HomeMy WebLinkAbout8574A (2)WORKERS' COMPENSATION DECL, IRI
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I hereby affirm that I have a certificateYE If 0"
insure, or a certificate of Workers' Compensation Insurance,
or a certified copy thereof (Sec. 38001 Lob. ) (T'
a 1
Policy No. Coma \ ., r
❑ Certified copy is hereb f ni h d. .
❑ Certified copy is filed with the county building inspec-
tion department. ADDRESS
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 ny manner
so as to become subject to the +mking
mpe sati .n- Ws,
Date r' ApplicantNOTICE TO APPLICANT:If, aftthis Certificate of
Exemption, you should becoto 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 Chapter9
(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.
BAP.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.)
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 information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and hereby out ori4e representatives of this County to enter
p,�th ovni rZed property for inspection purposes.
-7
ignature of Applicant or Agent Date
SIZE OE LOT
TRACT
OWNER 1
ADDRESS
CITY .
ARCHITECT
ENGINEER
CITY
PLICATION FOR BUILDINGPERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL 1N
® L1l Ctc \A-L� � �r
ZIP
NO. OF BLDGS.
r NOW ON LOT
J BLOCK LOT NO.
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SW, FT.
NO. OF
NO. OF
SIZE
I STORIES
FAMILiE
DESCRIPTION OF WORK
F
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USE.OF
EXISTING BLDG,
APPLICANT
(PRINT)
ADDRESS
PRESENT
BUILDING
ADDRESS
LOCALITY
MOVING
CONTRACTOR
ADDRESS
REQUIRED
ITT Rare YARD HWY
TOTAoon
P.C. Fee S 41"1
on
Total Fee
LIC,
NO.
LIC.
CLASS
_
CHECK
ONE
NEW
ADD ❑
ALTER ❑
REPAIR ❑
DEMOL ❑
TEL,
NO.
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NO.
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> 73'
SEE REVERSE FOR EXPLANATORY LANGUAGE
BUILDING
ADDRESS
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