HomeMy WebLinkAbout9497AWORKERS' 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.
License Number Lic. Class
Contractor Date
® 1 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
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
1 certify that I have read this application and state that the
above Information is correct. I agree to comply with all County
0 ordinances and State laws relating to building construction,
N and hereby authorize representatives of this County to enter
upon the abgy ij�d-prapetCq f5i Rispection purposes.
r-
Signature of Applicant or Agent Dote
COUNTY OF LOS ANGELES
BUILDING AND SAFETY
BUILDING
ADDRESS
! J -'
FOR APPLICANT TO FILL IN
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ADDRESS.��7 E
CITY l zip
LOCALITY
NO. OF BLDGS
`r OF BLDGS
SI7E OF COTNOW ON LOT
NEAR EST
C OSS ST.
ASSESSOR
TRACT BLOCK
LOT NO.
MAP BOOK
PAGE
PARCEL
OWNER A I c—,,^ I � LID PA5 NO.
USE ZONE
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ADDRESS
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ARCHITECT OR
ENGINEER
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ADDRESS
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LIC.
CLASS
SQ. FT.
SIZE
NO. OF
STORIES
NO. OF
FAMILIES
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USE OF
EXISTING BLDG. 6
APPLICANT TEL.
MOVING
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CONTRACTOR
NO,
ADDRESS
REQUIRED
YARD
HWY
TOTAL SETBACK FROM
SET BACK
PROP. LINE
FRONT
P. L
SIDE
P, L,
P.C. Fee $ r .7
Permit Fee
Issuance Fee
Investigation Fee
Total Fee
SEE REVERSE FOR EXPLANATORY
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STATISTICAL CLASSIFICATION
APT.
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CLASS NO. DWELL. UNITS
SEWER MAP
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