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HomeMy WebLinkAbout7750AWORKERS' COMPENSATION DECLARATION rtificate of insureboraafcertif certificate ofWorke s' Compensat on Insurance, Unit L p C I00"IN FOR BUILDING PERMIT or a certified copy thereof (Sec. 3800, Lab. C. ) (Bld 21) 67 68 69 g. I r COUNTY OF LOS ANGELES Policy No._1553546 Company HQMe insurance CO. ❑ Certified copy is hereby furnished. © Certified copy is filed with the county building inspec- Date 1/28/85 ApplicantCarlsberg Const.Co. CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars ($100) or less.) I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws. Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- with comply with such provisions or this permit shall be deemed revoked, LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. License Number '117 2'17 Lic, Class R—.1 ControctorC':arl dMrCf C:r)nG -_ Date 1 /28,/R5 I am exempt under Sec. B.&P.C, for this reason Date: Signature OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Professions Code): 1, as owner of the property, or my employees with wages as their sole compensation, will do the work and the structure is not intended or offered for sale (Section 7044, Business and Professions Code). I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec- tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued ,Sec. 3097, Civ. C.). Lender's Name Lender's Address I certify that i have read this application and state that the above information is correct. I agree to comply with all County ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter upon the above -mentioned property for inspection purposes. BUILDING AND SAFETY BUILDING SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date Os