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WORKERS' COMPENSATION DECLARATION _
I hereby affirm that I have a certificate en f s f
insure, or a certificate of Workers' Compe atio In try
e
or a certified copy there (Sec. 3800, Lab.
Policy No. . Company
❑ Certified copy is hereby furnt hg
f+
El Certified copy is filed wth,)he� c 1Mis N
tion department.
Dat Applicant
CERTIFI ATE OF EXEMPTION FROM W ERS'
COMPENSATION INSURA
(This section need not be completed if t e 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 Lic. Cla
Contractor Date
❑ I am exempt under Sec.
BAP.C. for this reason
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):
❑ 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
(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 a t to laws relating to building construction,
and hereb a one re tatives of this County to enter
upon th ve- e property for inspection purposes.
0001
Signs Ure of pplicant or Agent Date
tr APPLICATION FOR •
,_
,.
COUNTYOF •
OWN
CITY I
ZIP
LOCALITY
NO. OF BLDGS.
NEAREST
SIZE OF LOT
NOW ON LOT
CROSS ST.
I
ASSESSOR
TRACT
BLOCK LOT NO.
MAP BOOK PAGE
PARCEL
OWNER
NO. 966
USE ZONE MAP
�3Lc
NO.
SPECIAL
ADDRESS
r
CONDITIONS
CITY
ZIP
ARCHITECT OR
TEL.
DISTRICT GROUP ITYPE
FIRE PROCESSED BY
ENGINEER
NO.
CONS3.
�
ZONE
ADDRESS
0 d Q
TEL. t
O. 0146r
STATISTICAL CLASSIFICATION
APT. Cg DO.
CONTRACTOR
LIC.
CLASS NO. DWELL. UNITS
ADDRESS
- 04 NO.
CITYCOV1
LIC. /
G CLASS
SEWER MAP
BK. PG
VALIDATION
SQ. FT.
NO. OF NO. OF CHECK
SIZE
I STORIES FAMILIES ONE
O
Ji-
❑
VALUATION
DESCRIPTION OF WORK NEW
$ l / ,)
�l
ADD ❑
ALTER ❑
REPAIR ❑
$
&
USE OF
❑
EXISTING BLDG.
DEMOL
APPLICANT
(PRINT)
® TEL.
L NO.
FINAL
L/
DATE
ADDRESS
FINAL
PRESENT
By
BUILDING
ADDRESS
LOCALITY
MOVING
TEL.
=
CONTRACTOR
NO.
ADDRESS
i
REQUIRED
YARD HWY TOTAL SETBACK FROM EXIST.
L G 6 (;
SET BACK
PROP. LINE WIDTH
FRONTt
P. L.
SIDE
P.L.
(0 0
LDMA Ref. #
P.C. Fee $
Permit Fee cS .
Issuance Fee r u�
LDMA P/C #
Investigation Fee
Total Fee
LDMA Perm. #
SEE REVERSE FOR EXPLANATORY LANGUAGE