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Home My WebLink About1775A ' WORKERS'COMRENSkT10tV DECLARATFON I-hikeby offirm thai I trove a certificote of consent to sslf "os�re,or a cartificafa of Workers'Compensatiosi Insuronce,or 'fi"R'�° � �N,��,therey�p�.��ae��R �Eeoa�FE°�,�3� qppLICATION FC�R P�RMIT �Campany ��►r►� - SEWAGE DISPOSAL ❑Certified topy is har�y furnished. ❑Carrified copy is f�led wnh rhe county 6u�lding�nspectlon COUNTY OF LOS ANGELES BUILDING AND SAFETY departman. Dme��,�..�Appl iwnt ��+� � FOR APPLICANfi TO Flkl IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' ewtoiNc COMPENSATION INSURANCE aoorrcss ' �{ STAT��N °EvrH (ihis se<tion need not be mmpleted if ihe work involved by ihe iaqiitY nsaNnOie rz�FEReNce ��R pe�mit is for one hundred dollars(E100)or Iess.J NEArs�sT rrxoFcoNr+eCtiar� �[tJ�THFROM I cer�ify thot in ihe performonce o#ihe work for which this Cx05557. v. cone P.l. M.L TD F.t, permit is issued,I shall nor employ any person in any manner � rt-HO. so as to become subject to ihe Workers'Compensafion laws. OwNEg Co,nnv.NO. �Oe No. M41L �J TRUNI(PERMIT NO. ROAD PERMIT NO. Date Applicant ^a°Rfu F.. AfFIDAVIT WAIVfR EASElrlfNt RECOitO.IN5Tk.NO. DATE NOiICE TO APPLICANT: If, after moking ihis Cartificata of �iTY �- iEL NO � � mption, you should become subjea ro �he Wo�ke�s' iECAi ipensation provisions of the Labor code,you must forthwith DESCRIPiION lOTNO. �.NWY.ORST N'IDENING cumply wifh such provisions or ihis pe�mir sholl be deamed IBVOked. &OIX TRACi 'S7ATEENCROACHMENT LICENSED CONTRACTORS DECLARATION Np.pF BtDGS. PERMIi MO. I here6y oftirm that I am licensed under provisians of Chapter us[Ea`of Now oN iot 9(commencing with Sec7ion 7W0)of Division 3 of 1he BUSi- BUILDINGS �' Vh' CNaRGeS ness ond Professions Code,and my license is in full force ond Ef}CC�. CONiRACTOR g . '�� CONNECiION CHARGE FEE license Number �7�� lic.Class � Rcin+e� MEN*�tc q aooREss Con�rO[fOr �e�� p ^� OISTRICT NO. GROUP MAF PROCFSSED Bv U CITY iEL.Np. � ' /dQ/"C gK PG ❑I am exem t under Sec. af the L.A.Co. s''°rE u�. N 'G y � O P tICENSENO. ��J C1A55 \h F Plumbing Code and/or Sec. of the �O. DESCRIPTION OF WORK FEE NOUSE$FWER CONNECTING TO � � �A E� �/ VAUDATION � CUBiIC SfWER 8.8 P.Code for the following reason IC TAfJk SFE AGE PIT OR Z Gi15 ANDiOQ DRRIP:FiELD FiNAI Date �pUSF SfV/ER[ONWKTING iO BV PRNqTE�ISPQSAI SYSTEM $IgnOtule CONNKT AODITION0.:BIDG.OR , OWNER-BUII.DER DECLARATION woaK To Nouse sewea OVEAFIOW SEEPAGE Vli,ORAINfIEID I hereby a4firm that I am exempt from 1he Contractor's license ExrN.,c[sSrooL wtrweu.maNHoie Law for the followinq reason(S@C10f1 7O$I.S,BVISI18E5 Of1fJ Pf0- ALTEF,REPAIR OR F$hN�ON HDUSE � IOf15 COdC�: SEVJER OR DISPOS0.l SYSRM ,_,I,os ownar of 1he property,or my employees with wages os iheir sole compensation,will do the work ond ihe struc�ure is not intendad or offered for sale(Section 7044,Business ondProfessionsCode). OWNER�S Permi� E �D �{j ❑I,as owner of the property,am exdusively coniroding with A1�TH�RIZATfQN TQTAL FEE �iC2f15Bd contractars to conshuct�he project(Section�OIA, �HAVE AT THIS OATE A CONiRACi WIiH iHE HERE�N NAMf�CONiRACTOR f0 BUSi�955 O�d P�OfB55i0�5 COC�CJ. CONNECT THE ABpVE DESCR19E0 E%ISTING OW[LItNG TO iHE PUB:IC SEWfR r� CONSTRUCTION IENDING AGENCY � �`�- 1 l �,J�{i � I hereby affirm thof �here is a tonstruction lending agency SIGNEDTHIS DAYOF �9_ � a for the performance of ihe work 4or whi<h this permit is o,NNER°A�EN� #+° ! 1 O issued(Sec.3097,/�C�iv.�C.). 1 �-4J�1�Y1�'I �t�` ADDRESS � '-. a G l.S 7 lender's Name _ '- Gl,::(1= i�a��'s a�d'd.�� G�b`33 • ,: I cartify ihar I have reod r +s applicoti a d swN rhat�he Q 2,�E—�Q. above informolion is corre«.I ogre�to tomply with all Counry ordinonces ond Sfale law regulating Plumbing and Sowers, ond hereby authorize re acentatives of rhis Coumy lo enter upon �abovo-mentio property for inspsction purpossa. � f �' �_�'�� SiqnaNro �rtHttae Dote S!E RlV[Rtf f0�!%►LANATOkY LANGUAGE , _ _ _.. -- _- -— ----- . _ c��;��:�-�t;�t.�re re�E��.A�,x�rro� � • �•� �'t s �l"i4�i � M�a��-.�.. . .._., ...._.__"_ —�'_ _ s.. ._ ....' ..'._. _.. .. - , . . ,..a �." � �, � ;.�s:=r-r..' . _....y � _.._._.,.._._,t._._.. . . . . i tte� � i �Ffk-rx ti'a1 I:am ev.•:�gl fsnw;ihe C�wNrachot't _.__ ___� ._ � .. � . . 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