Loading...
HomeMy WebLinkAbout0887A WORKERS'COMPENSATION DECLARATION � 1 hereby affirm that � have a certiFicate o/consenr to self . . � inaure,or o certificale of Worken'Compenwlion Inauronce,w �6"6�70 � a ceni(ied copy theroof(Sec.3800,La C. � CE8091REY.1/8L APPUCATION FOR PERAAIT Policy No� dy Company_,�i��O.C��IJ/ �Cer�fied coPY fs he.eby fwn�ahed. SEWER - SEWAGE DISPOSAL �,Cerrified copy is filed with rhe couniy building inspeciion COUNTY OF l05 ANGELES BUILDING AND SAFETY depo e � �a `/ Dote Pb qpp���o���,�/./"/i�-$S'�J2�/ POR APPLICANT TO FILL IN f�% CONNECTION DATA C TIFICATE OF EXEMPiION FROM WORKERS' �qpu.� _L COMVENSATION INSURANCE �ess Q S CL�r� P�- C7• STATIpJ S— o[arH / (This section need not be complefed if ihe work involved by the i�,iiTy OCe��4 4 hNNNIXF REfERENCE 5 �� u°°E° permil is for one hundred dollors(f100)or less.) I certify that in ihe performance of the work for which Ihis CpO5�555i TY������� lE�(''�NF°OM permit is issued,I sholl nol amplay any person in ony monner Y� CUae m.t TO v.L. so as to become subjact to ihe Workeri Compenaation laws. ��a � � � P.c.�'O. !-' r c1' CO.IMP.NO. Jpp Np. ✓ pZ �'�� TRt1NK PERMIi NO. ROAD PEYMIT Np. ' Dole Applicont AOWtE55 .� a�L '�,_ NOTICE TO APPLICANT: If, after mokin this Cerlificob of arvioavir wuo[a e�5[�Nr c[[oao.ir�sm.rq o�ie 9 a,r rv:..� iELNO �y- o-O 6U Ezemption, you should become subjact to the Workers' LEGAI 7 Compensotian provisionz of the Lobw code,you must forthwith oFxaivriora iorroo. / � Hwv.ors ir.wiotr+itic mmply with such provisiona o. �his permit shall be deemed . revokad. eiocK TRA�T $TAIf ENCRO�CNMENi LICENSED CONTRACTORS DECIARATION r+o.a�ocs °ER ^�� S12E Of LO7 Mpw pN LpT 1 hereby affirm thai 1 om licensed under provisions of Chapter �� 9([ommancing wifh Settion 7000)of Division 3 af the Busi• eunoiNGs p�,��s nass ond Prof�ssions Code,and my license is in full force ond lHK�. /� �pNTRA[TOR �jJti�„ ' COM1N�ERION�HARC{FEE LICC(ISG NUTb!l,p��l[.CIO55 "�^�.p _ ADDRE55 � ' R[iMgURSFMENT i(E COI11fOC�Or (/-+L� �OtO I/��I/3`5 • ' DISTRICT NO. GNOUV � M�F PROCfSSED DY O CITY TEL.NO. � � ❑I am exem �under Sec. of the L.A.Co. srnre uc �J V P IICENSE NO C1A55 3 j�t" /�� ���i j,,� � NO DESCRIPTION OF WORK ffE Plumbing Code aodior Sec. of rhe �IpUSE SFWFR CONNfCTING TO OATE� ` � PUBUC$[WEq /7 /�-L/���' VALIDATION � B.8 V.Code for Ihe following reoson � �NK$(EP� aT pq d Mi5 AND/ON bRA1NF1FlD FNAI 1 N �o�e �ous sev.aR cowNtcnroc ro °`' �O 8 B 7 F yt�, iR1YAiE I Y � Si9nOfufe • �pNN(GTAOOiTIONILLlIDG.pft ,� r; • • • • � O OWNER-BVIIDER DECIARATION wa+K io NouSc sewta �j OVERiLOW SEEPAGE iIT,ORAIF61flD I • •2 /.S O I hereby nffirm tho�I om exemp�(rom ihe Connauor i License fXTN,CESfiVOOL DRVWEII./MNHIXE ' Law for the lollowing reoson(SlC�On JO3��S,BUiSOMS OOC�PfD• NTER.REP/.iR OR AlANOON 1qU5E fessions CodeJ: SEwEa on Disros�i svste�v, • • • 7 7 5 Q� ❑I,as owner oF the property,or my amployees wilh wages os . � �,2 2-8 Jr Iheir»le compensalion,will do the work ond the siructure is no1 infended or olfered far wle(Secfion 7044,Busineu and Professions Code). OWNER'S Petmit f )O SO ❑I,as owner oF the property,am exdusively comracting witF AUTHORIZATION TOTAL FEE S� ' � �ICensed COnflOC�O�S 10 co�strucf the prolect(Section)044, 1 HAVE A1 THIS DAfE A CONiRACt wITH fNE HfNEIN NAMEO CpVtI1.K10R TO �� � Bvsiness and P.ofxsions Code). ca+Nca iNc neovt oescaieeo ez�sru,�owewru�ro r�rueu�sEwep. CONSTRUCTION LENDING AGENCY �. I hereby affirm fhoi �hxe is o consfruclion le�ding ogency � SIGNEDTNiS DAYOF 19_ � for the performance of Ihe work for whith this permi� is ��R pQ � ' Issuad(Sec.3097,Civ.C.1.�/� o���s'°�NT . pODRE55 Lender's Nome_� �. lendei s Addrou � , I carti(y ihat I hove reod this applicmion ond s�a�e thM Ihe . above Infpmafion is torrecL 1 oyree to comply wi�h oll County � ordinances and Sro�e lows requbriny Plumbing ood Sewars, � and hereby outhorize rep�eseniatives of�his Coun�y to enier � upo�Iha abov�-menlioned prOperly for inepe[lion purposes. � � / � / ,�s �ro of Permitfe D fe SEE lEVfRS!fM E%tIANATOlY IANGUAGE � , . , � . _ I"l_=F�crO'.5�JoieS �)1�\'I I. LL7LI)� I.Ul?t'I rV.:\71(1�;', ' I.TY'�:��/:�L$ cr;e ir :rrOn:Sse•ianp- � ___'__'� .__ _ ________—_ _- _...I L�nL�atC�ci�t�it 1.un i�cmpl�n•:n Oic('onlr�dm's � . . . . � . � ... . ' I.ic.n.c Lu�+ Inr 11�.4���t1�+�5ii,f; rcn.,r. (Sr�r.'o�r 70,i1.�, ::v H � .._ .. _ _ � L'�oiui u ier.r!f'ra(,�ti���>>t.�Cnd<y'duc,'ftr c�io uq�'�rkitf.�.' � ^ •. . . :�� ;� C��.^. �p C i .I � __ .. . . _ . . . � r�.�u n�r.pen:uf fn�nn�lruct.rftrrr,un;rnce.d�n�<<li.ur � i„ .,,. . _. . _�__. - ._._ . _ . ... - . �."ie1 �e s::= r��s, .�.i. , r- . , . .. . ., � '�__''_'._._ '__' _'.'.._. _—_�_. ... .np �t 1��<•fi:n,f, r 1. nt� r n�re�.uhri r >du . . . -_ � n�,r�.o.[..�.�^.:,�r, ., _. _ .....�__. . . _ . .�..'� " .. _. ..__'..._._ '_ - c�.�i;.ui.1 f� ,u�1 p� il( 1-fc�a .n d Sla:cnie�!(h.x'L<e� . ,I ._. . .�.. , . .. Y — - _ -_ .� . � c"���^-er iJ rcv.� �.f�. . ... . � � � -- . .• ' �' -�~ _�- licer�uf purr��r 1 !'fd� j. �� 1� cl �7i C r��n�l�r's ... _ ,__ _ . . . l.i�c�i�il«�.�(Ch.�..��'il��nii��ntui,r'.7�5<<firi�7(J1171tJ �. _ .' _"_ __ .. _. .. . >�.r�a.ar�.�� sr�,*.ca '. � . __-_. -._'_.�__ __-_— Iliri�inradnfl,7rl�r��incs�nndl'�rrfr«iniraC'4?c�i�rr;r:r!l:ri+ : . �' . . - . . ..� .. . . . :.C'_P^�.SV`.____ _ _ _ _ - -.-- �a . _ _ . ... . . . " , exerr�pt fl�crrfrum rrud Ou l����i�for Uie nll;g��d ea��rrr��:irn:.� t.-c .i <•c .; � i -- : � .ti.i�ioln��nr�nf.Srctmn7ll.il.SLrnr��'np�.f��r.u[fn r��r t _. � �a , u.r�r. - - --� - -� - - .-�,— .. � r � ' J t! / ..�r i - .r � . . _ .. � - ' . , . . . � .. �! � ,i i E • o rni ni nr «�i i�� ��.�-Y.l i ap;rl.��n ! �� nJ i.aln i .� �� �Guui�d f flcn rS.i 10�.: _ �� �� . .<s _�[�- I �± - -- - ---�_ - -_--- -- . . . � . . L 1...,U.i onner nf tPc pi�pcitc uill da ihc uorl.,and '_ . __ __ _ ___ __-_ . ._."_.. ___.' __ _-'_-_____..'__...,�`_ .. ._'_�� .. ' _� ... :.�_._ .. . . . . . . ___ L:^structvrr it nn[i:ft:r.dcd or nCfa-rd for��:ilc. . � � � _ . .. ' - � . ' 'ISec"PIJ,Uutirrrcr�:;v717o�r��lnin('adr:TkcC��aharinr'.� . :. ^. .,. . � : .; _• . , -�_ _ _.. ' ----._ . ...._...._.... ...'--- �`---- -- . .. _.__.. • �-'--- , r,.�,l� t�,rur onnrr n(/,rn��•ir,K�d�� � , . .. . . . __�'— . _ ... � �. . _. . .._..� _.. h��iLhnr-iruprutr�(hrrr�u.m��ln�hr�. r ! rnrAlrim�c(f _ Lirrrtce Lar� ocs rrn:r Src�s � � " -�' - - - � � -- . . . .. � ' ' � prvti•idtd}liat e¢rlr in�proranrnn�are�u�,!ivaa��i���d ur�,�ff�.�d' _ __- , ,. ' '�� __._- mifdu�� u iu�•i �nf iv.��nld _ . _' . ..__ ... __ _ ._. . � _. . . . ._ , . j,. I !!. I �r C:e! < < . . . . .. � �. : .'__. _ ._- -.__-_ _ . . . �c�t �:r�rr rf- rplruun.dunnrer!li., i��i�(li✓�rf4e� . • . --__. :.___.___ . '___.____ _ __...-___.. — . . _ ..' '__. . -_-. ._ • . . . . . _ . .b . c rrf prncm.;;thu!L�r.5rl.im:f.uild ur 4'..,^evi,�f�,�U�r � . _ ... ._.._,.. .-... _'. _ . _ _ . __. . . _ . . . . _ � : . p:u�,.�cz n,�sc;..1 ,. .' � . '' ._ . _ . . _._.._ . ___.. .._ ._ �. _ .. . � � ._ , __ . _ :- �. . .. � '. :___ . '._ _.� j 1 ---- - _ an:c�ernpi u��c cr SCc.-----...-_-------. _ _ _ _____ _ _ _.- - _ _ _ ' ' i � --- ------ - � _ .(..fu� tht.��ason ----- , . 1�'�t' p , : . �_--_-------�-----.._....— - . . ' - --- —". r- _ . .. .. . -- - l>:tc .----- .. ', . __. . .. . _ �.__ .. __ ___ .-- . . _.. -- - - - - _ O«�r.�r— ----- . . ir�sreaor.'s rtoTas --.-_ _ ------- i , •. . . -- - _ _ _.