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HomeMy WebLinkAbout0887A (4) 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 hereby fu�Nahed. 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 Cpp5�55gT T�PEa�ONNE�TqN IENG�MFVOM 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 � � Compensotian provisionz of the Lobw code,you must forthwith o[scaivriora LOTNO. HWY.OR Si.WIpfNING 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$(EP� aT pq d Mi5 AND/ON bRA1NF1FlD FNAI 1 N Do�e Noust sEv.aR cowNtcnro�ro °`' �O 8 B 7 A ,� iR1YAiE I Y � Si9nOfufe • �pNN(GTAOOiTIONILLlIDG.pft ,� r; • • • • � O OWNER-BVIIDER DECIARATION wa+K io NouSc sewta �j OVERiLOW SEEPAGE iIT,ORAIF61flD I • •2 /.S O I hereby nffirm tho�I om exemp�(rom ihe Connauor i License fXTN,CESfiVOOL DRVWEII./MNHIXE ' Law for the lollowing reoson(SlC�On JO3��S,BUiSOMS OOC�PfD• NTER.REP/.iR OR AlANOON 1qU5E fessions CodeJ: SEwEa on Disros�i svste�v, • • • 7 7 5 Q� ❑I,as owner oF the property,or my amployees wilh wages os . � �,2 2-8 Jr Iheir»le compensalion,will do the work ond the siructure is no1 infended or olfered far wle(Secfion 7044,Busineu and Professions Code). OWNER'S Petmit f )O SO ❑I,as owner oF the property,am exdusively comracting witF AUTHORIZATION TOTAL FEE S� ' � �ICensed COnflOC�O�S 10 co�strucf the prolect(Section)044, 1 HAVE A1 THIS DAfE A CONiRACt wITH fNE HfNEIN NAMEO CpVtI1.K10R TO �� � Bvsiness and P.ofxsions Code). ca+Nca iNc neovt oescaieeo ez�sru,�owewru�ro r�rueu�sEwep. CONSTRUCTION LENDING AGENCY �. I hereby affirm fhoi �hxe is o consfruclion le�ding ogency � SIGNEDTNiS DAYOF 19_ � for the performance of Ihe work for whith this permi� is ��R pQ � ' Issuad(Sec.3097,Civ.C.1.�/� o���s'°�NT . pODRE55 Lender's Nome_� �. lendei s Addrou � , I carti(y ihat I hove reod this applicmion ond s�a�e thM Ihe . above Infpmafion is torrecL 1 oyree to comply wi�h oll County � ordinances and Sro�e lows requbriny Plumbing ood Sewars, � and hereby outhorize rep�eseniatives of�his Coun�y to enier � upoa Ihe above•menlionad prOperly for inepe[fion purposes. � � / � / ,�s �ro of Permitfe D fe SEE lEVfRS!fM E%tIANATOlY IANGUAGE � , . , � . _ I"l_=F�crO'.5�JoieS �)1�\'I I. LL7LI)� I.Ul?t'I rV.:\71(1�;', ' I.TY'�:��/:�L$ 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 La�+ Inr 11�.4�utlnaii�� rcn.,r. 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