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HomeMy WebLinkAbout0889A WORKER$'COMPENSATION DECIARATION � I hereby offirm thal I hove a cer�ificate of consent lo �elf � }1 inwro,or a certificate of Workeri Compe�sa�ion Insurante,or �d�6d20 U a carti(ied copy theroo((Sec.9800,�ab�, �E e°9,°E°.,,8��� APPLICATION FOR PERMIT Policy No D Compony��,_Cid.l�i9�/ ❑c'�����oP s hareby furnished. SEWER - SEWAGE DISPOSAL �Certified copy is filed wi�h the counry buildinq inspec�ion COUNTV OF LOS ANGELES BUILDING AND SAFETY depor�menL , Dore 'J/ �-�nppUmm - `�J5 `� FOR APPUCANT TO FILI IN �f-S CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' eunou� /� COMPENSATION INSURANCE �oo�ss �SSS � Lpn �e.. Gf sr�na+ 3 y o[rtH (This aection need nor ba completed if�he wwk involved by the � �« . NNNHOIE REfEHNCE UP°ER iouuTr permit ia iw ona hundred dailars(SIW)or less.) �ppF57 ircEp�co�wELi�Or� ���HF� I tertify Ihol in fhe performanca of Ihe work for which Ihis Ca055 St r. Nce v.i. ht4 i0 v.t. permit is iasued,I shall nof employ ony person in o�y mpnner so os to become subject to the Workers'Compenwtion laws. pwr�ER �./GJ,r [p o,w,rao, ioe No. S '��� Q /� /9 7 y TRUNR VFRMIT Np. YpAD YERMIi Np. Dole Applicont A�� '�� NOTICE TO APPLICANT: If, nHer making this Certificale of �iTy j�;,� /'� AfiIDAYIi w�rvia EASFMENT aKOQo.vastu.r+o. o�tt E�emp�ia�, you should betome wbjecl lo Ihe Worke�s' "'"` TEL.NO 7! G�0 Com �sa�7on o��s7ona of the Labor code, ou must fprlhwi�h oEscai r�iou tOT�+o. P� P� Y nwr.ort Si.wioerxr� comply wilh such provisions ar this permit sholl be deemed revoked. atocK iRACi �� S1AlE E ROACMMENT LICENSED CONTRAC70R5 DKIARATION r�o.a�oes RRMIT I heroby offirm�hot I nm licenaed under provisions of Chap�e� sizeo�ior wworniot � us[or ' 9(commen<ing wilh Setfion 7000)oF Division 3 of the Busi- eunoinGs O+utc[5 neu a�d Professians Code,and my license is in full force and llf�Ct. CONTRACfOP ��J��iY CONNECiION CNAN(�[f{E License Num r��Lic.Closs� RF�MBURSEMENT i{E A�DRE55 'y. ConhOCiOf " �ale �� a • DISTRI�T NO. GROUo MAY S' SSED BY 6 urv ,ei.rao �"' � V ❑I am exempt under ec. of ihe L.A.Co. iTc[r+s[rao cinss � �� �,� ,N.y�k,� O NO DESCRIPiION OF WORK FEE PI u mbi nq Code ond/or Sec. of tha FINAI 1qU5E SEWER CONNECtING TO � — DAiE r VAUDATION V 8.8 P.Code for the following rsoson °U°����° �l—2��.� . u� 1 �NK, EPA %T OR d PITS AND�OR DRAINF�ELD ����� � V� Daie HDuSF SEwER CONNECiING 10 BY �O�Pi�J FI ? iRIVA I Y y Signaturo CONNER AODITIpyµp�pG,p4 ► r,� • • • • 1 0 OWNER-6UILDER DECIARATION wo°K Ta�quSE'EWE° OY7RiLOW SEEvq�VIT,OY�INFlRD I hereby affirm thal 1 am exemp�fram the Conlracfoi s License FXTN,[ESSOOIX.ORYWFII.hNNHp�E � • •2 7.S Ci law fo�the following reason(Secton 7031.5,B�isness ond Pro- nirt4,aen�iR oa�r+oow�5[ � feasions Code�: Sev+ia oa o�svos�t SrSrFM � • � •�7.�r� ❑I,as owner o(the prope�ty,o�my employees with waqes ns their sole compe�sa�ion,will do ihe work ond�he srructure � 1,2 2—8� is not in�ended or offered for wle�Sec�ion 70A4,Business and Profassions Code). OWNER'S Permii S O SG ❑I,as ownar of the property,am exclusively conrrotting with AUTHORIZA?ION TOTAL FEE Z ,r0 licensed contraUors ta consrruct the project(Sectioa 7044, I HAVE AT THIS DATE A CONiRACT WI1H THf HEQE�N NAMFO COMO�CTOQ TO B�sinesa,and Profeasions Code). cor+�ci rNc neovc�sca�e�o Exism+c owEwrac rorNE rueuc sewea. CONSiRUCT10N LENDING AGENCY � , � I hereby affirm thar there is o cons�ruction lending agency ��DiHiS DAVOF 19_ for �he perfwmance of the work for which thia permi� is °''°�''F"°R iuued(See 3097,Civ.C.). n OwNtiesno[NT , Lende�'s Nome ���✓ A�� , , Lender's Addross . I certify that I hava read this applica�ioa and srofe tha�fhe , � above information is correcf.I agree to comply with oll Cou�ly ordino�ces and State bwa regutoting Plumbirp and Sewers, and heroby outhoNze rep�exn�o�ives of thia Counry to en�e� upon the obove•menlioned property for inspeUion purposes. � 3/ 5' furs o(Permi� �o e SEE RFVFI6E FOR E%KANATORY LANGUAGE .. . _ ' - . . ' . . ' . 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