HomeMy WebLinkAbout8581A 1601A 1602A (20)WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure, or a certif!,c
ff
Work3600, Lay Cs ian Insurance, or
a certified. copy (
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 one
hundred dollars ($100) or less.)
I certify that in the performance of the work for which thispermitisissued, I shall not employ any person in any manner
so os to become subject to the Workers Compensation Laws.
Date—
Applicant
NOTICE TO APPLICANT: If, after ma
eking
this Certificate of
e auExemption, you should become to aueusforth' Compensation provisions of the Labor Code, y n
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 9commencingwithSection7000) of Division 3 of the Business and
Professions
Code
full force and effect,0
License Number
Lic. Class
r
Conrracr Date .
1 am exempt from the licensing requirements os I am a
licensed architect or o registered professional engineer
acting in my professional capacity (Section 7051, Business and Professions Code).
Lic. or Reg. No.._------ Date
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's LicenseLawforthefollowingreason (Section 7031.5, Business and
Professions Code):
I, as owner of the property, or my employees with
ages as their sole compensation, will cloth work and
the structure is not intended or offered for sale (Section
s 7044, Business and Professions Code).
I, as owner of the property, am exclusively contractingwithlicensedcontractorstoconstructtheproject (Sec-
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
y affirm that there is a construction lending agency forrormanceoftheworkforwhichthispermitisissued
7, Civ. C.).
5a
a Dove read this application and state that the
Q as is correct I agree to comply with all County
J
uSie laws relating to building construction,
e r esentatives of this County to enter
Grd property for inspection purpose
6 I -- 31L-
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AGS__
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CITY
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APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
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