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HomeMy WebLinkAbout1520A � - _ _-_. __ , WORKERS'COMPEN54T!ON DEC.ARATION . ..� ...", ... .--+�' . . -�._ .• .. . , ` . . ... .. .. ... ... . -...-.. � hereby offirm Ibo! � F�ave o cerhi cute oF conse�v to self ... . . , � .. . .. �..� � ���� �'' . . � � nsur= o•a cer t m•e of Workcrs'Cornoersa7:an Insura�<�,or '=�`��� � " .. . .� � '� ��' �<e•,{�ed copy tnereo!(Sec 3800 ���C CE806'Fi. a�: qpp�}CAT�ON I�OR F�ERl1AiT Pol cy,2n+q.��y�_ Company---�t..-�"��-- - `JPs =ce.�7��i"1T.�reby��mishea SEWER - SEWAGE DISPOSAL — WUNTY OF lOS ANGELES �BUILDING�XNb SdFETY "' �xCerif�e.d<opy is 1 ed wi�n���e,coun'y bwldr�n nspectio�i .:.. .. ...,... ...... . ., • :... . .a,:..,_..... CP yImEn• "_ ... . � . . . ..u......... oo•o�/2QI�6.Apo��ca�,�.._�''����a'??__—__� FOR APPLICANT TO FIIL IN CONNECTION DA7A . . CFRiIF!CAiF OF FXEAAPTION'�F'ROiGS�WOt2R�EfcS' ;,> >•N;, f'�.�y� �o J �� �ra�Cn _~ :xP'�+ COMPENSAi!ON INSURANCF� ;;��u:�s���blU-Y�_�._'����_(..�� � •,'..'" _ _"_ jThis seriion r.eed nat be comple�ed ii•hr.work involved bv!^e .....,� .y p. !•:.\-I.^.I Hi°hkCNC: ��,�_ penn:+:s�cr one�•undred aoUars lS100'or IC55,'. .•• —'--.��.��--�/')�//�-----�—�..�-- 'YPC�1°CC\nF�.^.k A��.F�SI �JJ-b�_l.e..�— 1'Nu:rl.n(Yf. I ce�t•fy ��iot :n itie oe�forman:e oF rhe work for which Ihis ;,;p:,�,;�� _ �,�i'� r_ u:,� �'�-��,-. . . pprp�,i''S issucd I shal'no+ert•,p:oy any pc�son in rn•y manne� �' r r �.-; Gr1 so as!o be<on�e su't.��r.c�'c the Workers'Comacr.soncn:ox�s. ca��rc A,.�;DEN GRr _ �;�,F�:� ::F•.�: �o Y6� ' •:�cll �O �Oh ��2�j "t.�<Fk�'.•.'1C ROt��CF\•:'�. � n"I:�il>_ Do'c___'..Applicon'_'— -._-___ — -'_ , Fi,nr' .�:._� F4iC':��' R�CCFC I�cTF�:: '+•'�T= N0710E Tp APPIICANT �F, o4cr moiing •his Ccr:ficate of COVjra, - ^::�81��6' � �v :! r6xrmp'�on yo� stiuuld becomc s•ariec 'o thr Workeri -�A: " . � ^.p2�5O'i0i1 ornvis�ona o�'he�obo•cone you�h�'si io•;hw�ih pESCRIPiION lOTNO HWY OR ST WIDENING � � .,npiy w�rh s:,o• proviswnc cr •F.,x oermu +hall 6e oeemed 35754 --` �E!�Cked G.:),:< �kTCr '_3�'IT\C)�4;-I:'�:Y� i ICFNSEO C0�ITRACiORS�DECLARf1TiON ' •�°�°�-.'"y ------ _ s 1:c�.� .�+.3N.c; i hrreby affirm i�u:•�i om��censed.�ndPr oronsions oi Choofer USE OF 9 ;;o�nmr.nr.i�q w41� $eno��7D00' or J�vis�cr 3 0(•he B�s� swtoiNGS �HARGES ness and Pro�essions�ode.nnd r•y:•.crse�s'�n+;d '*orce a•id _„ ..� . .._ _.....- .,...... . .....____.._._..__._..__....___.__.___ Cfft'Ct �7 n CONTRACTOR � CONNECTION CHATf'GE FEf"���"� �. ..... _..�...._ _.., � !i:e^scN,i�r.ber_Q��T4SS1____;�� i.1055._.. �!��.._-- :•::.:F'-.ic BGGr Beechwcod �s �:']�.nSk::E\'F�� ' V ��'']CLPi�lAT7 __�a•e_._ :i .l��..t� ZO1Lc1 ,i•.:; ��:s.c:��.^ �z::.:. ., =�cctss:c3r co„��a���� H/2�Sb---.— .714L98Q-4_4.2 BK � o ,-,,-:— « . �I� I._ 'on:exemFt���da•$er__--.-_oft�^e-.A.Co �Cr�:;Etic `�4 _l4 L� � u � -.,__-' _' �'_� �iSCR�'InY 7F�^i:J3K _rF` _ r�:� ' .'�'.�. W P!�mbinG Code end�cr Sec._ ______ __of thr, - . � �i.�,s.r:,c�cc�nr-�o-c � -i.� � -�-r `�_.L�` / VALIDATION_.,,._.._, y 9 8� Codr.ior na followi��renson_._'___ , .t'."�'•-� , :.:__.. �-... ��^ " ' __' _-..._..__ ._ . .._...__..-.. . .. _ . . ' .. . .' ._..:..�._.__�.'�_.�_ '_"' ""'_.... ... .. ' " ! __ —_Dotc"____ _ i . . .. . � �^ . . . ,..:,,:� '__.._' '::__ : _ .. _.... .._" . . ..'""_ . _ - Signa�urc.-'_-'_.__._ . .. . �,•. .' .... .�.'. . . • . . .. :. . . . ..... ...: ..1_ ' OWNF.R�BUvDE2 DECLARA?IOV . . . .._.., '.._...... "•"'_ _-.... _..""".� . .._.. �.... � O E �hereby o?irm'ha;!nm exemp!i:cm:f•e("��.. .,;.....� , ;,,..�i. , '•. '.. .. ,• :: : .,. .._..._.....- ' "_ • ... -' I , . : :.: ^ _ .� __. � .�.. .._, :_... Law ior'he Fr,liowin,renso��Sectori 703L@. t° � .. .. ,.- ; " • , ' ' .H�+. � � I U ' .,:..,.�ors Cade} ��.,, .... . ..,. .� �'" .i.". .__�.. ..... ..... ..__' " . I,os own^•or d�a Property,or my em.;��oyecs�.vrh wnges as � I a�o)�,�� 'her,solc cr.mpensohor.,will do:nc wurk ai�a'r.e sirur'ure �s not�rrended o�oife�od for sole;Seran�70n4,B�sinese �a e�'�,�}{�� r.nd ProFess,or.s Codr-� QWNER`$ Permit i� Zl7 �J� � _ :.as nwrr.r ef�nc a�opc��y,nm ex-h:s�vciy<on�rac•ing wrth AUTHORIZATION TOTAL PEE , F� t�`[�.��7"'`�G`fl �:censed rnn'roclors ro cons��,:ct��^o proie:•!Sr.rlion 70nn I HAVE AT'- ::i[t„�7a•"u•� '.F•if+^Ein nna�;^,��'v�.:ce rc 8us��essandP�O'C55i0^s�OdE: CONNECT ^i=9C�F':`YRB"1.x�r•�c:r.: �i_•-rir�u6.rstn�a ' � CONSiRUCTICN LEN7ING AGEfv'CY �/' I hcrnby affr-� •Fin� �m+re is r. <o^c•ruuicr Ir.ndinq nqr.ncy SiG�CDThi:i��J4YQ- -+� .�4� , for ;i,e periormnnrr, r.f �he vvnrk fo� which �his pe�mJ is ^:`:�E:::k ly{� ✓ ��- _ �...�:.p.,:.:-\• ..�L--l-_a'�L — issued�Sec 3097,Civ C 1 n^�;cs $�- �E' � ' � Lendm's Nnme_"_-_'.,__'_".— �__- . ,. , . . . ' . . . .. ... . , . . . . ... ... . .. .. -. Lendw's Acidress_____.—_. � � � � � -� " '�� ,.... . .. .... .... . . .... � . , ��.rhfy �hn+ .' tirnr. •eaa �n�s npphconon c^ti s7c!e 'i��!nc� � abovc�nfo•manon�s oo�re« I cg.r.c�v comp�y wdr o'!Co�.nq� � . . � orci�•.encrs n^d S�rna Icws r�gWai'�ng Plurnbinq ana Sewers, , . �� ard nerecy au�harae renrese^�ohvr.s cd'his Cour:v to ericr upon rhe auove men'iore�i p•op;�.ny icr v:sac;�wn p.I:DU5C5 �,���� _ .�-2-s-Sr� S:��nor�,ic o�Pc�miltee Jarc SEE REVERSE FOR EXPLANA70RV L'ANGIAGE � �...._.�._._,_�s¢aS�EtiosYSa�osEs�.�.._�....._�._ `���R••�*JftI.£SER F��C�.E413A'TIQPd , .....m...�r_...t.....,._.,.�..,.....,.n.,.....��-..-...,....,.,.5 . . . .. . .,,., . 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