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ri Ile- CITY OF LOD I PERMIT No, BUILDING PERMIT APPLICATION ' 7 JOB ADDRESS DESCRIPTION OF WORK APPLICANT'S NAME MAIL ADDRESS ZIP PHONE OWNER'S NAME MAIL ADDRESS ZIP PHONE CONTRACTOR'S NAME MAIL ADDRESS ZIP Business Phone I Contr. Lic. No. ARCHITECT OR ENGINEER MAIL ADDRESS ZIP Business Phone Arch/Eng. Lic. No. LEGAL DESCRIPTION ASSESSOR'S PARCEL NO, LICENSED CONTRACTOR'S DECLARATION ] V I hereby affirm that I am licensed under provisions of Chapter 9 (commenc;ng with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. f License Clas's I License Numbe"r Date Contrac[or�, OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Sec. 70 31.5, 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 (Sec. 7044, B. S P. C.). I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, B. & P. C.). _ I am exempt under Sec. Business and Professions Code for this reason Date Owner 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. 3800, Lab. C.). Policy No. Company Exp. Date _ Certified copy is hereby furnished. _ Certifier copy is filed with the City Building Inspection Department. Date Contractor CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE 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 of California. Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers' Compen- sation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. 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 state that the above information is correct. I agree to comply with all City ordinances and state laws relating to building construction, and hereby authorize representatives of this City to enter upon the above-mentioned property for inspection purposes. Signature of Applicant or Agent bete OCCUPANCY GROUP BUILDING ZONE I TYPE OF CONSTRUCTION SQUARE FEET BEDROOMS SEWER SERVICE UNITS 1 APPROVAL: PUBLIC WORKS DATE PLANNING DEPT. DATE FIRE DEPT. DATE BUILDING DEPT. DATE C This permit becomes null and void if work or construction authorized is not commenced within 180 days; or If construction or work is suspended or abandoned for a period of 180 days at any time after work is comvmenceo. (1979 UBC) WHEN PROPERLY VALIDATED WITH THE BUILDING PERMIT NUMBER THIS APPLICATION BECOMES PART OF YOUR PERMIT AND MUST BE POSTED ON THE JOB BEFORE WORK 1S STARTED, !9p