HomeMy WebLinkAbout1492A (8)r WORKERS' COMPENSATION DECLARATION
I hereby affirm that I hove a certificate of consent to self
insure, ora certificate of Workers Compensation Insurance,
or a certified copy thereof (Sec. 3800, Lab. C.)
Policy No. Company
F- Certified copy is hereby furnished
❑Certified copy is filed with the county building Inspec-
tion department.
Date _Applieont
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE -
(This seelion need not be completed if the permit is for one
hundred dollars ($100) or less.)
1 certify that in the performance of the work for whichibis
permit is issued, I shall not employ any person in an manner
so as to become ��suyybb�j��ecci to the Worker ' e o Laws.
�
Dole ��Applicant--
NOTICE TO APPLICANT: If, after making this C t
eificote of
Exemption, you should become subject to t 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 mylilicense
y Is In full force and effect.
License Number
� _ •� �/•" / Lit. Class
Contractor J1/t" Ls, i, Date
I am exempt under Sec.
B.BP.C. for this reason
- —Dole:
Signatur
ate-
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 do the 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 controcton 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
1 certify that I have read this application and state that the
above information is correct. I agree to comply with all County
$ ordinances and State laws elating to building construction,
R and hereby auth ize rap se olives of this County to enter
5 upon the - e io pro erty for ' speciion purposes-
SEEREVERSE FOR EXPLANATORY LANGUAGE
Si nature of App cant Agem Date
APPLICATION': FOR
COUNTY OF LOS ANGELES
BUILDING PERMIT
BUILDING AND SAFETY
FOR APPLICANT
TO Flll IN
BUILDING
ADDRESS
BUILDING
ADDRESS L
ZG1 'C34
CITY Jrr L.O.ZIPv
LOCALITY i rCil-
NO. OF SLOGS.
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SIZE OF LOT
NOW ON LOT
CROSS ST.
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PARCEL
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PRESENT
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LOCALITY
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ADDRESS
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