HomeMy WebLinkAbout1503AWORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
iinsure, ora certificate of Workers' Compensation Insurance,
Ora sertAAfipc� 9-py therre of
; 380((0�, Lc� C. )
Qcy No. ���%- 'A Company 922 \'Js-
Certified copy is hereby furnished.
Q. Certified copy is filed with the county building inspect
j tion department.
{ Dale 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 any manner
so as to become subject to the Workers' Compensation laws.
Date Applicont
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
1 hereby affirm that I am licensed under provisions of Chopler9
(commencing with Section 70DO) of Division 3 of the Business and
1 Professions Code, and my license is in full force and effect.
J License Number .3 9/� 7 /Z? Lic. Class g
I Contractors' • e't4Dote
1-0 1 am exempt uncle Sec.
B.BP.C. for this reason
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):
1, as owner of the property, or -my employees with
wages as their sole compensation, will do the work end
the structure is not intended or offered for sole (Section
7044, Business and Professions Code).
0 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 it correct. I agree to comply with all County
--ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter
upon the obove-mentioned property for Inspection purposes.
Signature of Applimnl or Agent Dala
APPLICATION FOR. BUILDING PERMIT
[L('2 COUNTY OF LOS ANGELES.. . BUILDING AND SAFETY W 1, C I L �r
i
FOR APPLICANT TO FILL IN -
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nooaess r
ego
BUILDING
ADDRESS �ZZQ Atrn. (Ly:
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LOCALITY
CITV ..A/ r ,..ch [ U CLQ ZIP
NEAREST
CROSS ST.
NO. OF BLDGS.
ASSESSOR
SIZE OF LOT NOW ON LOT
MAP BOOK PAGE
PARCEL
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TRACT BIOCK LOT NO.
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NO.
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SPECIAL
OWNER - fj NO.
CONDITIONS
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DISTRICT GROUP TYPE
FIRE PROCESSED BY
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