HomeMy WebLinkAbout1599A (9)WORKERS' 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 CEApplicant
RTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one
hundred dollars (E100) 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 1 am licensed under provisions of Chapter 9
(commenting with Section 7000) of Division 3 of the Business and
Professions Code, and my license is in full force and effect.
License Number Lit. Class
Contractor Date
I am exempt under Sec.
B. BP.C. for this reason
Signatur8
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractors License
Law for the following reason (Section 7031.5, Business and
Professions Code): -
1t��M.. 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 properly, am exclusively contracting
with licensed contractors to construct the project (Sec-
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY -
I hereby offirm that there is a construction lending agency for
the performance of the work for which this permit is issued
ZSec. 3097, Civ. C.).
Lender's Nameg�elr'?]P&Amc Wf�EiL�,CO,
Lender's Address �ELt�T
1 certify that I have read this application and state that the
oboe 'on is car a. I agree to comply with all County
nces and to w relating to building construction,
reby r sentatives of this County to enter
n he above- i property for Inspection purposes.
ure o nt or Agent Dote
APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN •,
ADDRESS
BUILDING
70 f G l$J
LOCALITY )
�ADDRESS
_
CITY •V1tp- 1 ZIP -
NEAREST
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SIZE OF LOT -J•�= NOW ONLOTNO. OF S Ldl"LE
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MAP BOOK
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TOTAL SETBACK FROM
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WIDTH
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Permit FeeIssuance
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