HomeMy WebLinkAbout0519A (4) WORKERS'COMPENSATION DECLARATION , . �
I hereby affirm �hat I have o certifica�e of consen� lo self '
insore,or a certifico�s of Workers Compenao�ion Insuronce,or ��^��
PolcyfNo.`°PY'- '��osm���°°.`° .'. � ��°`�°.e,e" APPLICATION FOR PERMIT .
❑Cerrified copy is hereby furniahed. SEWER - SEWAGE DISPOSAL .
❑Certified copy is filed wi�h the couMy building i�spect�on COUNTY OF LOS ANGELES BUILDING AND SAfETY
� deportment. �
Da�e Appl�con+ FOR APPUCANT TO flli IN CONNECTION DATA
CERTIFICATE OF EXEMVTION FROM WORKERS' e�xwwo
COMPENSATION INSURANCE noa�ss SfATIpN �f�3 avrw
. (This section need not be completed if�he work involved 6y�he i�iiTy �wa�F pe�Ert�r�c UP�°
permit is for one hvndred dollors{5100)or less.) � R
1 certify thot in the performance of the work for whlch this ��S55T . iraEOvcdw[C7qN ��rr fqpµ
permit is issued,I sholl nol empioy ony person in ony manner �� CURe v M.L To►.i. � �
so as to become subjxl to Ihe Workers'Compenwtion Laws. ownER co.Ihw.No. joe n�o. � �i�/ d
u
��� TRUNK PERMIT NO. RO�D PERMIT NO. F�
Dale Applicanl
NOTICE TO APPLICANT: If, a4�er makin this Cer�ifim�e DI � ARIDAVII WAIVER e�5¢�.�[Nt RKOQD.ItJSiR.NO. �R7E d
9 CITY TEL.NO. G 1"
Exemption, yo� should become su6ject to the Workers' , �1
Compenwlion provisions of ihe Labor code,you mvst forlhwith pescaimora lOi WO - ryWy,pq ST.WIDENING C,
comply wifh such provisions or t4�is parmi�shall be deemed r'� tn
revoked. &ocK TXAGT J SiATE ENCROI.CNMEM �
LICENSED CONTRACiORS DECLARATION �'�O.OF&W5. fFRMIT MO. '�
SiZE OF LOT ripw p�1 lOi
I hereby offirm ihol I om licensed under p�ovisions of Chapter ��
9(commencing with Section 7000)of Division 3 of the Bucl- auimu�cs �,�5
nesa a�Pro4essions Code,and my license is in full force and
OKeCt. ��]�/��� COn1TRAC10R _� CpdNECiIpN CMARGE FEE
Licenae Nu�mb('a7r�__��:fl�LSC_�IC.C�asb` (�� ADD�+E55 � �� • � REIMBURSfMENT FEE �
Con\raf�0t`��/I ��'�.l�flf�o�R�/���iriZ CITY ���+0 1_ _ asrR�ar�o, c,ca�P MAP WOCESSEDBY
❑I om eeempt onder Sec. of�M l.A.Co. iic[Nst t�o. aass � � /!1� ,`�
/C �f"3 �
Plumbiag Code and/o�Sec. of the �o� DE5CRIPfIqV Of WORK r�e FiNAi
P�o&us��Rcon+�cnr,wTo � �Q wre / �,/ O�`/ VALIDATlON
B.8 P.Code for the iollowing reoson O T .
. SFPfIC i I.p4.$�P�Pfi pq � FINAI
PiTS ANpiOR URAIKIEID
OOtB 1q1)5[5Ay[p COMNERM�G TO BV
PRI Ai
$ignpfUro CONNECT ADMnpVAL lIOG.OR
� OWNER-BUILCIER DECLARATION WOR�'����p �
I berebyaffi�m ihat I am axampf from 7he Controcfor's License �iv��Cc55rop qtvwELLA���iKKE �0 5 1.9 A
Law for the iollowing reason(Secton 7031.5,Buisneu and Pro- ur[a,REr�ia oa�e�NppN NouSE �r• • • '�� Q
, fessfo�sCode): sEw[xoeois.osn�srsr�,n ,
� ❑1,os owner oF tha p�ope�ty,or my employees with wages cs - , � � • •L 7 5�
' their sole compensotion,will do ihe work ond the structure • • •.G 7 5��x,,
is not inbnded or offered for sale(Section 7014,Bueiness •
a�d Profeesions CodeJ. OWNER�S Permit i ; �(J �2,�L;�.8 3
. ❑I,as owner of the p�oper�y,am enclusively cootracting wi�h AUTHORIZATION T�TAI FEE �lD �
� liceroed conirodors to construct the project(Sectioo�044, I HAVE AT iH15 DAiE A CONTRAQ wliN THE nfRE�N NAMED CONTRACfOR TO
BusinlSS Onf�Pr0�6&fi0l15 COde�. CONNER THE AEpVL pESCpleED E%�ST�NG DWEILING TO 7HE PUBIIC SEWfR. ,
� CONSTRUCTION IENDING AGENCY /� } ,
� I heraby offirm rhat thera is a conslrutlion lending ogenry S�GNEDTMIS ��DAY F �/�G�I9�J . . .
' for ihe perFormonce of tha work for which this perml� is �''�Q� �
OWNERS AGFM
' iuued(SeC.3097,CiV.C.). . ' .
ADDRESS.
Lender's Nama ' .�
lender's Addreas � " �
I cer�ify ihat I have read ihis applicaiion and state thot�he - � '
above infwmotion is correct.I agree 10 comply with oli Counly .
o�dinonces and Slafe laws regulating Plumbing and SewerE, - . -
and hereby outhorize repreaenfolives oF th' Couary to enler �
�, upo obove-menli arly for ins ction purposes. �
4 i3—�3 '
� Signalure o er ittee pole SEE REV[RSE FOR E%PUNAiORY LANGUA6t
INSP:CroR'S t.oTFs Otit't`'EP,-B'UII.DIiR DECLARATION
P�Pr ROVAL$ onrz IhSPEROR'SS�G��ATU2E I LcrrS}'"�f��rm t:rt l am C2rn:�ot(rUn1(LC ConIS3Cta�5
NEW HOUSE SE'J✓:R
- " I.icensc I.a:i�for ch:tnllr,�ving rca�on/,Scction 7031.5,
� ' � 6us•i s an1 PrnJcssiors CoJrJ:Ars�� crsy or rounty
CDNNERPCDR:ONAI ft�/ti[I�rTC^ . 6 C�I;�ff!O C RS[Tt(Cf� Qll�f. �hl,YOt�f'�
BUILDING02WO�K ' - .. yr:ir<�c �� � �.
drs;nlieb, mpii m,y atrucS�re, rinr!n its iseuence,
$EFiiC T.4NK,SEEC,Git(S} r
AND/OR DRA:h'FIE:D , ,__ , � .. � � req�:t � tl r C�Ali�¢n(fpr S:ec)�fermit to,ffJC 6
CESSFOOL O CRVW'ELt❑ ` � ,
slgmcd statcir,rnt tl,�:rt h�• i; l:cr-�cd p,.rsr�cnr to thc
- � - � � fso ...onr ej tbr Cc«trc:tn-i Li;cr.sr Las�(Chaptrr 9
AL7ER,REGAIR,$EVhR OR ' - -
SEwAGf OISPOSAI 51'STE.N ��� -� ^u�ftl$c[Si.>n �000l��Divlsi�ft 3 of ffiC
I3usirtrs��c�-d Profosaion.r CodrJ or tl at Gc is crempt
n�ear�i or�i HOu[�wtx._ � tbrrcfrnua and 11,�:bc.vis Jur 1Lc Cllr�qcd crrm�tion.An1,
ea[Kvn�s[vricTnn�KS❑ - . . � . . . crola!io+irfSeciion7031.Sb1'en,YRFPIicanlJora(��rnrrt
scev,vir�si O-.cessvoets O� � s�ibjects tGr<//>li:svr eo c cirilper.olty of riot more than
- ' ' ' firc burcdref.dol.'_rs(SSOOJ.:
" - - . � � -� . � ' �'� ' -- � ❑I,ac[heor:nexafiheprcp��rtyr:illdothee:ork,nnd
' � � , � � - , ' ' , � � the structure is nat intended o-bf(c:ed for salc.
. �- — ' � - /Sr:: 70¢4, f1e.�i.=.r.as cri3 Prnfrssions Code:,TL+e Cnr.-
� • . . . .- . � .''- - . rrectnr:s I.iccr.sr La�n doc: nnr upply m ar, ov.�aer:J
, . , f�rof,cr:y u•bo F:,;Ids�.!-„rro;,�r tG�>�on,a..d wLo doPs'
. _. ' . racl i 5 kir:xe f�+roride3 ll¢!sut! improoementr
� crc nnt i.et,r.dr_�or q//c�rcd jor ecic.If,bou�cc�er, tl c
.�. . .. . .. - - , . ' . F,::ik:i . >.c^i is snld siebin oxe ycnr j
�� � - -� - - - ' � ' amrletinrir 1Gc'oe r�-rv?�urlder u�if!fiat�e�tba burden
. . " . ' f f.mrir.g tl.:t be did not build or i�nprot�c far tje
� � . pc fose of s�fc.J .
, I�m esempt undec Sec. ,
� B�P.C.far this rcason
Datc
„ O��n�r
. ,
'� I^:SPfCTOR'S MOTES � . . ,
� , � .� � - . � � �