HomeMy WebLinkAbout1559A 1651AWORKERS' COMPENSATION DECLARATION I
I hereby offirm that 1 have a certificate of consent to self. j
. Insure, or a certificate of Workers' Compenstion Insurance, or
a certified copy thereof (Sec. 3800, Lob. C.)fF
Po
licy "
Certified copy is hereby furnished. i
ElCertified copy is filed with the county building Fnspec- 1
lion department.
Date Applicant I
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE -I
(This section need not be completed if the permit is for one
hundred dollars (SI00) or less.) - -
1 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 Io become subject to the WorkersCompensation 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 licenseis in full force and effect.
License Number�Sf�T4i
210 �VL? Lic. Classy A`.
CO�I ntracl0-��'',,a`fe 2
❑
I om exempt from the licensing requirements as I am a
liqcensed architect or a registered professional engineer, .- -
acting in my professional capacity (Section 7051,
Business and Professions Code).
Lic. or Reg. No. Date
OWNER -BUILDER DECLARATION
1 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 -
woges as their sole compensation, will do tho Work and
the structure is not intended or offered for sale (Section -'
704.4, 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, CN. C.):
Lender's Nome
Lender's Address
I certify that I have read this application and slate that the
above information is correct. I agree to comply with all County
ordinances and Stale laws reloling to building construction,
and hereby ou4eo
!D�
tives of Ihis County to ter
` up t e bo.rty forinspectio purp es.
ignaturent or Age Dot
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APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FNGr_OR APPLICANT TO FILL IN
nooaess � .DIAMOND
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WIDTH
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SEE REVERSE FOR EXPLANATORY LANGUAGE
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