HomeMy WebLinkAbout1000A (7)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. 3BOO,, -1latob�.-CC.))
Policy No. Compony 5 '19/4s.% I
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 one
hundred dollars ($100) or less.)
1 certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers' Compensation Laws.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subjectto the Workers'
Compensation provisions of the Labor Code, you must forth=
ith 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, andel my license is in full force and RIfetl.
License Nu ber -y a� f L.C. Class �CJ
Contractor 1G
I am exempt under Sec.
B.BP.C. for this reason
Date:
Signature
OWNER -BUILDER DECLARATION
I hereby affirmthat I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and
Professions Code):
ElI, 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 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
tSee. 3097, Ci, C.).
Lender's Name
8
Lender's Address
I certify that I have read this application and state that the
ave Informalion is correct. I agree to comply with all County
dtnances an State laws relating to building construction,
j,W.r.by �Writ.,fves of this County to enter
operty for inspection purposes.
Iz &
Slgnaty ,Q Applicant or Agent Date
APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FORBUILDING APPLICANT TO FILL IN
ADDRESS
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