HomeMy WebLinkAbout3809AWORKERS' COAMEM:-ATION DECLARATION
I hereby affirm that I had, certificate of consent to self
insure, or a certificate of V:.,iKars' 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 oparl ent,
Date 41% 9` 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 10 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 70DO) of Division 3 of the Business and
Professions Code, and my license is in full force and effect.
License Number .-- 3 Lic. Class._
a
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 sole (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.),
in
Lender's Name
Lenders Address
I certify that I have read this application and state that the
a above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
d and her y uthorize rep entatives of this County to enter
a upon t ove-mention property for inspeV1*,onurp ses.
S gnature of A I' ant o Agent to
3"IN FOR
BUILOw"'ILOC,
y
PER IT
COUNTY OF LOS ANGELES
BUILDING ANU SAFETY
TO FILL IN
BUILDING,
ADDRESS r 57
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PFORAPPLICAN"ANT
NO. OF BLDGS,
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CONDITIONS
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GROUP
TYPE
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P%CESSED BY
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ARCHITECT OR
v CLASS NO.� DWELL, UNITS
ADDRESS I
SEWER MAP
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LIC.
ADDRESS NO.VALUATION
LIC. CITY CLASS$ O ?' �#
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SIZE STORIES�7 FAMILILI/ES ONE ,,��
DESCRIPTION OF
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USE OF DEMOL ❑ EXISTING BLDG. s
APPLICANT 4 JA
MOVING TEL.
CONTRACTOR NO.
ADDRESS
REQUIRED TOTAL SETBACK FROM EXIST.
SET BACK YARD HWY PROP. LINE WIDTH
SIDE
P.L.
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P.C. Fee $ Permit Fee ,-�
Issuance Fee ��,. G
Investigation Fee /
Total Fe �/ Cjf ��
SEE REVERSE FOR EXPLANATORY LANGUAGE
$
FINAL
DATE
FINAL
By
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VALIDATION
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