HomeMy WebLinkAbout0287A WORKERS'COMiENSATION DECLARATION �� � p}� I� ^
I hereby aHirm that i hove a terlifimte of consent 10 aelf , � ^� .�1 ���� �}� ��� a�
insuro,or a cert�fica�e of Waken Compenwtion Insurance,or �^^"'� 1,.{+ �p g 3 1 !•�(
a cer�ified c tMreof Sx.3800,tab C. ce aoe�x�v.e�s� � ■ d
°�Y � � �: ' APPI,ICATION FOR PE�Y� �� �
Policy No. Company
❑Certified copy is here6y fu�nia�ed. SEWER - SEWAGE DISPOSAL .
❑Cerrifed copy is filed wuh the counry b��Wing inapect�on COUNTY OF i05 ANGELES BUILOING AND SAFETY
deportmeni. ,
Daro Appliconl FOR APPIICANT TO FILL IN CONNECTION DA7A
GERTIFICATE OF EXEMPTION FROM WORKERS' eunqnc . ,
COMPENSAr10N INSURANCE �ooaess STntiC++ �oTH
�Thia secfio�need not be completed if Ihe work involved by the i��TY �AqNNpLE PFFEMNCE �y
permit ta for one hundred dollon(S100)or leaa.)
I certi ttwt in the rformonce of the work for which ihis �ST TY�a��R'�+ �r�ciMF�
y pe tqou sr. v. cuve v L M.L 10 P.l.
pe�mil is iuued,I�hall no1 empVoy any person in ony monnar
so aa to become subjec�b the Workan'Compenwtion Lows. �„�Q co:iMv.nw. ioe�. �
�o�e APPlimm . .. , wooarss � � TRUNKPERMITFq. . 0.0�DPFFM1iND.
NOiICE TO AVPUCANT: If, ofler making this Certificole of � S TH no � _�' ��►?•3 Arcror,wr w�rvert tnsENaNT aEtoao,iasra,rq. W*[
Exemp�ion, you should become subject ro Ihe WorRen' �E�
Compenaa�ion provis�om of the Labor tode,yo�musl forthwith oe6cair�pN lOTNO. NWY,di ST.WIOENING
�compVy with such provisions or this permil shcll be deemed .
rovoked. eioCK TRACT SiAiE EHCROKNN.FNT
UCENSEO CONTRACTORS DECIARATION � ��'a��� ������
52¢a wr Now a+ior �
1 hereby affkm Ihar I om licensed under prorisions of Chopler �a �
9(commancing wirh Sed�on 7000)of Diviclon 3 oS the Buai- µ�i�p�5 cNnrK,ES
nea ond Rofeesfons Code,aed my lieense fa(e full force and
�affecf. . . , . Cor+iR�Ooa CorwoERiow CMw+GE rEE
Y
Licenae Number � Lic.Clau ,i,��u / � � REIMBURSEMENT e d
Comr«ror Dme nr re�.rw.2/3 ,4 -,5374- wsTa�a no. c,aouv ru,v aseo er v
+�7�" aK x .
� ❑I am exempf under Sec. of Ihe L.A.Co. ����,�p, �(�3 ��� �1 'O
PlumbiogCodeond/o�5ec. � ofthe � ^�0� Rivlron�OFN�ORK Fa FiHqi .G
1qU$f$EWER CONNFCfING TO / DATf VALIDATION a
B.8 P.Code fot the following reason °�a�c se�R .
� Dme PITSMlD/ORpRA1Ni1ElD fiNAC . �
iqUSE SfWEP CUNI'�CTING i0 6Y
Y
Siynature CONNECT MDITIpJAI 91D6.Oi �'0 2$7 A
� OWNER-BUII�ER DECIARATION, �ro�'��R
oveaaow sten nT. raio •��Q
�. I hereby affirm ihot I om exempt from the Comractor's License cxrr�..cEssroa oavwrtu rnnmHae � �y�,� �.•• '
. Low for the followiag reasoa(Secfvn 7031 S,Buisneas and Pro• � u R.CEvua Oc M�wCObt HouS[ ,Su- �
$FWER OR p5�05M SVSifM �+�.�2 7.5 0
, feulons Code): �
�. ❑�,os owner of the property,or my emp{oyees with waqes os ��.YY�v� � • •`�2 7•F��
� their sole compenw�ion,wili do the work ond ihe sMuctura , / 0'�2 O_8 9
� is no�imended or offered for sole{Setlion 70�d,Bvsinasa �WNER'S Pelmit S f � l.y� �
� ond Professiona Code). �8� .
❑1,os owner of the properry,om e.clusi�aiy comracting with AUTHORIZATION TOTAL FEE a•
� �iCB�SQ[�CO��fOC10�5 f0 COn4hUCt t{�B projecr(See�ton�OAA, 1 NAVE At TNIS UAiE A CONfRACI WIiN iHE HEREIN NAMEO[tlMN�CfOR tp � �
� . Buninesa and Profesaions Code). -� �� cd+raecr tN[�eovt oEsca�eeo exisnyG pwct�rt+G io Ti+t PUe�ic 5[vrtR. -
CONSTRUCTION LENOING AGENCY .
, I heraby affirm Ihat Ihero is a coM/ruction lending agency SiGNED7H15 DAYOF 19_�
�, for Ihe performance of the wo�k for whith thia permi� is p��qSK�NT
� luued(Sec.3097,Civ.C.). .
. � .�ooRess
. lender's Name �
Lender's Address �
' 1 certify fhot I hove reod this opplicmion ood atote ihat ihe �
obove informotion is corteU.I agree to comply with oil County . �
. ordinancn and State lawa repulating Plumbiny ond Sewero, -
+�-�� y uthorize repreae aiives of�hi:Counry io enrer
� �u 11�abo e- tirne ope�y fo�inspedion purpoaes. � - �
,w.�. ��,�° �°��
�I _ Sin re f PermiNe �ote SfE REV4RSE KOk FX►IANATORV LANGUA6F
tNsveerac's rroTes OWN�R-HUILDER DECLARA7'ION
A�PR�Vf+L$ onic+iN.�cROA'S sics�an�ac 1 hrrcGy a([irm�t6pt 1 am exrmpt from the Contrac[or's
� - � Licence Luw for the fuliuwin�rer,un/Se�rran 703T.3,
NCV/NOUS[SFN2N ?L!�
, Bw:+.�. bnd Pr��uiun.�.CoduJ: A»y.dry o unty
mr�,ucer.wo�riemia� . . . �ubi�b rrqui.e.�a pernii��o conitn.rt, nit�r, improve.
auim�Nc oa woex � � � � Jerwolnb,or r.pair awy.r1.r.cfwrr,p*ior to lfs lsausnce,
SCMK iANK,5lEP,Gli(5) ' .
.auo�on,oaniNr�cm � � � . , aGo reyri r eh� qoplir.w7/or swrb pennit ro JiJe a
ccssr�a ❑ owvwcu❑ . ,r:Rr«7 swren�enr ib.r be�is ltoerueJ yunuant m tbe
. . . p.nv:riuw:o/tbe Cuxtrocwr:l.ke�+r Law(Cb.yter 9
'. AIiER.RFPAIR.SEWLR 04 � �Cp,n�nsnC%nA(1Nlb�.5�[{(un 7W0/�Diviiwn j!7�1P
SF�+nGE Oi5vO5a.t SvS�Em
. � Busiwesr uwJ Pr%riiu CodeJ or tbot he i+exeiapt
ABn�COH iqVSf Sf WER � lLw�orn Nnd tbe b+rk/r thr rU«ged sxe ption.Any
. e+armscvri<iA�Ksp - ' � 'ufuluxufS�rtrun7031.S6yrnyupplicwefuraperniit
. sccv,rrttsi❑ crtssvoois❑ ' � rab/�cu rbr qepNrwwt f��rl�llpr..alr�/n�e.,�orr tha.+
-- � . � _ � Jiw bnwJrrd AoJkn(f7t70J.: �
� � ❑1;u rhr awwr of the properiy wtll do[Lr work,and
� � [hr s[runnrr!e wt fu[endrd or uHrred for aale.
. . (Sea. 704i, B.uJw+u a�w!Prv/e�a/nnr Cwk: Tbe Con-
� � e.aero:s Li�rn,s Lau�doer not app�y ro are ow.er oJ
� . - prupw�y wbu Ar11A�ur 1n+provsc tbereon,arod wbo doer
- -� � � . _ . s4r6 urorA b1..ndJ'p.swN..f tbat ru�E in.proven.ewtr
. . . wnt lwrrwdd ur aJJ`red/ur.rale.f/, Gou,rurr, t6e
. . . . - � � buJldi�y ur 1 Ervv.wsewt :r iold wiebaa one yrr of
. � � � � �Non, tbe o ms.-br!lder wJ!!bane tbe brrdrro
� � � ' � ' " , , o/pout�g ab.rt br d:J.,or b�ilJ o�in+prvo�/o.tb.
. . pw.porr o/r./.J " .
i
j I am exrmpt under Src. ,
_ H&P.C.for this reason
Dete
Ow�ner
' {NSflCTC#'S NOTK . . � .. � . . . � .