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HomeMy WebLinkAbout1120A .. . . . . , . � � .5�.. � . . � . . . .. . � � WORKERS'COMPENSATfONDECLARATION .� ,; �� ,. ' ��.' ' . � , � � � ' � � � �' I hereby siflirm thot I hovr. a ceriificoie of consent io�self�� � �. � � � , � � .,-. ' . � . � � .�� � � � msule,�or n certificate ol VJorkers'Compensafion Inwmnce,or.. ..:,�.�eannsu .�,:, . ,...... .,,. �,�.,; . .. . , �.. �, .. �� � . �. . ; � �, a�e���F�e��oPY�hE�e�F�se�.38�,�a�,�., .::F�„R�kE�:a,�,� ::'APPLICATION FOR PERMlT Pol¢y No.__. ...._Company__..___ � � .�.�iqs � � � ��C�Cen fied copy���he�e�,Y��<<,�SF�ed. , � � � . ....:. SEWER - SEWAGE DISPOSAL� �� �� �, +..�.�: ; � � � �,I_�Ce�+ified�opy is liled.•.ith�hP�o�oty hoiioing�naoccrion. ! CpUNTY OF l05 ANGELES BUILDING AND'SAFETY � deparlment., ' '. ' . . "__..'___._ _'__ _—. ., ... -�..._...�____ "__" ' Da�e___...._.........Appi�con�.__ _........... ......_ FOR APPLICANT TO FILL IN CONNECTION DATA " CERTItICAiE OF fXEMPTION FROM WORKfRS' � � � r�uniNc -� " ^� " ""��"' -' "'"" � � � � COMPENSATION INSURANCE �� n�:utess ��7 C.� �� �.�jft��� l�,R�'iz, L.7LLsC�, srair,m j,..�-�`� ner�ni �' • :r.; .� , _._.. . .._. ��',�lhis section need not he compleied if the work involved by fhe �' - �� � uvv[a � M4h40LF FFFFRF�C'.F iowre �� ....; permit is for one hondred dollars(�1W)or IP.55.) .. . ... IOCAIRY.�1C�,y��( `�_�'���. �L.r9 17 ._____'.__�...'_ �""�.I c,ortil Ihnt in ihr. er4onnance�of�he work for which ihis�� ��ne[sr r ;�ixorcovNc.a�oN LWGiH4NU:d . _ ;(t Y . N ' f.VniS til. _��(,��,5/� (,(J LZ `�'�l�/ Y ("IIR3 v.l fl�.L.i0I'L. . . ��pennii is 35UP.({,I shall noi employ ony.person 7n any manner --�- - -- -•- •-----W � ���so os io become subjcct to�he Workers'Compensat' n lo�vs �� � 7 /� r�r.n•o nv.nrc F✓ � Y_ � �_ �Fl co unr no x.0 No. /' C��__._..� � t-�- � � Q�7��/��'/� �� . •� ' �� � � '�[� �j IkI1NrPeRV1'�O N()ADNER.Nii!iJ. ' . .,.Dalc._[lC._'�`7 P-F-APPliconf .� _""'_ ' AUnkE55�� '..:)G �,'._✓_ _ '. ��NOTICE TO APPLICANT: II, afier T ��� Ifl �P,t�l{iCOfG+ Of � AFr�A��1� V'JAIvrN kPS��AkNI kECURU�NSiR N(). UAIE � g «;YL_a_[�/�!�[��,a rE�.No�j� i.,7�-- r�� ' '.Exempfion, you should become subject io ihe Workers`�''� �F�.qi -�- �� Compensation provisions of�t�e Labor code,you must forthwith� �. , - r,vsr.amnou LOF�O. _�__ HY�Y.GRSI.WIUENbVG . ..,. ��� ;�.minply with such provisions or ihis permit shall be deemed, �.'�• ,' - -'""' ` � � . . , . _— '._.......- .�___._...._.____... ' "�P.vOI(2(I. � HLOCK ikP.Cl SiA�[FN"ROACIVMFNI ' � � LICF.NSF.D CONTRACiORS DECLARAiION ' � ^o.��ew�•S. r�ka�i?h°. .-------- --• . � ti11E l:F LVT �pY/O:!LOt ' '�I hernby affirm�thot I am licensed under provi5ions of Chapter .� �; ���� ---•---� . . � " �9(commencing v�i�fi Section 7000)of Division 3 of ihe Bvsi-: � p�p�p�h�gg CH.4kGE5 -` ' � '•���ness and Professions Code,and my license is in fulf force ond��:;.> - .�.� 2ffEC�. . .�.p . [/��, }. (:C�TR�CTVH �� ;-JQ L. .� ' p� � CCN�:.TIOV:.NA4,FFFF .. �' . ,'L!l:2l15P.NUTFIP. ���- `f �iC.C��SS�� � "� �' q(;'RFSS .Z� � " ��Mq�IRSFNF�11tk �- � ��j .z=�SC..�./E..tl�- ,c.! , r/ �. () � �r CO�I�lOCIOI I����Dnfe_ � .? P3 7'_ � �.9 ,- � �0����6J�_ u.s¢e¢r ho. <;xa�r ;anr F�2nCE55EU flY V .. 7"' . ��: CR� � iE..AO. �.. ' ��' Sihlk , I�(: / eK 1'la .CI I arn exempi under Sec._____..."___oF the L.A.Co.. �. ' � _^� l t��-1, o_nss L'"'�j W r c� . . 3 ----- �,.,� :. n . , .,.. ,...�. ii�rNs[rco. � �'[-= .� Piumbiny Code and/or Sec.._,_ _._ � " ^�� UESGRIPTION OF WORK FtE -=�--- - �-- f W --..__of ihe� � . ... '-- -- ��N^� � VALIDATION � � o�. ' ,. . IYJUtifyFWFR(:(:NNk(:lih�(f0 �. U [)�fk ���� / � PUOIIC SC\VFR �� B.&P.Code for the following reason ___.__ __ / --'-' �� .. .'... �'. SEI'IIC IP.n'F.SkE4'hGE 1'II CR fi�AL . ' VIISANI)�:)HLINAI4fl_lL` :+ � � �,�i IS .Date.-.— , . . __'. 5v ---""-'--'-" � �-- . II(:I1�F vf WF'!(:ntiUECI��`:G iU ' ' ,,� FP'VA�F DIti�CitiAL:'�YSIEIn � ._...."__ __'_"' "'c"-' •� ' $iynn7Ure. ...":' �� (:t?NNfCiAD'J171OnnL6LpG.OB Y. :: i� .� (,.i J ' •' OWNER�BUIL9ERUECLARATION � � � �'+�?�<roetousEsewtu _,_ . ov[e�iciti%s[[rncc PI?.CRA:NF FID-- I hr.reby affirm that I am ezernpl(rorn 16e Conir�clor's Licenxe � � Exlv. CtS51KYJL Cenvni,n+n!arc±ir � u �G�],J 4) "Law for ihe follovnn�reason(Secton 7031.5,Buisness ond Pro-� :�i� �riirFti:-evvniuoe ntsu.�ucu v.ous� ��� ��- �- _ � ..._ '�fesnions Code): ' . . srv:r.c ca oi_rosn:srs�cv,- ----- — c. „ . �.,' I...��.r ,_,I o:-.--._�.�..:pru�.c;7'r,u my a�rF:cya,;s v�h..eyes ca �----- -' -- -i.�• �;'- •% their sole coir�pensn�iort,will do the wo�k<�ncl�ihe stroUore� � � ' �� s not mtended or olFered for sale(Sedion 7044,Business '-- ---- � a��d ProfFssions�Codc). OWN�R'$ Permit 5 U ,� � . ��I,es ownw of the properiy,am�x lusivcly contradiag with AU7HORIZATION TOTAL FEE 7 ( p I Censed contrada•s to conslr�U ihe projer.�(Sr.ction 7044,' �!�qy�A'1HI5 UnTC A CJVTP.AQ V.'�TII 1V4}IFk61N U/.n.1CD COhIRAfJOR 10 ' �VS��B55(�!1(I Pf�fP,55i0i15 CO C IC�. � COYNifi illf A11pV'r Uh�('.NINlU tXISIIN:i LI`NlILI�G i()illF YI1N11::S.'rYtR � .. CONSiRUCT!ON LFNDING AGENCY ' � � � , . � ;��� hereby�ffirm ihnl fhare is a conslruclion lendin9 oc��ncy � SIGNfDTIII, __DAYOF __^_19,__ `for Ihe performance of thc work tor which this pr.rmit is'•��"� �."'��- ���'��reok , � � o•,vnexs.�crvr_ ��'�issued(Sec.3097.Civ.C.). --- -----" � �. .:Lender's Namc .;;.., ,,, nm:.t55`.......�._... �..�__....._.—'.' ___.. . _.._._. ' -1 ..,��. ...:. . ; � � ,;�: ;Len�ler'sAdcJress....'._............__ _. . ............_— � . . . ..•�I certity ihot I have read ihis appLcation and state Ihat the ;abovc infarmation is mn�ect.I ayree lo c:omply with�II Counly �" . � � � , .� ��iordinancas ond Sta�e laa�s regulatiny Plu�nbin9 ond Sewers, � •and hnreby aulhorire repres�ntativcs of this Coonty lu enter:..... .. . ' .� ,. , .,upon the obove-n�enliaied proP�'rt�y f7or inspeclion purpuses. � . . .��7 1�fl. 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