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HomeMy WebLinkAbout1370 VALLEY VISTA (33) . � � WORKERS'COMPENSATION DECtARAt10N . . � - � � I hereby offirm that I have a certificate of consent �o self insure.or a cediticate of Workers'Compensation Insurance,or 7dJi°'�0 a certifie �oP thereof(Sec.3800, a6 C.) , ���,°�.e,ej APP1.iCATION FOR PERMlT PoIiCY N . Company � �s ❑Certified copY�=hereby fumished. SEWER • SEWAGE DlSPOSA! �Certi4ied copy is filed wtth the county bu�id�ng inspection COUNTY OF LQS ANGELES BUILDING AND SAFETY de �lment. Dote��Applicont FOR AP LICANT TO FILL IN GONNECTIdN DATA �CERTffICATE OF EXEMPTION FROM WORI awmwc �1 gp7�p�y pEprH COMPENSATION INSURANCE noouess ( � �This sectian need not be completed if the work invalved by ihe i�iiTM � nuraMae wereceNce i�R permit is for one h�ndred dollars($700)or less.} N�AqEST � TyPF pF CONt�&CTION ��yCTN FROM !cerlify ihol in the performance of ihe work for whlch this crmss si v. cuce r.i. M.i.To P.t. permif is issued,I shall not employ pny person in any manaer . so as ta 6ecame subject to the Workers'Compeasalion Laws. owNER P��No co iti+a.ra. ioa rao. ��� i2UNK PFRMIT Np- ROAD VEPM�T NO. Daie App�con1 '10°�� AEFIDAVIT �NAIVEft FASEMFNT FtECORO.INSTR_Np. DATE NOTICE TO APPLICANT: lf, ufter making thic CeAifkote of �iry iet.No. ` �nption, you shou{d bamme subjeo to the Workers' �E� . � .fpensation provisians of fhe tobor cods,You mus�forthwi�k oescaivriory torr+o. Hvn,oRs�.wioeNi�vc camply wilh such provisions or this permit shall ae deemed revoked. e�ocK tRACT SiATEENCROA�HMENT LICENSED CONTRACTORS DEClARAFION �'�&D� �T� s¢e oc�oT Now oN�or I hereby affirm rhot I am licensed under provi:ions of Chopler �oF 9(commencing with Section 7000}of pivision 3 of the Busi- auiioi�s a+t�eccs ness and Profeu�ons Code,and my license is in full force and g{{g��. � CONTRACTOR CONNERIQN CHARGF FEF T licanse Nomber�9�83�_lic.Class � n � � REIMBURSEMENT FEE O Contractor �0�6 � Y / 015TRICT f10. C�f20U7 MAP P0.00455EU BY V .Q��_ —J��- ��r TE��.�13- 3a-3/ BK � z ❑1 am exempt uflder Sec. af the l.A.Co. ���g� Q c�ss [� (Q � � NO. DESCRI IpNOFWORK iEE ~ • Plumbing Code andlor Se�. of the F��� V FqU5E5fWEpCONNECF5NGT0 DA'E VALIDATION y � B.&P.Code for Ihe following rea n PU&ICSEWER fl•��',� ; ' SEPTIC TANK.SEEPAGE PIT pR F�� z I ' 9455 AN��OR ORAINFI�iD 8Y l� I Date rq�$[$[WER CONNKTING 10 � PRIVATE��S L SYSTE � � ' Signoture ��+�T^��T���.� ' OWNER-BUILDER DEClARA710N WORK TO iqVSE SEWER ' OVECFLOW SFEPRGE PIT.DRAINFIEID : � I hereby a4firm that I om exempt 4rom the Caniractor's License extw. cessvOIX,ukvwFu nu�w+Ote 1 tnw for the follawing reason{Secron 7031.5,Buisness and Pro- ntt[a,aenaia oa aealloont taouse _ . --. . ___ ._ ,.�- � - - t s6wiR oR DiseaSn€sKSSNa-=—.•--�. -� - - .ns Cade}: ea } �I,as owner of the property,or my empfoyees with wages as� ! their so4e tompenwtion,wi11 do ihe work and tfie siruclure '�3�E,L}� j is not infended or offered for wle(Secfion 7644,Business , { and Professiens Codej. OWNER'S Permit 8 t� � ,+{• •.� �� L� AUTHORIZATION ' � ❑!,as owner of the property,am exclusively contmcting with TOTAL FEE r' r, � ; licensed contractors to can:truct the projed(5ection 704a� �}{p,yE A(TM15 DATE A CONTRACi w1iH THE HEREIN NAMFn CONTRPCTOR 10 � • •K�:,v t5) { BUSII1B55 O11CI PfOfES510I1S COdB�. CONNfCT iHE A90VE DESCRIBED EXISTING DWEIL�NG TO TME FUBIIC SEWER + � CONSTRUCTION LENDING AGENCY °� `��.�O�� � I hereby a4firm that thete i5 o consfrucfion lending agCncy SIGNEDTHIS DAYOF 19_ � � � for the performance of the work for which �his permit is ��ps��µs � �'��'`� � � issued(Set.3097.Civ.C.). ADDRESS lender's Name - tendar's Address � _ _ - - - - I cerfify that I hove read this apptication andstale.that.the - �� � �- - -� - - _ - _ _ . . �- -� � � above irtformation is correct.t o9ree to comply wiih all County .... - .. . . ... ........'�. .._... ...-�--- ....- -._. .. . . .. � � ordinantes and State faws r�gu�ail�g Plom6ing Ond$ewers, � � I and he�eby aufhorize represenio�ives of this Counfy�o enter , � � upoa t above-mentioned property For inspection purpoges. ( r 1� o�o � � _Ll ignalure of Permittee Daie SEE REVERSE FOR Fl(PLANATORY tANGUAGE t ��� � ... T��.�-�""' , .._.�..�� x►,�°�,� . .� ���� � -� ,� �,�,,� � . � , �'�� ,.,� ���.��� � �� ���� ��� - � ����o� ���:.������� � o� ?����v ��x � ��'�-�.,�g�`� -T�µ :h= r""� x` ��"' �, �:w�i ��� Q �"� Si �� ' �, a v �� ��,�^�'�'���� r��������� . � �` . � �� � � �„"� � `^ ~ "• � � � �t�`�= �,,, .�''� +�"5''S s�3�o, ��'� "��'�� � � '� d, ,<,��� a o�`�,�7�;;a q �G�.. 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