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HomeMy WebLinkAbout2102AWORKERS' COMPENSATION DECLARATION ,y affirm that I have a -certificate of consent to self /, or a certificate of Workers' Compenstion Insurance, or �ertifIed copy thereof (Sec. 3800, Lab. C.) Policy No. . Company Certified copy is hereby furnished. ElCertified copy is filed with the county building inspec- 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, 1 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 I 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 I hereby affirm that I am exempt from the Contractor's License Law 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 Lender's Address I certify that I have read this application and scat@ that the above information is correct..1 agree to comply with all County ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter upon the above -mentioned property for inspection purposes. COUNTYAPPLICATO"IN FOR BUILDING PERMli OF •BUILDING FOR APPLICANT TO FILL IN BUILDING ADDRESS BUILDING ADDRESS €': -� q C e mwe LOCALITY - CITY .f ' ma`s �r ,ii g <f .-- ZIP NEAREST CROSS ST. NO. OF BLDGS. ASSESSOR SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL TRACT '? 7f p— BLOCK LOT NO. USE ZONE MAP NO. TEL. { SPECIAL OWNER DEL, (I2 d i- NO. `�€' �� CONDITIONS DISTRICT GROUP TYPE FIRE PROCESSED BY ADDRESS � ,7 (�_� � �'�:s'�e'.�' �'`-���'"� �CONST. ZONE CITY =T F ZIP '�(... STATISTICAL CLASSIFICATION APT. ARCHITECT ORp _ TEL. ENGINEER Z I w '°a € 0 CLASS NO. JCONDO. DWELL. UNITS TEL. CONTRACTOR 1 "(. NO. ADDRESS LIC. NO. CITY LIC. CLASS/1 7 s - SQ. FT,,, NO. OF SIZE ) r' 1 I STORIES ,, NO. OF IF CHECK ONE DESCRIPTION OF WORK USE OF EXISTING BLDG. APPLICANT (PRINT)V 4VI, r ADDRESS PRESENT BUILDING ADDRESS LOCALITY MOVING r'rINTR Gr'Tnp SEWER MAP BK. PG, VALUATION NEW ADD $ ALTER ❑ FINAL REPAIR DEMO L ❑ DATE FINAL TEL..By NO TEL. NC) YARD HWY TOTAL SETBACK FROM EXIST. PROP. LINE WIDTH LDDRE //4J 6 U Permit Fee Issuance Fee n Fee Total Fee - VALIDATION Signature of Applicant or Agent Date SEE REVERSE FOR EXPLANATORY LANGUAGE ©s