HomeMy WebLinkAbout4108AWORKERS' 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 (See, 3800 Lab,
Policy No,. - Company
❑ Certified copy is hereby furnished.
Certified copy is filed with the unty building inspec-
tion department,
Date Applicant z5u %ze_
C RTIFICATE 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 ork for which this
permit Is Issued, I shall not employ any rson in any manner
so as to become subject to the Wo ker Com(peennsationn Laws.
y' 4ate 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-
th comply with such provisions or this permit shall be
emed 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 an ffect.
License Number/ Lic. Class ,1.
Contractor Date
® 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):
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).
L] 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 inforNala
ct. I agree to comply with all County
ordinances s relating to b ding construction,
an h resentatives`o is County to enter
up the d propert or inspection p poses.
gnat or gent D e
APPLICATIO'N
R
UILOW"'ING PERMIT
COUNTY OF LOS
_. =7.
FOR APPLICANT
TRACT
OWNER
ADDRESS / ' S
CITY 4 4'
ARCHITECT OR
ENGINEER
ADDRESS
CONTRACT /:12
ADDRESS r
CITY /10
SQ. FT. N(
ZIP
LOCALITY
f
C -� L' - J A i C"'°`,
NO, OF BLDGS,
NEAREST
NOW ON LOT
CROSS ST,
ASSESSOR
BLOCK
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MAP BOOK
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um
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USE OF
EXISTING BLDG.
APPLICANT
(PRINT) J i 11-6 a
ADDRESS/ / '� / "" v
PRESENT
BUILDING
ADDRESS
LOCALITY
MOVING
CONTRACTOR
ADDRESS
REQUIRED
SET BACK YARD HWY
FRONT
P. L.
SIDE
P. L.
P.C. Fee $
Investigation Fee
ZIP 11 l
TEL.
NO.
DISTRICT GROUP TYPE
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t'
FIRE
ZONE
PROCESSED BY
S"~NO.ti���'
STATISTICAL CLASSIFICATION
APT. CO DO.
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CLASS NO. DWELL. UNITS
y NQ_./U
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SEWER MAP
CLASS
Y
BK. PG.
VALIDATION
NO. OF
CHECK
FAMILIES
ONE
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NEW
VALUATION
ADD
❑
ALTER
h I
REPAIR
❑
$
DEMOL
❑
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NO.
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FINAL
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TOTAL SETBACK
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PROP. LINE
WIDTH
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LDMA Ref. #
Permit Fee
pp'�
Issuance Fee 4
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LDMA P/C #
Total Fee"
4 (
LDMA Perm. #
SEE REVERSE FOR EXPLANATORY LANGUAGE