HomeMy WebLinkAbout6555Am ! WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
41- Insure, or a certificate of Workers' Compenstion Insurance, or
ice.% I a certified copy thereof (Sec. 3800, Lab. C. )
(Jo ^Policy No. Company_
I I Certified copy is hereby furnished.
r
0 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 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 subject 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 Business and
Professions Code, and my license is in full force and effect.
License Number Lic, Class
Contractor Date
❑ 1 am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer,
acting In my professional capacity (Section 7051,
Business and Professions Code).
Lic. or Reg. No. Date
OWNER -BUILDER DECLARATION
t hereby affirm that I am exempt from the Contractor's License
Low for the following reason (Section 7031.5, Business and
Professions Code):.
❑ I, 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
(Sec. 3097, Civ. C.).
Lender's Name
m
Lender's Address
I certify that I have read this application and state that the
above information is correct. I agree to comply with all County
$ ordinances and State laws relating to building construction,
d and hereby authorize representatives of this County to enter
upon the above -mentioned property for inspection purposes.
a
Signature of Appllcanl or Agent pate
AP''. FOR BUILDING PERMOT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN BUILDING
UIL CG M
BUILDING
ADDRESS ��aL nV. Cf R� i�(/�CJLiJ�,
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SIZE. OF LOT NOW ON LOT
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ADDRESS 44aa i AAP03 ne
DISTRICT
GROUP TYPE FIRE PROCESSED BY
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STATISTICAL CLASSIFICATION APT. CONDO.
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ENGINEER a OLF- NO. Lill
CLASS NO. , _DWELL UNITS.
ADDRESS IY60
CONTRACTOR
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NO. OF
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DESCRIPTION OF WORK
NEW
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By
APPLICANT
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ADDRESS
MOVING TEL.
REQUIRED TOTAL SETBACK FROM LEXIST.SET BACK YARD HWY PROP. LINE
LFRON7
P.C. Fee R Permil Feel
Issuance Fee
Investigation Fee
SEE REVEVSE FOR EXPLANATORY LANGUAGE i
VALIDATION
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