HomeMy WebLinkAbout7223AWORKERS' COMPENSATION DECLARATION
hereby affirm that I havecertificate of consent to self QiT9C@fiON FOR BUILDING PERMITinsure, or a certificate of Workers' Compensation Insurance,
or a certified copy thereof (Sec. 3800, Lab. C.) CQUNTY GELES BUILDING AND SAFETY
Policy No. Company -
Certified copy is hereby furnished. TVISaW BUILDINGADDRESS
El Certified copy is filed with the county building inspec- BUILDING
tion department. LgDDREssa ) / /=!; i'"'--'%[.
Date Applicant
CIN 4 .,.V t "^^` ZIP / f / LOCAUN
CERTIFICATE -OF EXEMPTION FROM WORKERS'
NO. OF BLDGS.
SIZE OF LOT NOW ON LOT ( NEARESTCROSSST.
COMPENSATION INSURANCE ASSESSORThissectionneednotbecompletedifthepermitisforoneTRACTBLOCKLOTNO. MAP BOOhundreddollars (§100) or less.),-. TEL 7' /
OWNER ,N'i.'<: Z C j C -i,' NO : S -/ f.- t U USE ZONE
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner ADDRESS %^ '' ', 1 r,
so as to become subject to the Worker Laws. Compensation
CITY ^'-^t.""+a!n/:.+ ZIPLr/ter
Date ' "•% Applicant /;'`""r'! r'T^1'"'"" ARCHITECT OR TEL DISTRIC
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO
Exemption, you should become subject to the Workers 10,
Compensation provisions of the Labor Code, you must forth- ADDRESS
with comply with such provisions or this permit shall be TEL. S
deemed revoked. CONTRACTOR :3= NO.
LICENSED CONTRACTORS DECLARATION LIC.
I hereby affirm that I am licensed under provisions of Chapter9 ADDRESS NO.
commencing with Section7000)of Division 3 of the Business LIC.
and Professions Code, and my license is in full force and effect. CITY CLASS
SO. FT. t NO. OF NO. OF CHECK
License Number_Lic. Class SIZE > STORIES FAMILIES 1 ONE
Contractor Date DESCRIPTION OF WORK ,tt ^ ,,; ... ,;7 tr NEW
VALUE
IN
I am exempt under Sec. r 1,
ADD
ALTER
B.SP.C. for this reason f' >`• REPAIR
Date: USE OFEXISTING BLDG. tf• " J 'a. '-" DEMOL
Signature, APPLICANT ., TEL
PRINTI j , C r—'i NO '- J(: = FINAL
OWNER -BUILDER DECLARATION d
DATE
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and ADDRESS y J '` i'' a +'rf' FINAL
Professions Code): PRESENT By
ICf` I, as owner of the property, or m employees withPPYrYADDRESS
BUILDIN
wages as their sole compensation, will do the work and
the structure is not intended or offered for sole (Section LOCALITY 00,
7044, Business and Professions Code.) MOVING TEL.
I, as owner of the property, am exclusively contracting
CONTRACTOR NO.
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code.)
CONSTRUCTION LENDING AGENCY SEAT ggCK YARD HWY OTA SET AUK 1. EXIST.
I hereby affirm that there is a construction lending agency for FRONT
the performance of the work for which this permit is issued P. L.
Sec. 3097, Civ. C.). - - SIDEP.L.
Lender's Name illillill
LDMA Re
Lender's Address - P.C. Fee $ Permit Fee
1 certify that I have read this application and state that the Issuance Fee `s LDMA PJ
above information is correct. I agree to comply with all County Investigation Fee r
q Ordinances and State laws relating to building construction, Total Fee tr. G_S LDMA Pe
and hereby authorize representatives of this County to enter
uPon 1 yboGe/menti:
e,
e ,Pl Perry for inspection purposes.
r '.i+r' % f / ,•' (i.-r...y •.''; ` SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date
TATISTICAL CLA'S(FIC TION APT. CONDO
CLASS NO. DWELL. UNIT$
SEWER MAP
BK. PG. VALIDATION
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