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HomeMy WebLinkAbout8574AWORKERS' COMPENSATION DECLARATION I herebyaffirm 'that' I have'a certificate of cons insure, or a'cerfipy.fhereof* (Sec. 3800, Lob. ficcte of Workers'q6mpbi S (ye or a certified co I ®Trt" r Policy No 91)k I Certified copy filed with, Company fu F1 Cer'tlfie&copy is h by rn is ❑ C the n 1 tion department. Date Applicant CER-TIFICATE,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"W'Ciek for which this permit is, issued, .1 shall not employ any. person in any manner W so as to become; subject to the,orkers' -to mpeqsatio.n Lpws. Applicant' ' NOTICE .TO APPLICANf.. it,. after making this Certificate, of Exemption, you should -became subject to the Workers' rkers' Co mpensation ' nsation provisions of the Labor Code, you must forth- with' comply with such provisions: or deem this permit shall be, ed rqvp,1(6d.- LICENSED cbNTRACTORS.DECLAPAtION I hereby affirm that I am licensed udde r provisions of Chapter 9 (commencing with.section 7000} of Division 3 of the Business and Professions *Code, and my. license is infull force and effect. License Number Llc: Class Contractor. Date ❑ 1 am exempt under Sec. B.&P.C, for this reason Signature OWNER -BUILDER DECLARATION I,hereby affirm that I am exempt from the Contractor's License Law for the following reason -(Sect I on'7031.5, Business and Professions Code): El1; . as 0,wher*of the, property, , or my employees with wages astheir sole compensation, will do.the work and-. the structure is not, intended or offered for sale (Section 7044, Business and Professions Code.) El1, as owner,of'the property, I am exclusively . contracting with licensed contractors to construct the project ;(Sec_ tion 70'44,_ 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,, Ci.v.: 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 A6thorize representatives of this County, to enter upon the . —abov67men4oned property for inspection purposes. —/7 Signature of Applicant'or Agent Date J 'APPLICATION FOR BUILDING PERMIT COUNTY OF LOS ANGELES BUILDING AND SAFETY SEE REVERSE FOR EXPLANATORY LANGUAGE