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HomeMy WebLinkAbout9371AIORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self insure, or a certificate of Workers' Compensfion Insurance, or a certified copy thereof (Sec. 3800, Lob. 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 beco e s bject to the Wor Com ,ensation Laws. Date % Applican*rn l! NOTICE T APPLI ANT: If, afteing 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 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 APPLICATION f BUILDING COUNTYOF • FOR APPLICANT TO FILL IN ADDRESS m BUILDING ADDRESS caG (v. r 1L°L�m. LOCALITYy 0 CITY, Lf ZIP A 4®� NEAREST CROSS ST. NO. OF BLDGS. SIZE OF LOT 1. 01CIL NOW ON LOT �'S ASSESSOR MAP BOOK PAGE PARCEL TRACT BLOCK LOT NO. USE ZONE MAP ry NO, 4! OWNER tiJ �/ • NO. j S SPECIAL CONDITIONS ADDRESS r L �cc a� Tt'1o,, - C� , DIS RICT GROUP TYPE FIRE PROCESSED BY CONST. ZONE CITY r✓I zl ZIP ARCHITECT OR !) TEL. ENGINEER S L, STATISTICAL CLASSIFICATION APT. CONDO. OL- \ d.r�e. NO. ?,() lia " u7 e,n i- l7n sires a_ CLASS NO, DWELL. UNITS CONTRACTOR CITY SQ. FT. NO. OF SIZE STC)RIFS USE OF EXISTING E APPLICANT e• - volt " I . / p e xvvErc ivi mr TEL. J-I % NO. h �%-. j�0 BK. PG, LIC. NO, VALUATION LIC. CLASS $ NO. OF CHECK FAMILIES ONE NEW $ ADD p� v ALTER FINAL REPAIR ❑ DATE DEMOL FINAL By MOVING TEL. CONTRACTOR NO, AnnRFCC REQUIRED SET BACK YARD HWY TOTAL SETBACK FROM PROP. LINE EXIST. WIDTH FRONT P.L. SIDE P.L. P.C. Fee $ Permit Fee Issuance Fee 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 Investigation Fee ordinances and State laws relating to building construction, Total Fee / d and hereby a •,orize representatives of this County to enter up ove-mey�tipned property for inspection pur oses. �ljp (('` SEE REVERSE FOR EXPLANATORY LANGUAGE i nature of Applicant or Agent Dote VALIDATION A e� (>, 0 0 .I 9 .., ©s