HomeMy WebLinkAbout1637A � �-... �WORKERS'COMPENSATION DECIARATION , . � � �
� I hare6y oifirm Ihaf 1 have a certifitate of consent fo self �
insure,or o certificote of Workers'Compenso�ion Insurance,or �ene/so -
' a ceriified copy tMreof(Sec.3800,La6 C.) �E��RE�.B;B�, . APPLICATION FOR PERMIT -
'�� Policy No. Campony m�
❑Cerfified copy Is hereby furnished. SEWER`- SEWAGE DISPOSAL .
. ❑Cenified copy is filed wi�h(�the coonly building inspection COUNTY pF LOS ANGELES , BUILDING AND SAFETY �
oaro r,�.5'],.�L npplieon�.�'"� �+' 4'' FOR APPUGANT TO FILL IN � CONNEC710N DATA �
` �CEkTIFICATE OF EXEMPTION FROM WORKERS' eun�v� /�� .�+A STpTiON ' �PTN
I GOMPENSATION INSURANCE � ���u 3 W��r` uvcEp
� (This sncrion need no�be comple�ed if t6e work involvad by 7he �� ' IMNIKKE REfERENCE� � c
� permii is fw one hundrad dollars(f100)or leas.) . 1O���TM tvvcorcoraNectiow t��cTH vvorn .
I certify tha� ia the performance of the work for which�his cRos sr. y. . ��y p.l. M.l.TO P.L.
. permil ia iasued,I shell not employ any person in any man�er � r.C.No. .
� w as to become aubject to the Worken'Compenaotion Ltlwb. �y�rypq co.irnv.rao. ���"o�
A�O�YE55 � �/3 G��.l fL. iRUNK PERMIT NO. ROAD PEiM1T Nq.
��B APPIICOnf ,� � AffIDPVIT WA�VER EASEh1ENt RECOMD.IN5TR.N0. DAif
NOTICE TO APPLICANT: If, ofter mokinq this Certifimta of - ��Ty re�.r.p. �
E.emption, you ahould bemme sobjetl to the Worken' i�
Compensotion povisiom of the W6or code,you muai forthwi�h oescn�rrrot+ l01 P�O� MWY.OR ST.WIOFNING
comply wi�h such proviaions ar this permit ahall bs deemed
�revoked. e�ocK TRAR STATf ENCROACHMEM
NO.Oc&DGS. PlRMiT NO.
LICENSEO CONTRACTORS DECLARATION s�ZE pF ior raw aa ior ��.
I hereby aHirm�ho1 I om Ucenaed unde�provilions of Chopter �a �
"9(cammencing with Sx�ion 7000)of Division 3 of�he Busi• emiar�s a�oc[s _,
� ness ond Rofcaaions Code,and my license I�in fvll fores and - / _���� � �
effect. . �rp�pR `..�y.apT�( CONNECfiON CNaGGE FEE }d i
License Number 255^� L(c.Class� ��ss�� . . Yf4MlUNSfMENS e V .
/� � q / ',,� ��� pQ_�, o�sro�a ra. caouo MnP PROCESSFD BY
CoMrocto �tNr� �.�+'^,Date `�s�� aTrV-T�vNh TEL.NO. SW"�"'�� z
� � O
�^� �c-z,s�►� �� �a �
❑i am exampt under Sec. of the l.A.Co. uc[Ms�no.
Plumbing Code pnd/or$ac. of Ihe �� DFSCRIPtIpJ OF WORK �
HdJS[$EWER COI�M�ECTING TO DA C� C O J VALIDATION N
B.-&P.Code for the following raason °0°°��R �'�'`�•v�
PTIC 1AN�t.$EfP >li pll FINAL.'� ?
� Wi5AN0/ORORMNF�EW By
DOte 1KK15E SEW[Y cONMCTMIG TO �r 'i
PAIVAiE Y M
$i9npfVrB " - COPNYCTAO�IiIpNAI&OG.OR ► �.
OWNER-BUItDER DECLARATION ��To'wus�s�w[x
OW SEfPAGE fli.pN�tNF�ElO
I haroby aHirm that I am exemp�fram tha CoNracror i licanse- eKrt.�.,c�ssvoa.aerweu,new'+ote � - �
Law for the failowing reoson(Secfon 7031.5,Bvisnesa and Pro• !�7�R.a�a�lk ou�6�.NOON�qvst •
fassions Code): StwER oQ asPOSu SvshM . n'� �J'3 7 a
❑I,as owner oF the property,w my amployaes with wages as , �• •+ • 1 O
iheir sote compenso�ion,will do�he work ond ihe slrucWra '
is not intended or offered ior sale(Sec�ion 7044,Business OWNER�S �
ond Profeuions CodeJ. Pe�n'lit S O �A o 2 1,5 0
❑I,as owner of ihe property,am exdusively conhacting with AUTHORIZATION T�TAL FEE �. � � �.�s,L�.�Q�
Ii[9n59d ContfatiOfS�O COnSffVC�Ih9 P/O�eCt�$GCtiOn JOA4� I HAVE nT 1NiS DAiE A CONiRACT WIiH TNE 1iERf1N N�MlD CONTW.C�OR TO
Bvsiness and Profeuions CodeJ. co�+wecr t�neove oEscAisEo¢x�sr�rac oweu�r.�To*Ne wa�c s�'+u�R. i G'�Q 5_,&6
CONSTRUCiION LENDING AGENCY , �,
SiGNE�7Hl5 � DAY� � 19_ ,
I hereby offirm thot ihere is a tonstruction lending ogency ��R� �_
(ar the performance o� the work for which this permit is pyyryFRSAGENT
issued(Sec.3097,Civ.C.J. , .
��ess
Lender's Nome
Lander's Address '
1 certify tbot I hove read this applica�ion and sto�e thot the . �, .
pbove information is correct.I agree to comply wilh oll County , ,
ord ncas and Slale laws regulating Plumbing and Sewers, .
on roby authoriu roprasenlatives of this Cooniy to enter�-
upo e obove enli property for inspeclion purposes. '
�•�,�,c..e..— � s(�^L
S�gnalure of PermiNae Date SEE RE4ERSE FOR E%PUNATOlY IANGUAGF � /
• +rav�aars No�s OWNER-BUII.DSR DECLARATION
. - APPROVALS DATE. �NSPECfOR'SSV'3NAiUFE . • . .• I{lCtCLyBHitdlll�lllYmCElmp[�f(/0t�lCOOLLP[lOt�6
����R . . . License Law ior the foi6owIng xasom(SKNoM 7031.5,
' ' Bwirwu asd 71�nJaeinw CedeJr My riry or corMty
wn�"oa+c�o°cD1wiow�ic � � wbieb regwiru�a penMit ta martrrcR ate�.,.nnprooe,
d�aiolisb,or r�pal►asy aenrcan.9rdor,to itr issmece,
YRICTANK.S&G.PIT(i) � �y�ry� q�jfq� � �}p�f ,�B
Nq/OR DRAINFIElD ' ' - ' - pG0 RG/ l 9YCll t t0 R
� � sig�saat swtu�t ibat lM o lietitsd pr�r�t!o tbe �
cEssroa O -oavwEu❑ . . . . . - Pro�'u.oss 9/tb Coraretmr's Lkwru Im�/Cbapfor 9 �
� u,�:�..�.,s�oR �ro�»,�o.�:,�,,,:u.s.�cm.�aoa!��3.�rae
�YYAOE a5106AC 5Y5fEM
� wxa+wa vtt�nr�u Brr:w.sr owd AoJ�esJaar Cod�l or tbsr be sr exwnp:
� �e�won Houst sew[a eb...J.�onr aMd tbr baab Jar tbr attrs.d.x�aytiow.A�y'.
MCKHLI SEPfIC TMIKS D . . U;t1IYitOK Of SYC��MI 7OjI.5 by ary appJicme Jor'o p�nnit '
. st►,vrt O �ssroas O - � � . .. � rrbjocts thv a¢Plkast to a rJdlp�wa7ty oJwat.wore tba�
� � . � . . . , . , Jiue Mardrp!dollas(1500/.:
❑I.as the o�vner o{tLe ptopetty wlll do tbe watk.and
the avactnm la aot inunded or offaed for eale.
' . . -. . �. ' . '� (Sec. 7044.Brtisar ad P►oJeuioiu Codr. TM Ca.-
. �� � - .. . . hxtor's Llcew Lam daa�ot ypply M w ow�r oJ
- - -__. . --- - M'nPeity tabo brilds ar lrproov tb�r�oM,swd wbo doer
. . . _ � srtb worlr biMus�j/ymnld�d tbat src8 iw�¢ioosrnants
� . ' are wot twl�wded or ofJed Jor aale.;f,bauwwr. tEe
. � . - - . hcildiNg or neprowwiest k sodd ude6i�ow�war aJ
� . _. . ' . . ... . . . .. . . . . . t°w`Plepor, !bv wuwa�b�dldn wil/Lvw tbr b�rdas
�Pr�+�B lbai!x did fwt br1ld or arpro�x for tbe
prrpase of taJ�.l
� _ � I am eaempt under Sec.�_,
�
B&P.C.for thic reason
Date
Qwner .
INSPECTOR'S HOTES , �� ; ' ��
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