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HomeMy WebLinkAbout2101WORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self insure, or a certificate of Workers' Compenstion Insurance, or a certified copy thereof (Sec. 3800, Lab. C. ) Policy No. Company El Certified copy is hereby furnished. Certified copy is filed with the county building inspec- tion department. Date Applicant 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 Lic. Class Contractor Date I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer acting in my professional capacity (Section 7051, Business and Professions Code): Lic. or Reg. No. Date 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 (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. 1 1111 FOR APPLICANT TO FILL IN BUILDING ADDRESS BUILDING ADDRESS 71, . c,> p: e: LOCALITY ,3,d/4 11 NEAREST CITY t- ,r"".a k' e d� ZIP CROSS ST. _ f" c�. " y ✓: as n NO. OF BLDGS. ASSESSOR SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL TRACT _ eT' - BLOCK LOT NO. USE ZONE MAP NO. TEL. OWNER e d..,7 ; NO. `` SPECIAL CONDITIONS DISTRICT GROUP TYPE FIRE PROCESSED BY ADDRESS rr FT �� _ �� C.p% ,�,��; ��,,,��, CONST. ZONE CITY .1 r_-;` ZIP =A . 7 STATISTICAL CLASSIFICATION APT, ARCHITECT OR _ TEL. ENGINEER ✓ s�7" C fNO. d=" °C JCONDO. CLASS NO. DWELL. UNITS ADDRESS SEWER MAP TEL. CONTRACTOR r^.. a NO. BK, PG, LIC. ADDRESS NO. `,.� eC,1 VALUATION LIC. - CITY CLASS) r ;,� $ - SQ. FT.. NO. OF NO. OF CHECK SIZE S STORIES FAMILIES ONE NEW �. ADDEl $ DESCRIPTION OF WORK { ALTER FINAL REPAIR ❑ DEMOL DATE FINAL USE OF EXISTING BLDG. By APPLICANT (PRINT) - 14-11 11-1. } � TEL. ,0 NO. ADDRESS LOCALITY n �� MOVING TEL. CONTRACTOR NO. ADDRESS REQUIRED TOTAL SETBACK FROM EXIST. �, y SET BACK YARD HWY PROP. LINE WIDTH d FRONT P. L. SIDE P. L. P.C. Fee $ 5�' /rf—�J I -' Permit Fee 7 ,+ Issuance Fee Investigation Fee Total Fee VALIDATION Signature of Applicant or Agent Dote SEE REVERSE FOR EXPLANATORY LANGUAGE ©s