HomeMy WebLinkAbout MILLER ST_ 30-195
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CITY l.AK l..Slh!( RE LDII�IG .'
BUILDING DEPARTMENT B . . 3 3 7 5 PERMIT . APPLICATION
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CpNTitACTOR CONDITIONS
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TEL. NO. _—_ PLANNING DEFT DATE
CITY AP/RovAl
STATE tMCINEEwING olv. - OAT¢
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LOT 70 _ BLOGKL__ �_ APPROVAL
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LOY 517E tQOIK�ON LOT _ APPROVAL
Y DATE
USE OF FXIST'NG
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FOONDATION LOCATION
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NAME:
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DEPARTMENT OF BUILDING AND SAFOIY
CITY OF LAKE ELSINi RE
NOTICE TO APPLICANT
In conforming with the provisions of the State c,f CalifQrnia Labor Code Section 3800,
the applicant shall have on file or filed with the City of Lake Elsinore Department
of Building and Safety a Certificate as designated in Item I ab II below, or shall
indicate item III, Iv or V, whichever is applicable.
CERTIFICA`iE OF APPLICANT
Please mark the appropriate block:
Ir Certificate of Consent to self-insured isE;ued b_v the
Director of industrial Relations.
Certificate of Workers' Compensation insurance issued by
an admitt6d'insurer.
Copy on file L—� Cog.f submitted
Ill. The cost of 'the work to be performed is $100.00 or less.
�� ► Iv. . 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' Comp-
ensation laws of California. I further certify that,
in the event I become subject to the Workers' Compensation
_ provisions of the Labor Code that I will comply forthwith. '
with the provisions of the Labor Code Section 3800, ,et seq.
and understand that, i,f' l do not comply,:Whe perwi.t shall
be deemed revoked.
certify ss the owner (or the agent of,the owner) that
__mod a
in."the per. ormance .of the work far which this perait,.is .;
located I have engaged..:. _
contracto> . {Contractor,
must have�on _rile, sir.:subaa t certificate rq((p iced,by .l '
or `11 above) . 77
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42047141 Rev-, 3/78 .41
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