HomeMy WebLinkAbout0888A (4) WORKERS'COMVENSATION DECIRRATION i I hereby affirm �hot I have o tertifica�e of tonsem to nelf �, ineure,w a certiFica�e of Wo�kers'Compe�w�ion Infurance,or 16�6110 a certified copy thereof(Sec.3800, b C) CFBOBIREV.1IBJi ppp��CAT10N FOR PERMIT �� Policy No. � Company �¢'O���� p ❑c°�; �o,�� heraby furnished. SEWER - SEWAGE DISPOSAL �Ce�r'rfied copy is f led wi�h the couety 6uilding ieapection COUNTY OF LOS ANGELES BUILDING AND SAFETY � depor me t. Date��<+po�icom ��!• SSt� FOR APPLICANT TO FILL IN '�f— CONNECTION DATA C TIFICATE OF EXEMPTION FROM WORKERS Wi�qr.K, �! COMGENSATION INSURANCE �000[ss ds I E� w�Ie✓ ST^tip�3 —7 o[nN �This aecfion need not be completed if fhe work involved 6y the i�i�rY ���F hy,NHp�E RFEpENCF � � �p permi�it lor one hundred dollors�5100)or lesf.) I certify that in the performonce of the work for which this C�iro�5s5gt. � TY�a���r� ��'T��� Y. CU4! G.L. M.I.�OP.I. permil is iuued,I shall nol employ any person in ony manner P�� so os to become subject�o ihe Workers'Compensotion Laws. owrxa t C f� �o.,�.�. ,��. 3'a� Dole Applicant A�ooluEss P���'7� � Z 7FUNCPERMITNO. IIO�DrFRMITNO. NOTICE TO APPIICANT; If, afiter makin this Certifimte o( � �' y_ AfFiOAVIT WAIVEN F�SEMFN7 rt[coao,nasrn.no. o�ic 9 CIiY YV�R TEI.NQ / Q' ���� Exemplion, you should becoma subject lo the Workers' iE��� Compenwtion provisions o!Ihe tabor code,you musl forthwith oe5ca�mara lOT NO. /O Mwv,px 51.w�otr+n+G comply wilh such provisions u this permil shall be deemed / revoked. e�OCK iFACT ��(p � ' SiAif NOACHMENT LICENSED CONTRACTORS DECIARATION � np.or&oGs �ERMI I heroby off�rm�hot I am licensed under provisions of Chop�e� s¢eoc�or nwworaioT � 9(commencing wi�h Sect�on 7000J of Division 3 oi ihe Busl- �IiDI°Fr.ws �HAQ(ES nessand Profeas�ons Code,and my license is in full forca and . 'B(feCl. CONIRACTOR �(�j!H.G+�� ' CONNFCIION GNAR�E fEE Lice�se Numb �Lic Claas � �oDatss REiM�BVRSEMEM iEE 0. r Con�roctw � Dme ' ' oistoia wo. c,uouv iuwv .� ��CC ESSEO BY O CIiV TEL.NO � �� V ❑1 am axempt under Sec. of ihe l.A.Co. iiCEnsc r�0. tias5 � � Plumbing Code ond/or Sec. of the �� DESCRIVTION OF WORK rce HN� �� 3 O 1qUY YwER�pNNlRIIJG Tp � DATE /� B.&P.Code for tha following reason ���i��" v %T� � l���/�� VALIDATION � FINA� Z nrs�wo�a+oewnaiew � s 0£?&fi A Dore �s��e cavu[a�n+c to er PRIVAT I Y M $ignotU�e CONNECT ADDRiONu BIDG OR � � OWNER-BUIlOERDECLARATION `N07NTONOUSFSfWER � � Sr • • � D NFIOW AGE PIT.ORI11NilElD � I hereby offirm thot I am eMempt from the Contractor's license cztN,cessvopi oarweu�nr�+�ac ' r , ,2 7 5 d Low for the following reason(Sld00�O31.S,BuibnlfE Ond Pf0- M1FR.REPMR OY A!►N001J IqUSE fessb�s Code): sEwEp oa oisros�i svsr¢n+ _ , •2Z5G� ❑I,ae awner oi the property,or my employees with woges as rheir aole compenaotion,will do the work and fhe structuro � �.C�—P�rj . is not in�endad or offered for wle(Sectio�7044,Busl�vas ond Profesaions Cods). OWNER'S PB'm�t : O s"� ❑I,os owner of�he p�operty,am exel�stvely co��rocttnq with AUTHORIZATION TOTAL FEE � 77 licenaed conlracion to tonstruct the project($lC�IOn n144, I NAVE AT TNiS DATE A CONTRACT WITN THf NE9fIN NAMEO CON1RACiOR TO BuEin!!S Ond PIO�lAioM COde�. CONNfR TMf AlOVE DESCRIlFD E)(ISTING DWELUNC TO 7Nf PUBIIC SlWEG. CONSTRUCTION LENDING AGENCY � 1 hereby affirm Iho� Ihere is o cona�ruclion lending agency ��EDiM15 DAVOF 19_ for the perfarmonce of Ihe work for which fhis permit is ��R� OWNEf15 AGENT Iss�ed(Sec.3097,Civ.C.). I/� lender's Nomei_�� ��F� � Lender's Addreu � � ' 1 cenify that t Iwve raad�hla opplkation and etare fFwt�he ' obove infwmo�ion is correU.I oqrse�o comply wi�h all Co�nty � o.dinances and State laws regula��ng Plum6ieq and Sewers, ond hereby ae�horize repreaen�orives of this Coo�y lo enrer upon 16e above-menlipned prope�ty for inspeUion purposes. � �/ / � Signa of Perminee a1e SEE tFVUSE FOR E%/IANAT0l9 LAN6UA6F r � . . .. . .- - , � 'IN!fEQO�'S D?OTLS � � � O�V'��T.Y:-�5�,��I.I3j'.R�,T)l.t:T�):�ie�.�1�IC)�: � . � /P QV.".L$ cn,e r.;v;�r�osv,�.Rnie:� . . . .._—___._._' ____—___—_.___ I Pu.L}aCli:m[li.it 1 am c���mpl t'rnm thc('i nlraUnr'ti ' . __�_�_"_.__' _.--- I � . 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' ep�,(nunr�urs�.cL��rniilL f.�i��r,Surdal.:fan�u.!(hn�lrii' _ ���—�. �� � � - -� .. firr�reed`punuui:(tn U:r proricinn�'of�1L•e ('vntroc�ur's c.,;:: i rJ o•,�.::p I ' .—.---. --� -. , -- ' " __ �'-'.t ... _ .__. .. �_ , _--- '.�-. ��_ .. . � ,. , . �- � - I.icu�c�l.n�,!(/ r J I �mniu�c�n,,�udr S�churr 71J0�1)rf r�tr�� �r,n : � . . - , . .' �, . , �. � Du�vor:Jpftl(�1� � �an�'I'rnf a�fnr C r11�rN�rtliric ..- . .. � . . .. __._. _ . .... .. ______.'_'__,__ _. __'__ _ __'.__ __ _ � r.�rrr�p�lLarrf o,L nnd du�L�ni�/nr!4� 1!�A.+ . t eu. �. Cti �� -a'� � _ '�lnr ri�i(u[:or�nf SrJi�ni 7031.�/}mq u,�.l�<ui 1 f�r u�i�rr;ril - "+h� �v M��__�4w ' _ ' __ '"_ '_ � -Kri �,_� j . . ' . � '� .��ti�l 1 N. �;�Iicrcl(hu�iri7porra!!�n(rn, , ��La�+fi�i •uor � _ .�r� -�r �.<....-,,,<(7 i . . ._ .__ ___ _-__. .. ._ _.. . ' .. ' . . 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