HomeMy WebLinkAbout1491A_ WORKERS' COMPENSATION DECLARATION
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a , APPLICATION FOR�.BUILDING PERMIT -
► or acertified copy thereof (Sec: 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
aCertified copy is hereby furnished. - r
Cerlified copy is filed with the counly building inspec-El -
lion department. '
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.)
�erlify that in the performance of the work for which.ihis
permit is issued, I shall not employ any person in any manner
so as to become subjject io the Worke• ' om rs ion laws.
-'/Date C I Applica ,
NOTICE TO APPLICANT: If, ofter'mck ng this erlif'C icafe of
ExeInption,'you should became' iubject 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
(commencing with Section 7000) of Division 3 of the Businessand
Professions Code, and my license is in full force and effect.
License Number Uc. Class
Contractor Date _
'r ❑ I am exempt under Sec.
B.BP.C. for Ihis reason
Dale:"
OWNER -BUILDER DECLARATION
.I 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 properly, 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 contractors to construct the project (Sec- '
lion 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
a above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction, _ and here y authorizer resentatives of this County to enirr
upon b —ept, qd properly for inspection purposes.
c / A,
Sign' r . of Appl.-ant or Agent -- Dora
FOR APPLICANT TO FILL IN
ADORING
JPD 1.4
BUILDING1
ADDRESS
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CITY ) v
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NO. OF BIDGS. I- -
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NOW ON LOT z
CROSS ST.
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TRACT BLOCK
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MAP BOOK PAGE
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STATISTICAL CLASSIFICATION
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CLASS NO._ DWELL. UNITS
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ADDRESS NO.
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SEE REVERSE FOR EXPLANATORY LANGUAGE
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