HomeMy WebLinkAbout1002A (7) • WORKCRS'COMPENSATIOND£CLARAT[ON �6A642� APPLICATION FOR PERMIT �
CE BOB(2-80)
�1 hereby aff"vm that I have a certificete otcnnsent to self SEWER-SEWAGE DISPOSAL
insure,or a certificete ot Workers'Compensation Insurence,or
a,cqr�',fie��np�trye�ep�(�ec.3800�ab.C.�� n COUNTY OF LOS ANGELES BUILDING AND SAFETY
I F{3ficY I�(o. `f �l:ompany r/4� -
�Cert�tied covv is hereby furnished. FOR APPLICAN�TO FILL IN CONNECTION DATA
Oeu��mr�c � ^ sT�riOn G6�TN
Certified copy is filed with the county 6uilding inspectlon ADD11ES9
depertmenL p �+�'1 � MANNOL6N6F6RENCC VPPgp
LOGIILITY GM1� LOW6R
Date ApPlicant N6111�6lT TYYB OF CONN6CTION L6HGTM FXOM '
CERTIFICATF.OF EXEMPTION FROM WORKERS' cnose ar. S(,�,1�jr c � Y, CURB ..�. ..,�.to v.�.
COMPENSATION INSURANCE •.c.no.
OWN[R � CO.IMr.XO. JOB 1'10.
�rt MI�IL
`.,115 SCC�IOiI IIlCd 110�hCC rnmpietcd 1(t�1G WOI�C IIIVO��'&� /1DDq888 4 eQ 1 TRUMK�6RMIT HO. ROI1D�6RMIT NO, �'
by the permit is for one hundied dollars (5100)m less.) j Fo�p��� ,N,� �< <o�p.�,,.r�.� o�,� �
ciry re�.na. V
1 certify ihat in the performance of thr work for which this �ccw�
permit is issued,1 shali nnt empluy any person In any manner OE9CNIPi10N �or r.o. �
so as to M1ecome subject to the Workers'Compensalion Lews. o`� wwr.ox sr.winaninc �
BLOCK TRACT � O�J � fT��6 6NCROACMMCNT
�6MMIT NO.
Date Appiicant no,ov e�ocs. W
NOTICE TO APPLICANT:If,afler making this Certifcate o[ a�za ov�or tiow or��or Z p.
Exem tion, you shnulA hecnme sub'ec! to the Workcrs' �se o•
P � BUILDING9 � S CXARG63 Z
Compensation provisions of the Labor Code,you muat forth- —
with comply with such provisions or this permit shall be � CONNECTION CNARG6 vee
deemed revoked. conrwwcrow
LICENSED CONTRACTORS DECLARATION wooxgss �� R61MlUI�l6MlNT F6E '
I hereby afiirm that I am licensed under provisions of Chapter � *w�cr.. cwo�. r.• ..oci.seo.. . ,._.
9(commencing with$etflon 7000)of Di�ision 3 of Ihe Ausi• cery � re�.xo. - f � �_Ie` -
ness and Professions CoJe,and my license is in full farce and ��C6N56 NO. CLI1B8 e � /� �� N �-+�, v""'�"—
effect.
� NO. DESCNIPTI N OF WDRK FC6
y,��,�� i1NAL VALIDATION
License Number�l.L'Z"rr� Lic.Class � u.'c:E.i+�o�������`�o C� owr� � �f
• . � / n� as.r�c r.nK,��....oa e r o �
Coniractor��//%dll�zJ�ate O ++oro. ..�..F�.� R ,
ous[sCreR CONNGet�l+c w FINAL
❑ w�vwT�o�frOs��Sv�T�r BY
I am ezempt from the Iicensing requirements as I em a eonnier.00�.�o.wr..�oc.ow
licensed architect or a regiatered D*ofessional engineer wowr.o wou..�iwew :
acting in my professional capacily (Sectian 7051. Bus- �ow s�o.ce.�•,o..�
iness and Professions Code). F c�s•roo�,ow.we«,r.ou.c .
Lic.or Reg.No. Date �
HOME OWNER�BUILDER DECLARATION
1 hereby a(f'vm that 1 am exempt frnm the Conttactor'S �NER�$ �fR11L t (f
License Law tor the following reason(Sec�ion 7031.5,Busi• AUTHORI2ATION TOTAL FEE „i,- �
necs and Prn/asions Code): ,r�.„�„e.s�x..
� 1, es owner of the property,will do tHe work and the o•w�.osuc s.w... ���oviToesennao aw�. �� Q Q 2 A
itruCfUfe IS 11oI Intended Of offered f0f 93�E (Section S�GNED THIS OAY OF 19 ' tt�'� � � �Q
7044,i3usinew and Protessions Code). ow�in o. � �
CONSTRUC710N 6F.NUING AGENCY �c�f��� I.� �2 2 S O �
1 hereby affirm that there is a construction lending agency • �2 2 Jr O�
fnr lhe performance of the work for which lhis permit is • . .
issued(Sec.3097,Civ.C.). ' �2�4.�8�� .
LenJer's Name
Lender's Address
I certify[hat 1 have read Ihis applica[ion and statr that the
above information is correct.I sgrer to comply with al�Cour,ty
ordinances and Sbte laws regulatinC Piumbing and Sewers,
and hereby authorize repres ntatives of this County to enter
upon the aby ve�mentioned roperty tor inspection purposes. •
,� � �� ��T�� SEE REVERSF.FOR EXPLANATORY LANGIIAGE
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