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HomeMy WebLinkAbout0892A (4) WORKERS'COMPENSATI DEGLARATION - . I hereby offi'rm �hot I havs a terti ica�e of ca�ssm to sslf ' insura,or o certificme of Worken'Co penw�io�Inwronce,or �s.aam a certified copy e� {�5e�.�,�a �., �E��RE°.�,e�; � ppp��CATION FOR PERMlT � Policy No�� 3 Compony +4 � - ❑c°��sa�o��� e.e�f�.��+�d. SEWER - SEWAGE DISPOSAL ) ,�$Cer��fied topy Is t�led w�rh tha cou�+y bu�dinq inspection COUNTY OF LOS ANGELES 6UILDING AND SAFE7Y depanmen�. Dote//:2/-�'.rqppl�cont �/�•4 . /yi4-55�72.� FOR APPIICANT TO FILL IN f-g GONNECTION OATA CERTIFICAiE OF E7CEMPTION FROM WORKERS' eunon.G COMPENSATION INSURANCE �ud+[Ss O S �q� SraraN oFnN (This sec�ion need not be tompieted it the work involved 6y the �«�iiTY �4 i J ' IMNIqIE!ElfREN[E I O°PE permit is for one huodred dollon(5100)o�less.) w p I cmtify rhat in the performance of rhe work for whith ihi: ��ssr. - - TVPE���R� �u�'M�e°w . permii is iuued,I shall not employ any person in ony manner �� Cuae P.l. M.l.TO P.L. so a:to become subject to the Worker%Compenaalion lows. v c..+o. S�.7 owNEa /e./� Co.u,w.No. �Oe rao. IMIL � TRVN[PEQMIi Fq. RpAD pEqMIT NO. Do1e � Appliconf �ODRESS /�p L NOTICE TO APPIICANi: If, ofter making IhiE CortifiCO�e O� [�TY /r/�A! TEt,NO. AfFIDAVIi WAIV[c EASfMENT RECORD.INSTR.NO. DATE Examp�ion, yau should become subjxt fo the Workers' /V� O' li Compensotion provisions o(1he Lobor tode,you muot forlhwith o[scRivtiow �orr�q. � tomply wi�h svch provisions or fhis permit shail be deemed HWv.pRST.WIOENiNG ravoked. eiocx iRACT � SiNIE ENCRO�CHMENT wo.a�oc: c�a�.0 LICENSEO CONTRACTORS DECIARATION SRE Of LOT qpw pni�oT I hereby off�rm tha�I om licenaed under proviaions o/Chopler �� �� 9(commencing wilh Section 7000)of Division 3 of the Busi- �iioi�,s w�ecES ness ond Professions Code,ond my licanse is in(uli force ond effeu. ��p��p' d CONNFCLION�HAq(�FEF license Numbe Lic.Class �'� � �pEr� aEiMBUrtSEA+ENT RE '� S Conaocro. L6 Do�e //-.�/"�S arr �Ei.�. oism�a roo �caiv �y nv,c �o er v ld�c ve ❑I am exempt under Sec. of tha L.A.Co. ilcENs np. Cuss ' � �;�j � 3 'a �- DESCRIPTION OF VJORK rEE / � Plumbing Code o�d/or Sec. of the pNA� � VALIDATION uVi M1615C 9lVYER COI�kECiING 10 - � �� O�TE �^� B.8 P.Code for the following reason ` / -'�J w. VIiS�ANO/OY ONAINi1ElD� F� 1 ? �t� IqUSE SEWER CpVNECTING TO BY DRIVAT i $ig110tUrQ CONNECi AppinpN�l&W.OR � OWNER-BUIIDER pECIARATION �K T�"a��° QFl FP4Cf PIT.0R41NF1[tD I here6y affirm tha�t am e�emp�from the Connactor's license E1tiN..Cf5SP00�ptvWELL auorott Low for the following reason�Sec�on 7031.5,Buisness and Pro- at�v.Ren�w on�es.HooN Hous¢ � � � feuions Code): seNrta ox oisvos'a svsrtM ❑I,os owner of the properiy,or my employees wirh wogea os thefr sole compenta�ion,will do the work and the svucturo :'G E 9�Z A ia not imended or effered for wle(Sectio�704.1,Busi�ess permit = Q s� and Professions Code). ��1/NER'S �� . � . � � p ❑I,oa owner of the properry,ar�e.clusively controcting with AUTHORIZAtION TOTAL FEE ,r 0 I�censed conhaUors to construct�he projeU(Section 7Od4, I HAVE AT TMIS DRE A CONTRACT WITH Ti!MlRFIN N►MfD CONTl�CtOR TO I • •2 7.5 0 Business and Profeulons Cods). Cor.N+ecr rN[nsovF o[scRieEo lx�SnNG DwEuir+G To tHE weuC 5[wte. CONSTRUCTION LENDING AGENCY •.a e�'j.5�� I hereby affirm �hat �here is a co�s�ruction lending agency �EDTHI$ DnVOF i9_ for Ihe performance of ihe wo�k for whith this permit it �"�p� I 1.2 2-8 5 iuued(Sec.3097,Civ.C.J. �/ owrxe5wc,�ntt lender's Nome /�" ��E� � lender's Address � I terlify that I hove reod this opplicolion ood slo�e thot the � a6ove i�forma�ion is correct.I ogree lo comply with all County ordinonces ond Sla�e lows requloting Pl�mbing ond Sewers, - � � and hereby aufhorize-raproaeMotives o1 Ihis Coumy to en/er � upo/n the abovs-mentioned propeNy for inspecti purpoaes. � ' L�/�� ��/�� ��- � Si ure of Perm'le4 Doi SEE/EVE16E FO�f%qANA�OtY IANOUAG! • . _ _ _ „ . . _ i�:sr:cror.s�iors , !Ot1'^�'I.I;-I;U11.UP R DI:C'I 1L; . , _ l7'ft)V _ � APPC'OVlrLS oai[ :ttct�c��si^ri�.r r-e . . . .. . � ______—_,_____—'_ I i�irc6c af'irrii[;c�t 1 an�i�nnpf tro�n thc('oolrectur's . � � N�•�,H �. _ . . . ...� . ��� �_ I,iccn.c I.:rn� (ur lhc fnllu��ir;rc.:s�.n lSrrl�dn ;P31.i�. 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