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HomeMy WebLinkAbout0890A WORKERS'COMPENSATION DECVIRATION � I heroby affi�m tha� I hove o cert�f�core of ca+se�� �o aelf insvrs,or a certificme of Wor4en'Compenaoi�on Imurance,or �snsuo acerfifiad�opy her of(Sec.3800, obC.) ,/� �E�a,aE°„B�; APPLICATION FOR PERMIT � Dolicy No`�J��Company�1JAJ f�Ll/ ❑c,/,,,�f,�a oPY;, e,�by f�,�;,,,�. SEWER - SEWAGE DISPOSAL �erti�ied copy is filad with�he munty bu�ld�ng�nspecrton COUNTY OF l05 ANGELES BUIlD1NG AND SAFETY deporl�men�� � Dore_1�(.�1�Y_2Applicanr � FORAPPLICANTTOFILIIN -�-,s CONNECTIONDATA CEkTIFICATE OF E%EMMION FROM WORKERS' �1tD1^� � S7 E• C.a KI COMPENSATION INSURANCE �ooc[ss � .c y 5��T��'' �' s �°�� (Thia�ection need not be comple�ed if the wo.k involvad by the i«qiiT� p� Q� rMN�+ptf REFEQENCE � �Q permil is for one hundred dollora(5100)or leu.) I certify�hat in the performance of the work for whicb�his aosssST Trv[aca�e�[crroa ��n�FypM permit ia iuued,I shall no1 employ ony persoo in ony monner �� CURe V.L. M.L TO P.l. w as�o become subjed�o the Workers'CompenwGon Laws. � P���°1O� owr,�a Ct� co v.w.rw. �oe no a AMII .Dr N I / �� TRUNI(ifRANT MO. ROAD P[4MIT Np- Daro Applimnl ^�`� NOTICE TO AVPLICANT: If, ofter making Ihia Certifitole of �iT� AFfIDAVIi wuoEx E�SEn�ENr RKO40.tN5TA.r�O. Or.tE Eaemp�ion, you ahould become subject to �he Wo�kers' `�'M� 4 �E�.r+o /'�' L,O—�L , IEGAI � Compensafion provisions of Ihe Labor code,you must forihwith pEsca�vrioni ioiNO. nwy,pt St.w�otr+iHG comply wiih s�ch provisions or this pe�mii shall be deemed r revoked. eiocK TiAR � J SiATE ENCROACMMENT LICENSEU CONiRAC70R5 DECLARATION � no.a�oes �R""� " I he�eby offirm�hat�I om licensed under provis�ons of Cha ror sue oFioi ivow orJ wr P ��� a?I• / � � 9(commencing wilh Section 7000)af Division 3 of IF�e Busi• euiton+a5 [�waC�[5 nesa and Professions Code,and my license is in(ull force ond / � BfflCl. CONiRA[lOR �(y 1� 4 CONNEC71pN CHAq�f[E License Number Lic.Closa P �"' AOpRf55 ���UWSfMfNT F[E �onIfOCIOf �Ole �� � � 0. DISiR��f Np. GRWi MAP ROC D B� O CIiY TEL.NO. � � L7 ❑I om exemp�under Sec. of the L.A.Co. ii�M�� a�ss a �3 �C /3 Q Plumbing Code a�dior Sec. �of rhe �� DFxRIPiiON OF WORK ae FNAi � NOUSE SFwEY CONNECTING TO DAIE // Z/ .�7� � VALIDATION 0. B.8 P.Code for the followinq reoson ��i��µ�� aMiE nt px /7 D :0 8 9.0 A Z FITS ANO/Oi DRAWFIEID FYNAt � �ole / �5[gW(Q CONNECTiNG 70 B� �+ • • 1 O PRIVAi Y • Sfynaluro . CMiNECt�WDii�ON,.,�&OG.OQ . . OWNER-BUIIDER DECLARAT�ON "�K TO NOUSE YWER � I�� •�7.S C pY�qF�pW PA ORAINfiEI� I heraby affirm thof I am eKempt from the Coniractor's Licanse EXTN.CFSSf�OI,ORYWELL nuN�a[ Law fo�tbe foliowing reason(SeUon 7031.5,Buisness ond Pro- µna.a¢r�iq pq�Npow�quy, 0 2'],j C� fessions Code): sEwEa oa o�svOsu Svsnrn ' ❑I,as owner of the p/operty,or my employaes wifh wagea as I 1.�2—8 5 their sole compensation,will do Ihe work ond the sfr�Cture ie nol in�ended or offered for mla(Section 70d4,Buainesa ond Profesa�ons Code). OWNER'S Permit S / SD ❑I,as owner of the property,om exclusively contracttng wi�h AUTHQRIZATION TOTAI FEE �,7 S� licensed convattora to constrocr Ihe projecl(Section 7OM, I MAVE A1 THb UAtE A CONTRACT WIiM i11E HEYEIN IWhYO CONIRaCTpI TO BuSine35 Ond PfOf053IOnf COd!). CONNECT TNE AlOYE DESCR�EED E%15TING DVIEIIiNG TO TME GVlLIC SEWER. CONSTRUCTION LENDING AGENCY , � hereby affi�m thaf there is o co�slruclion lending ogency SIGNEDTMiS DAYOF 19_ !or the performonte of fhe work for whith this permit Is �p� pWfJFRS AGFNT �S3UGd($RC.�7.�Iv.�.�. .^/� II ADDOE55 lender's Nome ri� Lendei s Addreu ' I certify that I have reod Ihis application and staie thot the obove information is correcl.I ogree lo comply with all Gounty ordinances ond 51ate lows regulating Plumbing ond Sewers, ond hereby oulFwrize repreaen�otives of thia Counry ro en�er upon iha obove-mentioned properly for inspaCti n pu poae� / � p� Sign of Permitree Doro S!E RiV[RfE FOR[X►IANAtOM IANGUA6E . . � � ��:-�i�o��s�,�T�. o�^,;�rr.-�;U1t,l)I:[:S7Ii{'i.A►.,t�rro�;. . . � P�^r r:OV:aLS onte �nsc�aou�Su_ar�ict ' _ _`__ _—_ - - 1 Lci�ln atYlrm[ha:1�m�c�cmpt f7'un�7hc.Caftr.ictur's . . � ._� .�_�__ � u[viNcc•csr:�,o- . . . _ . .. . . . � . .I.icensc 1.a» for fhr fnl!o�rinp rrason ISrclicn 7f191.5,: - • :,� � . 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