HomeMy WebLinkAbout1510A (15)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, Lob. C.) %
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Certified copy is hereby furnished.
® Certified copy is filed with The county building inspec-
❑on deportment..''
rrDot Applicant
TIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one -
hundred dollars ($700) 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 os 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.
wlTh comply with such provisions orthispermit 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 license is in full force and effect.
\ License Num8111C=
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Contractor !S 1/CC Date
`❑ I am exempt under Sec.
B.BP.C. for This reason
Date:
Signature _
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from The Contractor's License
Low 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 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 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 Nome
Lender's Address
I certify that I have read this application and state that The
above information is correct. I agree to comply with all County
ordinances a d State laws relating to building construction,
' and here Al thortza represenlati s f this County to enter
$ uponIh6 a ve-menti rop or inspection purposes.
e / Sign a of Applicant or Age Date
APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL INBUILDING
ADDRESS d
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BUILDING
A-bDRESs O
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LOCALITY
NO. OF BLDG'.
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SIZE OF LOT
NOW ON LOT
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MAP BOOK
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MOVING - TEL.
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REQUIRED YARD "WY TOTAL SELBACK FROM
SET BACK PROP. LINE WIDTH
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IDMA R.I. N
P.C. Fee $
Permit Fee
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Issuance Fee IQ I
LON P/C N
Invesigarion Fee
Total Fee
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