN ADDRE55 �d � � 1 �
� Cerlified mpy is filed with fhe county building inspec- BUILDING /
tion deportment. ADDRE55 IOCAItTy /
� NEAREST /'�
Date ApplimN CITV 21P CROSS ST. C-
CERTIFICATE OF EXEMPTION FROM WORKER$' NO.OF BLDGS. ASSESSOR
GOMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEI
(This section need not be completed if Ihe permit is for one USE ZO E �P
hundred dollors(5100)or less.) TRACT BLOCK lOT NO. � No. -' �
TEL Q SPEOAL ,(' T �O }
I certify that in the performanca of tha work(or which this owNER N0�7/� Cr' CONDITIONS f/ /%�L /� �L' 6.
permlt is issued,I shall nol employ any person in any manner / Di TRiCT GR UP TYPE FlRE PR SSED BY 0
so as to betome subjeti lo fhe Workers'Gompensafion Laws. ADDRE55 � /� �L • � � CONST.f ZONE � �1
� 02 3 t' � �zf"_. o
Date Applimnf ��ty Z�P STATISTICAL QASSIfICATION APf. ONDO. F-
NOTICE TO APPUCANT: If, after moking this Certi(icafe o( ARCHitECTOR e�. U
�Exemption, you should betome s�bject to the Workers' ENGiNEER i O. Cu�55 NO. �/ �WEIL UNITS c
Compensation provisions of tho La6or Code,you must forih- qDDRE55 � � - SeweR�P N
with mmply with wch provisfons or this permit shall be / Y �
deemedrevoked, COMRACTOR V Uy NO. BK.IX PG.�� VALIDATlON —
______.____.__LICENSEDCONTRACTORSDEQARATION____.__________ _____._ __.-____.._ _-_____.__..__.__L�C...__._-__-__.___ ._-___.______________-_______..- _
I hereby affirm that I om licensed under provisions of Chapter 9 AD�RESS NO. VALVATION
(commenting with Section 7000)of Division 3 of Ihe Busineu ond ��� / ���1�
Professions Code,and my license is in(ull forte and effeU. CItt C1A55 S �> , �
� 50.FT. v/ NO.OF NO.OF CHECK
license Number lia Closs 9ZE STORIES I FAMILIES I ONE
COnlraCtor Date OESCRIPfION OF WORK
NEW � S
�I om exempi under$ec. � ADD �n '
ALTER ❑ FINAL '-o
B.BP.C.for fhis reason -� REPAIR � DATE �.9-�j=� +� � � . . � i
USE OF pEMOL /
Date: EXISTING BLDG. ❑ gY A� /��'�fj i I • � �� ?, ,
5(gnature APRICP.NT TEL ���� � . '
OWNER-BUIIDER DECLARATION PRWT E n10. J ' i ��� - -.
I here6y o(firm lhot I am ezempt from Ihe Contractor's Ucense q DRE55 oc N�C.�G ► '� � �
Law for the following reason(SeUion 7031.5, Businese ond ' �' � � �
Professions Code): PRE EN
� I,as owner of Ihe properiy, or my employees with AD'DR 55
wages as thetr sole compensation,will do fhe work and
the stractare is not intended or offered far sale(Section ��4L1TY
7044,Business and Professions Code). MOVING TEt.
� I,os owner of fhe property,am exclusively canirociing CONTRACTOR NO.
with licensed contmctors to construd the projecl(Sec- ppDRE55
tion 7044,Business and Professions Coda).
CONSTRUCTION LENDING AGENCY REOUIREo TOTAL SETBACK FROM EXIST. � ,
SET BACK YARD NWY PROP.IINE WIDTH ,
1 hereby affirm fhat Ihere is a construction lending agency for FRONi � � � � �
the performance of Ihe work for which this permif ie iesoed v.i. � -
tSec.3097,Civ.C.). soE . '
m �,u,�,��r�r n� P.�. ��_ ;
Lender's Nome
$ Lender's Address�Qa�Ci� ���,���'�f—���— P.C.Fea S Pe.m�t Fee /� �� '
� I certify that I hava reod this applimtion nd sta5 te that the I:suan<e Fee �� � �
� obove information is correct.I ogrea ro tomply with oll Couny inveaigarvon Fee ,/ p
ordinances and State laws relafing to building construction, ioml iea ��J'�� Q.-
C1 and h eby authorize repr sen tives of this County fo enter
� u e above-m i pro rty for Inspection �r oses. .
SEE YEVERSE FOR EXPIANATORY IANGUAGE
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