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HomeMy WebLinkAbout0886A - -__.�_ ___�--__ __. _._ _. �_� _._., _ _. _ _ __ _ _ ._ WORKERS'COMPENSATION DECIARATION I Mreby offirm �ha� I ha�e e certificate of co�sent to self , ' }l insure,or o cerlifico�e of Worken'Companwtion Insurance,or �e�aa7o U a cenified copy rhereof(Sec.380D, a .) �E�e,qE�.,,e�; APPLICATION FOR PERMIT P,�;/�y N Company���,d'•4d,T SEWER - SEWAGE DISPOSAL ❑C��� p�' y erh ie co heieb fwnished. �Certified copy is filed with the counry buildi�q i�spection COUNTY OF LOS ANGELES BUILDING AND SAFETY aepartmen. /� Date .S npplicant�N•/7A5S��P1� fOR APPUCANT TO flLl IN �JS' CONNECTION DATA CERTIFICATE OF ExEMMION FROM WORKERS' eunar� / �' STAnor� - �.S f o[mM / COMVENSATION INSURANCE �oonEss OS� E• CQ (G (This section oeed not be compleled if 1he work imolved 6y Ihe �a�Y� rMNHIXF RffERfNCE �R permit is for ane hundred dollms(5100)or less.) iouuTr i I cert�fy �hot in�he performonce o(the work fo�which ihis C�SST. rrc[atO�tcrqN �N(TMFYpM permit is issued,1 ahall noi employ ony person in any manner •� NRa •P.L M.l.tOP.I. so as�o become sub"eci�a the Workers'Com enwrion Laws. �. P��'�''O- � P owr.�R P�e,r co.iMv.ra. ,oe r+o. �e� Date Appliconf ��55 P•�U I Z� TRUNCVERMITNO. ROI-0PEiMiTNO. NOTICE TO APPLICANT: If, after ma4in Ihis CeAititole of T /r� ` ARiD�VIi w�rveR e�5een[qt e[cpto.n�stn.rap. O�iE 9 CITYyI✓iN! lF. TEl.N0,7�7� G�-O�GO Exemption, you should become subject lo ihe Workers' i��i Compensation provisions of ihe Lobor code,you masf fo�lhwith pescairriori lOT Np. HWY.OR 5T.WIDEHING comply with SUCF1 PfOV1510l15 0�this permi�sholl be deemed revoked. azoCK 1FA�T � STw}E E �CM�ENT UCENSED CONTRAC70R5 DECLARATION r+o a e�ocs ffR""° I hereby offirm thot I om licensed under piovisioas of Chap�e� siz¢a io� roowow ioT 9(commencing with Section 7000)of Divisioa 3 01 the Bvsi- eUu�iio�5 cN�cees neas ond Profeuions Code,ond my licenae is io full{wce ond . QHM�. CONTRI.CTOR D(,W/�p Y CONNECTI�N CNAp(�(f(f Lice�se Number ��'9�Uc.Clau � � ,woaEss REIMBURSEMENi iEf ��p����/ / r r CofltrtlCtOr_��_Date / • DISTRIC7 NO. GYOUo � MAP a� �SSED Bv O dTY TEI.NO. � ❑I am exem �under Sec. of Ihe l.A.Co. � � � � u P iiaNSf No cia55 No oescaivrioni oF woarc �c 3 m Plumbing Code and/or Sec. of the FNAI � Nous[sevrex cor+reci�nc ro �. o�rc (��� j VALIDATION W � Pux�c sewFa 7 v sew 8.8 P.Code for the followinq reason ANK,SEEY nr FiN�� d ' YITS ANO/QR DRItMREID y Doro Hp�Sp SEyIFA CONNfCTING TO BY � .� PRIYR 1 � $ignOtUrp CONNKT AWIi1pVµ6L�G.pR OWNER•BUItDER DECLARATION �R�o�+ous�xweR q p I hereby affi�m Ihat I om ezempt from fhe Contmctor's Licanse E�pF�CE55VOOl DRYWEUMMANMIXE �O�i U 6 A Law for�he following reason�Secton 7031.5,6uisneu and Pro• � kr�a rtev��x on�Noon�qust feuians Code): sevrto on asrosk 5•Si�n �� • . • • � Q ❑I,os owner of Ihe properly,or my employees wilh woges oa I ^ •.Z?,j O their sole compensetion,will do Ihe work ond fhe�/rucWre . in no�iMended or offered for sole(SeUlon 704�,Busineu - and Professions Code�. OWNER�S Permi� s �b S—O � � �2 7 c�Q� ❑I,os owner af the properry,am exclusively con�racting wi�h AUTNORIZATION TOTAL FEE 7 ,�O q p I�censed contractws�a construcr�he projecr{Seaion 704�, I NAVE AT THIS DAiE A CONiR/1Ci WITN TIE MHE1N NAMFD CONTRAQOR TO � I �.C:—C)5 Buainess ond Professions Code}. cowraa rNe neov[ocsca�e�o ex�sn.ic w•rt�uNe ro rra rueuc s�weR. CONSTRUCTION IENDING AGENCY � 1 hereby offirm ihat the�e is o conahuclion lending ogency S�GNEDTHIS DAYOi 19�., 4or the performonce of the work for which Ihis pe�mi� is O1"�R� iuued(Sec.3097,Civ.C.�.�/ ^ OWNENS AGENT 1 AOpRf55 lender's Nama_T /�r'� Lender's Addreu I ce�tify that I have read Ihis applicotion and stots that Ihe � above informotion is correct.I ag.ee to comply wi�h eIl County ordinances and Stafe laws regularing Plumbinq and Sewars, • ond hereby oWhorize repreaen�mives of this Counry fo anie� �, upon Ihs above-menlioned propehy for inspetlion purpoxs. �� �jl-,�Qt�� �i-a/-�� $igpcyurooiCrormiiree�.t-- 'Vote SEElEVERSEFOIE%KANAiORYMNGUAOE �� �� � , . ir.sr�cTor.srror�s . 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