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HomeMy WebLinkAbout1516A WORKERS'COMPENSA�!Olv DEC ARAT�ON , . „ , .�.. . -�- � . , ,- ,.. , ,.- , � . � i hereby , „ , , „• I elf ..... :.. . .. . ... . .,. ., . . . ... . ... . _. . . � , . .. , .. .,. . . .. , ..,�._. . .. . .;., ,, ins�rc,o•. . , , . . ,.,. �br;a'az6... � .,., ., . . . � +� .. , .,:�. . .r, or . . a<e•••ie.• ... �.••.,. . 1,`;. Ceaoe�eeo�eiei; APPLI�AT{�N FOR����R�VII'T :� . �.. .�.. . . . . . Po�<v N��. . �`!/�.} .,.�. :,t. .._unc -- �� �:.,��,��r-� � o�s�eny+wnished SEWER - S�WAGE DiSPbSA� �` � � �',Cer�tied cop�is+i�ed wrh•ae caen!y budd:ng i�•spac�ion COUNTY AF LOS ANGELES BUILDING AND SAFETV ��� . ' departmer- ' �.�.,,...'.. ' , . , . . .... .. . ..... . .,, ..... .. .. �___ , . . .._,... 0<,:�3/_2Q�8fz n�P���o�,_. .rxeeman_.__..____ FOR APPLIGANT 7p FILL IN CONNEC7ION DATA CFRTIFICATE OF FXEMPT'bN FRO.XYi�WORKERS'�� � :!��.�i•�:; �� ;? �� � ,;,. �� „__� ' COMPENSATION INSURANC: nc^a:s` c �r��,� �_���{�j __ :Tivs section need r.ot bc oomplcica ii nc�work�n�clved b +he _� �%"F� E,h,,n Y ^'c T J/�n •/l�\�v C 3T%FF:M1�F pPrm��:s far on dred dollnrs;5100;a�less "-� �a�ll__.______.__ _ _._— .CrYf.R .Fcir[o: > -� (� �v::�p::G��F:�ION :vGi.,�4G,+ ' <ertify •hat in ihe periormnnrc o4 �hc wo.k 'or wni<h ehis ��a:^.;s; _.��__��)�.t,y= c.:v3 1•.'�F� perrtu:�s issund, I shn!�no'emoloy ony pe•son in eny mnnner — - ��--__ -- so ns io beco���e su6�ec+�o•he�Workers'Compensa�ior.i_aws ,A,��,� '(x� � �'� 'W ,�� qWNFR CO.fMP.NO. 706'NO � TRUNK PERMIT NO. � ROAD PERMIYNO.� MAIL .. . .._ ,_._ Do:e A::.!' :•,• .... AWRESS ..,... 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OWNEk�S Pe�mit S �.� �jQ ' , �-��(� :1 ! as ow�cr ot rhe prope�ry ;: , . , .. . , �4UTHORIZATION TOTAI FEE �" Q .. ,,,, . . ......... .:. '�ccnsed<cn•ra�ian�a con��. ....,,, , ��r..�,�,,...�.!. � " � •� •. . ..I::.r.:T 1�.�^�\F f :;�'iA!i.11T�•• ��CR;\\a•.'I):::?V'::.:-^:i. , ....,.., . . �. f0( Ihf! pf�fT< Onf:: •••Jrr';:'"IC.:�:i��::rS'i:if'=%�:\^^.t'[._Ihf'o'-�r.r„C:':5:':.=r� ' ......... . ..... ..... - I h�gc,bi as'`arndhal'�ncess �.�.`.-:��,..`..,..._. 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