HomeMy WebLinkAbout1030 N GOLDEN SPRINGS DR (10) . WORKERS'COMPENSATION DECLARATION � �
:he�eby affiim tho� I hove a cenifico�e of consent to salf . _ __ -
��sure,or o cartificme of Worke�i Compensniion Insurance,or �e�'b'z� . .
�Y�d�''���c���,na°°,`°b�ona�rt ��'R"B,B„ APPLICATION FO.R PERMIT �
�Cerfified topy is he�Cby furnishad. �SEWER - SEWAGE DISPOSAL �.
�Certified copy�s filed wilh the county boilding insPection � COUNTY OF LOS ANGELES � BUILDING AN�SAFETY � ' .
' deportment. .
�ore 7 82 Applicont � � �� FOR APPLICANT TO FILL IN CONNECTION DATA '
� CERTIFICATE OF EXEMPTION FROM WORKERS' �,iouac . .
COMPENSATION INSURANCE ���u 1A30 N. GO�.C�EIl 5i�tqN ocrTH
This section need not be compleled if the work involved by the d pW,NVq�E REfERENCE ��R �
�ermit Is for one hundred dollars(f100)or leas.) �W uTr
'certif Ihat in tbe erformonce of ihe work far which this �P'�T . irveO�cd+NKt� �r�TNFypN ,
Y P CROSS ST. Y. CURB P.4 M.L TO V.L. �
iermit is issued,I shall not employ ony person in ony mannar ` P�� 0- �
�o os to become subjett fo 1he Workeri Compensation Laws. Dyy�,�q � � �p,�,Mp.r.p, �r.q, � � .
b1e Applicanl
� AOD1 RE55 629�C.qvi.n� Blvd� IRUNK PEGMIT NO. 40�D PERMI7 ND. p�
ARIDAVIT WFNER EASFAAEN7 RECORD.INSiR.NO. DAiE �
JOTICE�TO APPIICANT: If, aftar moking this Cerlifico�e o( aiv .Sd[1 �1T1�S lEt.tr0.714 49-6864 . � �
:aemp�ion, you should become subject-to the Workars' �Gµ - W
:ompensation provisions of rhe Lnbor code,you must fo�thwirh o�scvivriau torr.q.$ �l�i n �t} � �w,.,p�ST,,�,io�N�r�c p- '
:omply wirh sutF provisions or this permi�sholl be deemed '�
evoked. etoo: T'�ACT 31274 4Q386 STATE ENCNOACHMFM T
� LICENSED CONTRACTORS DECLARATION � r�p.a e�n�s. . �RMrt r�o.
SRE OF LOt NOW ON LO7
hereby oifirm that I om licensed unde�provisio�s of Ctiapter �a
)(commencing wi�h Section 7000)of Division 3 of fhe Busi- puilon+Gs � ai4kGEs
iess and Professions Coda,a�d my license is in f�ll force and
sffect. . cprara�croa CONNFRION�HARGE FEE
i�cense Number 37158Q t�a Closs � Ap�u REIMBURSEMENT iEF '
Contraclor '1�IE ANIJEN G!� �/`82 oisT4icT no. ca+ouc wv.v mocesseo sr
T- CITY iEl.NO.
STA1E LIC. BK PG
❑1 om enempt under Sec. of ihe L.A.Co. ��Ng nip, aass �� �� �,L1 �
Vl�mbingCodeand/or5ec. ofthe �' �`�R�PfiONOFwORK ffE FNAI
Mous�s�weccorm�cnracro DAiE � 8, " VALIOATION
8.8 P.Code for fhe following reason � °UB11C�'"FR d . ,
� SEOSK TMtlC.5((PA�PIT OR FINAI
cITS AND/OR DRAWFIEIA -
�1@ `qUY SEWE4 C01�MRING 70 Ov
PRNATE OASR�L SYSIEM .
sgnofure c�ecr a,ownoNu&oc.ou � .
OWNER-BUILDER OECLARATION 6 �K TO����R
pJERF�OW y(iAGF R7,DR�MF�ELD '
I heraby offirm that I om eaempt from�lhe CoMractor's License [xTN.,c[sspoo�oqvwEu.nw�HotF � �
Law for the following reason(Secton 7031.5,BoiEness and Pro- ��p�p�4�M�+NW3F - � � f,3 2�.4 A �
iassions CodeJ: � .
❑I,os owner of the property,or my employees with woges os . #' � •,•.��� .
� fheir sole compensaiion,will do the work and the sfruc�ure � � .
is nof intended or offered for wle Sedion 7044,Busineas
and Vrofessions Code). ( OWNER�S . PCrmit f �v I��•9 3 5 D
❑I,as owner of rhe property,om exdusrvely controding with AUTHORIZATION TOTAC FEE 9� �d •�• •9�5 0�
licensed comractors to conatruU�he P/O�pCi'SB[�i011�OAA, I HAVE AT TH�S D4TE A CONfRACT W17H TFE�RfIN N!1M[D COMRACiOR TO � �
Bus�ness and Profecsions Code). corar�[cT n+e neove�scaiee�exisTir�owew�ro n�t vueuc scwca. ' 'O�O S i 8 2
CONSTRUCTION IENDING AGENCY ; ' .
I haraby offirm thot there is a construction landing aqency 3�GNE�TH15 DAVOF 19_ � - .
for the performante of the work for whlch ihis permit is °W�RO4 � .
issued�Sec.3097,Civ.C.). owr�aSAc,�N*
CAIIt].II2IIte1�. TZZL$R�_ aooaess . . . . .
Lender's Name , �
t�r�,�'n����� ��si9�� �7.7.. 5Q6�.3
I cer�ify�Mt I have read this applicotion and s�ote thal the - - - � .
above informalion is correct.1 agree fo comply with all Counly � . . . ' �
ordinanCes and State laws reguloling Plumbing ond Sewers. � � � �
and hereb, uthorfze representa�ives of ihis County ro enlar � -
upon 1 o e-me �o ed properly ior inspettion pu�poses. � � . .
� y 7�/SZ " '
6
Signolure of Permit� Da SEE REVERSE FOR E%fLANATORY LANGUAGE