HomeMy WebLinkAbout7748AWORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self APPLICATION
Insure, or a certificate of Workers' Compensation Insurance, Bldg.24
or a certified copy thereof (Sec. 3800, Lab. C.) y
PolUNTY OF LO$ ANGELES
Policy No. n90
❑�553546 company__ HaLne Insurance CI�.its 76,77,78,79,8
Certified copy is hereby furnished.
® Certified copy is filed with the county building inspec-
Date 1/28/85 Applicant Carlsberg COnSt•CO.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one
hundred dollars ($100) or less.)
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers' Compensation Laws.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be
deemed revoked.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Code, and my license is in full force and effect.
License Number 317237 Lic, Class B-1
Contractor Cart gb= Ori date-/28/85
I am exempt under Sec.
B.$P,C. for this reason
Date:
Signature
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Low for the following reason (Section 7031.5, Business and
Professions Code):
I, 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
ISec. 3097, Civ. C. ).
m
Lender's Name
S
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,
U and hereby authorize representatives of this County to enter
upon the above -mentioned property for inspection purposes.
n
' Signature of Applicant or Agent Data
BUILDING PERMIT �
BUILDING AND SAFETY
BUILDING
SEE REVERSE FOR EXPLANATORY LANGUAGE
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