HomeMy WebLinkAbout1494A 3555A (8)f �S' COMPENSATION DECLARATION
that I have a certificate of consent to self
•ificate of Workers' Compensation Insurance,
W thereof (Sec. 3800, Lob. C.)
Company
ipy is hereby furnished,
ropy is filed with the county building inspec-
- Tiondepartment.
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.
permitis issued, I shall not employ any person in any manner
so as Iaa �beec�o�me, subject to the Workers' Compensation Law .
Dote_{-LJJT."' Applic ni
NOTICE TO APPLICANT: If, after makinb 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
(commenting 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.
B.BP.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 clothe 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
APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN
BUILDING
ADDRESS 4 GGA
BUILDING � 7'f L n 2 /�- ^T -y7 A f 1
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I certify that I hove read this application and state that the
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above information is correct. [.agree to comply with all County
CITY N m /1. A ZIP T`
LOCALITY
ordinances and State laws relating to building construction,
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NEAREST
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Lender's Address
I certify that I hove read this application and state that the
above information is correct. [.agree to comply with all County
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter
upon above -mention pro erty for inspection purposes.
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REVERSE FOR EXPLANATORY LANGUAGE
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