HomeMy WebLinkAbout1007A (7) . 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.
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