HomeMy WebLinkAbout5877AWORKERS' 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.)
Policy No. Company
Certified copy is hereby furnished.
Certified copy is filed with the county building inspec- tion department.
Date Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
This section need not be completed if the permit is for onehundreddollars ($I00) 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 mannersoastobecomesubjecttothe. Workers' Compensation laws.
Dote•=!Applicant '.i''
NOTICE TO APPLICANT: If, after making this Certificale o/
Exemption, you should become subject to the Workers' Compensation provisions of the Labor Cade, you must forth-
with comply w'11t such provisions or this permit shall bedeemedrevoked.
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 Number Lit. Class
Contractor Dale
f am exempt under Sec.
B.BP.C. for this reason _
APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES RI III ell.- .
FOR APPLICANT TO FILL IN
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LICA
BUILDNIGADDRESS r F 4 l- J !
BUILDINGADDRESS
Law for the following reason (Section 7031,5, Business and RESS
Professions Code):
CITY I' 1 ` ZIP
E.NT
LOCALITY
D!( RESSwagesastheirsolecompensation, will do the work and
NO. OF BLDGS.
SIZE OF LOT ! f NOW ON LOT NEARESTCROSS ST.t
7044, Business and Professions Code.)
I,
ING
TRACT//:• 6LOCK LOT NO.
r% ASSESSOR
MAP BOOK PAGE PARCELOWNERTEL, I' f: /J %'i 11' ':!:' NO.USE
CONSTRUCTION LENDING AGENCY
ZONE AIFJOP
ADDRESS.' I ) ! 1 17. SfECInL
CONOITIONS-
1;
1
CITY ZIP
Lender's Name
lender's Address ae :_
I
ARCHITECT U4 TEL. / : ENGINEER J7 I'i' J ` ' J7i 1 r / NO. : i` J
DISIRICI
I: GROUP iYFECONST. FIREZONE PROCESSED BY
ADDRESS ' • .•J r IJ r/i/: ..
CONTRACTOR NO. S1niISllCnt CLASSIFICATION
CLASS NO. DYJELL. UNITS
APT.ID.
LIC
ADDRESS NO.
snr
SO. FT. NO. OF NO. CL
SIZE STORIES ` FAVILI[
DESCRIPTION OF WORK fl iE' I :" 1
nI 'r. 1 .
157
Signoture
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LICA
OWNER -BUILDER DECLARATION PR:x
I hereby affirm that I am exempt from the Contractor's License
ADD
ALTER
REPAIR
Law for the following reason (Section 7031,5, Business and RESS
Professions Code):
I,
E.NT
as owner of the property, or my employees wish D!( RESSwagesastheirsolecompensation, will do the work and
ilia structure is not intended or offered for sale (Section lln
7044, Business and Professions Code.)
I,
ING
as owner of the property, am exclusively contracting TRA(
with licensed contractors to construct the project (Sec -
lion 7044, Business and Professions Code.) RESSAE
CONSTRUCTION LENDING AGENCY u!R
I hereby affirm that there is a construction lending agency for
NISET
I
the performance of the work for which this permit is issuedSec. 3097, Civ. C.).`. E
Lender's Name
lender's Address ae :_
I certify that I have read this application and state that the
above information iscorrect. I agree to complywith all Countyugot
ordinances and State laws refoting to building construction,
and hereby authorize representatives of this County to enter
upon_.the abov -mentioned property for inspection purposes.
Signature of Applicant or Agent Dale
TEL.
TEL. NO.
SEE REVERSE FOR EXPLANATORY LANGUAGE
VALIDATION H
CHECKONE
BK. PG.
ADD
ALTER
REPAIR
VALUATION
i
7
CE :'.CL
1 FINAL
DATE
FINAL
ILy
SEE REVERSE FOR EXPLANATORY LANGUAGE
VALIDATION H
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