HomeMy WebLinkAbout1336AWORKERS' COMPENSATION DECLARATION
1 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:)
Policy No. • Company_
Certified copy Is hereby furnished
Certified copy is filed with the county building inspec-
• tion department.
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 shoil not emplo51n person i ny manner
so as to become sub'ect to the Wp s on Laws.
Date A'If, afe '-
NOTICE TO TO APPLICA T:. If, after mak chi Cergfico-
Exemption, you should become 'subject- to the Work n; ! .
Compensation provisions of the Labor Code, you must forth- -
with comply with suchprovisionsor 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 my license is in full force and effect.
License Nu r Lic. Class
Contractor Date �=XZ�
I am exempt under Sec.
B,BP.C. for this reason
Date:
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 myemployees 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 contractors to construct the project (Sec-
-tion 7044, Business and Professions Code). ,
CONSTRUCTION LENDING AGENCY
hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued f
tSec. 3097, Civ. C.),
Lender's Name
Lender's Address
Icertify that I have read this application and state that the
above infcorrect. I agree to comply with all County
ordiCfheAe-
State laws relating to building construction,
a dze representatives of this County to enter
upont oned property for inspection purposes.
(gnat Applimnt or Ag nr - - Date
APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES. I BUILDING AND SAFETY
FOR APPLICANT TO FILL IN
ADD BUILDING
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