HomeMy WebLinkAbout6500AWORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance,
or a certified copy thereof (Sec. 3800, Lab. C.)
Policy No. Company
® 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.
_ `{ ss 1 License Number( � ��,�f� Lice Class ) %
Contractor Z. -Y ' Li—L Date �i `� J e qy C
® 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.
APPLICATION FOR BUILDING PERMIT
COUNTY OF LOSAND SAFETY
F/ORl APPLICANT TO FILL IN
BUILDING 't i
ADDRESS Gt C �,•� C%t-z�-
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LOCALITY
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NEAREST
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tT OF BLDGS.
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CLASS NO.
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USE OF
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APPLICANT
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ADDRESS
PRESENT
BUILDING
ADDRESS
LOCALITY
MOVING
CONTRACTOR
ADDRESS
REQUIRED YARD HWY
SET BACK
FRONT
P. L.
SIDE
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VAL TION
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NO. OF CHECK
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REPAIR ®
DATE
DEMOL ®
FINAL
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P.C. Fee $ r^ J Permit Fee f
Issuance Fee ® �I ` �'s
Investigation Fee
Total Fee O I 1� "°'o
Signature of Applicant or Agent Date
SEE REVERSE FOR EXPLANATORY LANGUAGE
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