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HomeMy WebLinkAbout0902A (4) ---_ ___ . ._ _ _ ---. .__ _ ---. .__. _ __ __ _ _ _- -- �_�. _._ _ _ . -�, WORKERS'COMPENSATION DECLARATION � ' � I hereby affirm �hm 1 ha�e a cartifica�e of conaent to self � .. I inwro,or o ceniflaole of Workeri Compenw�ion Inaurance,or �aee�zo I � o certified copy t reof(Set.3800,La �, �E�e�RE�.,,e�� - , �.APPLICATION FOR PERMIT � � Policy No. � � Compony !E'C�,Q.f��C� �� ❑ce`�a�py is hmeby furniahed. SEWER - SEWAGE DISPOSAL I �Ce�tified copy is i�lad w��h the counry building iospection COUNTY OF L05 ANGElES �i�98UILDING AND SAFETY departman�. Da�e //;,1/-PS Appiicant ��,U.,fyR SL.�- FOR APPItCANT TO FILL IN �: '� CONNEGTION DATA � CERTIFICATE OF EXEMPTION FROM WORKERS' �+ �} COMPENSATION INSURANCE +ooa�s�s OS,;D �LAh LGb � sT�i'°N o(�" 'J�- acAH �p (This section need no�be comple�ed if the work involved by the ��i�tr ��� � pWNMpE 4FiFRENCF �U� � R permit is for one hundred dollors(5100)or less.) ��s rrreacW�tttan 1 certi{y�hot i Ihe performonce of t6e work for which this txo555i. - � � �"K'��� permil is�asued,1 aholl not employ any pe�son in ony ma�ner v. CUR! v.t. M.t.70P.1. so as to become subject to the Worken'Compensolion laws. � °����OO� OWNFR CO.IAN.NO. JOe NO. A�E� .� / "�'� IRUNN RihNT NO. pp�,p P[¢,WT NO. Daro ApplicaN NOTICE TO AVPIICANT: If, afier mo4in �his Cer�ificaie of aFiw�wr wwrvto e�va+[r+r aecoco.iram.w. o�re Exemption, yoo should betome su6je9C1 to the Workers' ��TY ly;w-e �R. iei.NO. /1�- �jd'�i Q . LEGAL Compe�smion provisiona of the Labor code,you muar for�hwith oEscaivriou wTr+o. 3 NWY.OYST.WIOFNIIJG comply with suth provittons or lhis permir sholt be deemed rovoked. aiacK ta�cr ,3�p ,� s�u er�tvo�cw�en* UCENSE�CONTRACTORS DECLARATION ni°.°F&oc5. °ER °'O� 512EDFlOT NOWONIOT ' I heroby uff�rm�ho�I om limosed under provisions of Chopler �a , 9(commencing wi�h Section 7000)of Oivision 3 of Ihe Busi• � ewiouws � p��y�S ness and Prafessions Code,and my licenae is in full force ond affec�. bp � � Ca+iRacrpc �� � CONNKi10N CNAq(�FEf LicenaeNum er a7� LicCloss "___.-Sr �� � b '/ _�— ApdtE55 RE�MWRSEMENT E - Conhoctor L.5 &y Date./[�.2/�,�.:� ' . : oisra�crr.o. c.co�v PoLm..r �r- oar V --� orv iei.r,o. e(t w ❑I om exempt under Sec. of the L.A.Co. uceHse rro. cinss � �� �- /3� O NO. DESCRIFTIONOFWORK FEF p,. Plum6ing Code and/or Sec. of tht H�i wus�s�wt■eo�r+eeri�ro � OAif r VAIIDATION w B.8 P.Code for the following reason �p`ICµ�•gEVAGE MT OR /� //_ ZO^�� Z VITS AND/OR ORAINiilLD FINAI '. DOfe FIOUSE SEWEY CONHE[TMIG TO BY NtIVA Y T . Siyna�uro (pNNE�T ApORIdYI 61W.O4 � ',_n�;C���,1 �. OWNER•BUILDER DECLARATION '^'�K ia���y`'Ep i� ' ONER LOW FPAG(R1.pQ/i1NFIElD �heroby offirm tho�I am eeemp�from the Controcror's License E%iN,�E$$qpl pYYVJEII r+wN�qt[ - $; . . ... � Q � law for the following reason(Sxron 7031.5�BUISt1e3S Ol1E Pf0- M1E4.REPAI4 OR AMNDON XOUSE � fe33iOn5 COt�e�: ��R Op d5�06�L SYSRM � � a ��7,5� i ❑I,os owner of tha property,or my employees wilh wages os their sofe tompentotion,will do the work ond�he strudure e r �' j ; � ��1..:'�c� � ia nol infeoded or offerod for sale(Sectb�>OdI,Busi�eas � ond Profeuions Code). OWNER�$ Permlt � 3 S'j'! I �,c 2-n S ❑I,oa owner of the property,om eaclusivsly controctin9 with AUTHORIZATION 70TAL FEE � 6'� licensed con�wcfors to consnuct ths project(SeUion 701�, �qAVE AT TMb GAiE A�pNfRJ1CT WI1M iME 11ERE1N NAMED CONIY�CLOc TO � � Buainess and ProFessions CoAe). Caur+EGi iNt neovt of5ck�eto EMiStinK pwEttiHc to iNt vue�ic Stw[a. � . �� CONSiRUCTION LENDING AGENCY , ' i 1 here6y affirm Ihai there is a consMUUion lending opency ��FDTHiS DAYOF � ID_ ��, for the performcnce of ihe wo�k for which this permit is ��p� � isa�ed(Sec.9097.Civ,C.). ,�J)JJ owr�as�c�Ni • � lender i Name /J[�/� A�F� '� Lender's Address � ' , � I ce�tify ihut 1 hove read this opplicption and stote Ihal ihe - � o6ove informmion is correct.I ogree b compiy wirh all County :� � , ordinoncea and 5tate lows requlaling Plumbinq and Sewers, � ond hereby ou�horize repreeeo�aiives of ffiis CooNy b enbr � upo�fhe above•menfionad pOperly for inspectio� urpoms. � - �� �'� � Sig e of Pe�mine le . 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