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HomeMy WebLinkAbout0893A (4) WORKERS'COMPENSATION DECLARATION � I hereby affirm thot I have o ceniHcois of crosent �o eelf � �. . }'� ioaure,of o ce�tifito�e of Worken'Compensotion�nsuronce,or '6"6'7o U o�e,�.fied copy rher �c��.�,� CC 9091REY„e�� ppp��CATION FOR PERMIT Policyslq /3 Compony d��+V/ ❑Cem ed copy i heraby furnished. - SEWER - SEWAGE DISPOSAL �Certified copy is f��ed wirh the muery building inspxtion COUNTY OF l05 ANGELES BUILDING AND SAFETY depor e r. Dars 1��Appl�can� FOR APPLICANT TO FILI IN ti j f CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' guuprac; �+� � �J COMPENSATION INSURANCE �Eu S E CJ�- �� 5�P'T�� J �� (This section need no�be completed if�he wwk involved by the ��i�T� s� M4WqtE REifMENCE p S' UP°E° permit is for one hundred dollors(5100)or less.) � r�e�eEsr Tveeacaw�p�or+ I certify tlwi in the performance of the work tw which this crtoss sr. ' � ��'��f� . Y. CUCB G.l. M.L TO P.l. permit is issued,I shall no1 employ any penon i�any monner / �7 so as ro betome subjeci l0 1he Workers'Compensolion Laws. p�,y�R �.CJ'( co.i�,No. ioe rHi�o. 5d/ NKII �� /��� 9 6 � TRUNK fERMIT NO. ROAO PflM1i NO. Date Appliconl �°°°E'S 1C.) NOTICE TO APPLICANT: I(, o4ter making this Certificole of Ctrr F'bT4{ 7EL.NO. � �Y� 4 p�D AfHDAVIi w�r�a [�Se�nENi kFCOQo.iNSfi.rq. DwiE Exemp�io�, you should become subject lo the Wo�keri iEGµ Compsnaa�ion provisions of the Lpbor tode,yoo must forthwilh �xu�.rip,i ioT r.o. � comply wiih such provisions or this permil shoil be deemed / Nw�'.a+sT.�no�N�r�c rovoked. uocK TRA�7 ��O � SIA7E fNCRO.�C11MfNT UCENSE�CONTRACiORS DECLARATION ' r/°.°F e�°�S "� �'P1O I hereby affirm tha�I om licensed under povisions of Chopier siz¢oviot raowor�ioi �� 9 commencin wilh Section 7000 oi Division 3 of Ihe Busi� �a ( 9 ) ammir�s a�ac,�s �eaa ond Professions Code,and my license ts in full fwce and effeef. �pnrtanetore �I��� �' CONNECTiON CNA4GE iEE Lice�se Number�lia Class �p�u REIMNIYSEMENT FEE � � / • . D�SINKT NO. GROV7 � M1UP WfOCES5F0 B� O COnhoCtor —5 DOIe ' CITv TFl.NO. BK VG V ❑1 am e.em t under5ec. of Ihe L.A.Co. Si�iE , uC � P IIGENSE NO CLA55 � NO. DESCRIPTIDN OF WORK fEE EE �3 �' Plombing Code and/or Sec. of the �`���R���i�fa DA E� /' VALIDATION V /("�p^7�� B.8 P.Code fo�the followi�q reaaon i �NC, [Y o�r oa � pW, RT$M1pipR OYAIMIfLO fINA� N Date ��gw(e CONNF[ruy(�,70 e� Z oltl A � Sfgnafuro coNN[cr,wortroNAl e�oc.oa ► OWNER•BUIlOER DECLARATION WORK TQ Iql15E S�W(p pVlpf�pW EOAGE%T.DRAIWIELD � I hereby offirm that I om exempt from Ihe Conirotlor's License cxnr.c[35ro0�,ptvwEu M�NHOtF law for the following reoson(Sectoo 703L5,Bvisness ond Pro- kna.Reo�w pc�g�,wpp�Nouu fessions Code): �'�p O�a5�05�t 5�'sTH.t ❑I,as owner of the property,or my smployess wi�h woges oa - iheir sole compensotion,will do the work ond�he slruduro `G�0,3� Is no�inlended or offered for sole(Section 7044,Business and Profexioas Code). OWNER'S Permil S /p ❑I,os owoer of the properry,om exclusively contracting with AUTHORIZATION TOTAL FEE S1� � � �� 1 � Ii<QI�bld tonrroctorc�o cons�ruU the projecf(Section JO44, I HAVF AT THiS D�TE A CONiRACT WIiN THE MfRE1N W.MFO CONTRACTOR 10 . I " • C 7�S D BUiI nllS Ond Pf0{lSSIOnS COt�l�. CONNECi fME A60VE OESCRIBEO F%ISiNJG pN'EIIING 7D TIIE PU&I�$EW[R. CONSTRUCTION IENDING AGENCY • � e 2'],S�?, I hereby affirm fhot Ihere is o conshuction lending ngency SIGNED TNIS DAV OF 19_ for the perfo�monce of the wwk for which �his permit is o�qs�tNi � I �.2�_8,�i iuued(Sec.3097.Civ.C.)�/� Lender'a Nome ADO�ESS r Lender's Address ' � 1 cenify Nwt 1 hove read�his applicafion ond ara�e�hot rhe obo�e informotion it corrocf.I agree ro comply with all Couny - wdimnces ond State lows reyula�i�g Pl�mbinq ond Sewers, ond heroby au��torixe rapreseNofives o(lhis CouMy b enler � - �pon fhs abo�e-men/ioned prOperly for Inapection purpoaes. /�/'�� /r/�//�� oluro o Peywi 9 �e SEF�EVfKE/OR E%RANAlORV lAN6UAbE �� . . _ . .__. . , . �./ f .. . . . . ,,, . . .. .. - . . . , t•l:'CrTO.'S t!oT[i 01t'\F.l:-I:U(I.11Ti):Ili':Cl.;t1',•"�'llt)\' p �' ' - � - � i �`G.PP�',OVT LS n��E n.si`aoo;s____cr�,:n�^;^� --. -- --- `------------�"-------- � [i�crcb}:iif:n:i ticit 1 am r�empt fror.t�hc Contra�trr's rrt.� ..._ ... I . . _ . 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