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HomeMy WebLinkAbout1774A � WOIi1fER5'COMPENSAiION DECLARrtTfON � I here6y affirm ihot I hava o cartifimte of �vnserit to self �j insure,or a cenificate ol Workers'Compensallon Insorance,or >sanaso II ,;cY�`r�, °'��n�'.`°b��� `E�e'RE°"6" APPLICATIQN FOR PERMIT � ❑Cenified copy is hereby fornished. � SEWER • SEWAGE DISP�SAL ❑Carti4iad copy is filed with the counly building inspection COUNTY OF LOS ANGELE3 BUILDING AND SAFETY depart enL ,� t� � oaie .�. Applicant��� POR APPUCANt TO FLl IN CONNECTtON DATA CERTI ICATE OF EXEMPTION FROM WORKERS' euuoiN� COMPfN5AT10N IPdSURANCE noor�ss � '` S�ATIDN cevrn (This section nced nor be completed if Ihe work involved 6y�he �«A��TY k,nNHat RcrEa[n[f �� permit is for one hundred dollars($100)or less.) � � I<e�lify �hat in the performance of the work for which this C�Sqsst iYPEOFCONPIfCiIqJ �raGtMfrtOm permit is issued,I sholl not employ any person in ony manner r� cuae v.t. M,�.70 P.�. so as to bemme subject to the Workers'Compensation Laws. OwNek � CO.IMG.NO. JOB NO. ��� � TRUNK FE2MIT NO. ROAD GERMIT Np. Date Applimni AODaEsS NO710E TO APPUCANt: If, after makin ihis Canificate of aFFionvir N'AIOER ens€mcmr RE[ORD.INSTR.NO. P4iE 9 CI7v iEL Na. — . �nption, you should become su6ject to the Workers' tecai �pensation provisions of�he Labor code,you must forihwith DESCRIPiION �orNo. j � # HWY.OR ST.WIDENING comply with su<h provisions or this permit sholl be deemed revoked. s�ocK iRACf � StAt[ENCRpACMMENT LICENSED CONTRACTORS D€CLARATION ^i°.o�&°�s. ���1 N°. I hereby affirm that�am lirensed under provisions of Chopte� SizEOFlor Now oN iot 9 commencin with Sxtion 7000 of Division 3 of the 8usi- use oF _ ( 9 ) BUItDINGS CHARGES ness and Professions Code,and my license is in full force ond ¢ffe[�. ts�.� Q �ONTRACTOR �� CONNECTION CHAR:.E FEE License Number �7�J�C7C7 lic.Class V nooREss �RE'^^euRst r FE� y, COnilOCfOI I`.3 Oi6 � � [� D�STRICi NO. GROUo MAP PROCESSEO BV a �CITY " �} TEL.NO. . �7 O ^ 6N P�. V STA7E LIC. � I` ' ❑I am exempt under Sec. of the L.A.Co. ,iceNs[rva. � anss �^` � NO. DESC IpfION OF WORK FEE Plumb�ng Code ond/or Sec. of the Fi"Ai VALIDATION O , HOVSE SEKEQ CONNECTING TO DAiE p PUBLIC SEK'ER CfD �/ B.8 P.Code for tha following reason ic rnNK,s�e n cit oa a � a PIiS ANp/OR ORdINFIEID ��NA� � yy Daie NOUSE SEWER CONNECTING TO BY � �_j(p_� Z PRfVA'E QISPC SVStEM Si9�p�UlB CONNECTADDITIONAlBIDG OW � OWNER-BUILDER DECLARATION womc To Nouse sewea I hereby affirm�hat I om ezempt from fhe Controcror's license ex�ri}��i55p�oai oRrwoRp�ruNHoie � Law for the following reason(Sec�on 7031.5,Buisness and Pro- n�.rER aevnia oa a6wNC,oN House � -�ons Code); sewee ae oisvosai srsrzM u I,os owner of the properfy,or my employaes wifh woges as their sole compensation,will do the work and ihe structure is not intended or offered for sale(Sect�on 7044,Business PC�mit E -�� 7����t a�d Professions Code). OWNER'S � ❑1,as owner of 7he property,pm excl�sively cororocting with AUThORIEATION TOTAL FEE . licensed conrraciors ro construc��he o'ect Section 7044, �° � ' � C P� I ( I HAVE AT TNIS OAiE A CONTRACi WIiM THE HEREIN NAMED CONTRACTOR i0 Bu5inC55 4nC1 PrOfE55iDn5 COdE). CONNfCT LHE ABOVE PESCRIBE�EXISTiNG DWELtING i0 iHE PU&IC SEWfR. I e. 0 2'7,5 n CONSTRUCTION LENDING AGENCY I here6 affirm thal Ihere is a mnstruction lendin o enc SIGNEDTHiS �AYOF 19_ m , - ' c: x Y 9 9 Y owr�ec ou - :. c l,,.,t]c for ihe performance of the work for which this permi� is OM'hERS AGENi issued(Sec.3097,Civ.C.). �2,`��—�� nooaess lender's Name ���.�A�'s " ' g3 1 car�ify Ihai I have reod is applic ' n d stafe thot t6e above informotion is cwract I ogrea ro comply with all County ordinances and Stata law regularing Vlumbing ond Sewxs, ond hereby aothwize re esentotives of�his County lo eMer uponf above-meMion � property for inspecfion purposes. 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