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HomeMy WebLinkAbout1007A . WORKERS'COMPENSATION DECLARATION -� � � .� � - � . � . . � � I hereby affirm that I have o certificote of consenf ro self . . . � � �� . , �. � � . � ' � insore,or a ceifificare of Workers Campensation Insurance,or �� '�°20 ' �. ���' - �' -���'� " � - � . a cerrif�ed copy thereof(Sec.3600,La � c�ana�zev.vu3i�� � �. . � ��� ,�I . Pa��� Na. . �m�°p� ��z�,2cc� �'�S,� APPLICATION FOR PERMIT e„� �o����e�y f�rnished SEWER - SEWAGE DISPOSAL ! 0 Ce��ified copy is f�led weh the nty butlding inspe tion j ... . . .,COUNTY OF LOS ANGELES BUILDING AND SAFETY , � �� departmen�. / � f ; .. Date,�'����Applicant �.- � +�` � 9 FOR APPLICANT TO fILL IN CONNECTION DATA � CERTIfICATE OF EXEMPTION FROM WORKERS' � e�itowc � � COMPENSATION INSURANCE ADDRESS �I j . .� L„y/ STATION OEV�H (This secrion naed not be compleied if fhe work involved by the //. . ���/I ��� (�ANHOLEREFERENCE UPGER permit is for one hundred dollors($100)or less.) 1OCA'°TY Y � iowea I certify iha�in ffte PeffOrmOnCE of Ihe wolk fOr WhlCit fhi5 . CppuSst iYPEOFCONNECiION IENGTHfROM . . permit is issued,I shall not employ eny person m ony manner �� /�� r CURB P.L. M.L TO�.L. �a P.C.NO. so os to bemme subject to fhe Workers'Compensafion�pWS. OWNFR ��J• pQ,� 7Q L� .��`' �"C� Co.iv�v.No. los n10. �.� �`�'�� �^ , TRUNK 4ERMIi NO. ROAD PERMIi NO. � Do�e - Applicant A�DRESS ��7+ L�- 7� �^�II(�S. �oI'�. ' ��) r� AfiIDAVIT WAIVER EASEMEN7 RECORD.INSTR.NO. DAiE � NOTICE TO APPLICANT: If, ofter making rhis Cerlifimfe of � �irr �(/`GC(�t+�`t��0 TE��N .j�.Y��j� .�sZ� � Exemption, you .should become subject to ihe Workars' tec.at d �� Compenso�ion provisions of.rhe Labor code,yo�m�s�forihwith �FSCRIPiION �or No. O Hwv.oR sT.wioeNinc i comply�with s�ch provisions or this permit sholl be deemed . �evoked. � � s!ocK tRACT� �(�s"�� � SIATEENCROACHMENL � � UCENSED CONTRACTORS DECLARATION 'J / NO OF B�DC.S. PERMIi NO. .. SIZEOFLOi JI�O �yyl .�(a.�Y•NOWONLOi � I hereby offirm that f am licensed onder provlsions of Chopter � use or 9(commenc�ng with Section 7000)of Division 3 of ihe BU51- BUILOINGS �p�'� C��[CL: aaaces � nese and Professions Code.and my Ilcense is in full force and � �� effect. .x��/ � (y� ;� CONTRACTOR . (3 � � �f jy�� `� -G� CONNECiION GHARGE FEE ' ���� � �-��-�Litense Number �1�'-`fC� LiC.G�ass '✓ �,� ADDRE55 Q 3K ,j��(s�,/A S 7'� � � 4 � f� )/�� ir �RtIMBURSEMENi FEE , ���� COl1fIaCfOf��i1�Q,[I'�VR/i2��Ipg/e ��I��o'� CITY Af"' q� TEI.N �1 �r��y��,�� OISiRICi NO. GItOUi MAP PRfXESSED BY � BK PG ; ❑I am exempt under Sec. of the L.A.Co. SceNs�No. �Q(3�I ct�nss '�� � q,�_� �. � No. DESCRIPTION OF WORK �tE ' ,#,'. �.. � Plumbing Code and/or Sec_ of the � FINAt YALIDATION `' u�j " MOUSE SEWFR CnNNECTING TO DAiE ���'� ' I PUBLC$iWiR 6.8 P.Code for the following reason j SEpiIC TANK SEEPAGE PIT OR �' � � PIiS AND/ON�RPINFIELD F NAl � �' � Oa1B_ - VpUSE SEWER�ONNECTING TD BY �. � �, 7RIVAtE DISOOSAI SYSTEM ^ '� R• S19f1O�UfE �� CONNEC�A']OIT+ONAL BIDG pR � � � � - OWNER-BUILDER�ECLARATION �voaK 7o r,ouse s�wex � a. WERFLOYJ SEEPAGE P�T,ORAINFI�LD � � �.t �' I hereby offirm thof I om exempt from the Controcior'z License EXiN..cesSPOOI,Davweu,n�aNr+Oie � � .� Law tor the ioilowing reason�Sf[tOn 7031.5,BUiSnE55 and Pf0- ALiER,REGAIR OR ABANDON HOUSE � fC55ian5 CO(.�C�: SEWER OR DISPOSAI'SYSTEM - S � ❑I,as owner of ihe properly,or my employees with wages as _ � "-'-- ' -�npensation,wiii do ihe work and fhe structure � is noi Jntended or oRered for sole.(Sedion 7044,Bus�ness � � ;" I �Q /f} �. . and Professions Code�. OWNER'S Permit 5 ❑f,asowner of the properly,am exdusively contraning wi(h AUTHORIZATION TOTAL FEE � #° �" ° ' � � licensed cOntraciors to consirucf fhe project{Section 7044, � i HAVE qT iM15 DAiE A�ONiRAGT WI1H iHE HEREIN NAMED CON7R C70R TO ' y q�7,�C �� BUSinC55 pnC�PrOfE55iOr14 COdE�. � CONNECT iNE ABOVF DESCRIBED F%1511NG OVJE�UNG 10 iHE�UBUC$fWER. CONSTRUCTION LENDING AGENCY �� � � � ��j,j�` � I hereby o4firm that lhere is o conslNclion lending agency �� SIGNEDiH15 DAVOF � ' 19� , . for ihe-performance of Ihe work for which this.permit i5 OWNER OR � ,�. �., �6,2�I��J : � OWNERSAGENi issued(Sec.3097,Civ.C.). . � � � .$.� ���f .�. �, . lender'S Name �A�okess � �Lender's Address 1 I cenify that I have read fhis opplicatlon and stare�ha�the� . R� .nbove informa�ion is correct.I oqree to romp�y with oll County � � ordinances and Smte laws regulating Plumbing and Sewers, � � � . ond hereby aulhorize�epresentmivas o{this Co�nty io emer . . � � .-upon bove-mentio� d pro rf for ins ecti n p ��� �' � - � y p pur oses. � ���.�����' � ���' i�of ermitle � Dofe SEEREVERSEFOREXPLANAiORYLANGUAGF ��� . - .�,:, , . . �Ns 74Aala>� �.�DF2 �nt''�z'- ,3 _ y � �^ I �I�z a { � i� . . . _ .. � � x��Z`�u � ..Gn�Z?� S� i � � � ; ' .i � � . . � �7 � # !.A�i�< ' i $ � 'i i � ; � I ., ' . .. .n I=r. �n� ���cino� �°�':r. { �..� i 7 3 �C' 0.;�17,ID VI i��� .. . � �� f I � , � I ' . . . . . • � � . : r � C'I.n I: 7 �� i z �� � i � j i � . � n � .I �U ' I t R 3 � � � ' � i i . 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