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HomeMy WebLinkAbout1523A (8) _ __ __ , _ .... __ I _ __ _ _ _ _ __ _ _ . . ... . .. .... . . .. .... .. _. _ _ _ ._,_. . . . WORKERS'COMPENSATION DfCLARATION� ! hereby .u.. � � .onfi .. . . .,. � ., . � -` •^� r..r : :...�rcte o consenr ro self _ i�surr or��•�,:r••�':�,•'•�: :,�,•.���t'Co�*+pensa!�on insurnnrc O• 16Aba1D . n ce��.+,ed a:,. ...,.:y� •.,'�9S�h C.;��d ;='a .., �° �4PPLlCATION �OR PERM�(T . ; P����Y h"—��7r�jcymP� V----'-------�— � �- "° SEWER - SEWAGE DISPOSAL � G:rrd�ed/t�� is.itKtiy.`urr.m5hed. ., .. ,. .. . �+ COUNTY OF LOS ANGElES BUILDING AND SAFETY a Cer•i?ied cony is fuen•uith fhe rou�ry b�iidmg mspechon ,.urw-, .�,:,,� ��� .,�sri.: ��, �x..:,. .. .•,.,.� . ...: � , I I �_' F.03R�APPLlCANT��S��E�,v �� —.—n=` CONNEGTIO '�'xr �'a� :'.i�: eocrtmen• , , �o�e ._8_20_8�A;,�� �on�,_F2°2e�1E1 --- N DATA CFR7IFICA7E OF FXEMPTiON FROM WORKERS' "''� =i..c�.� �'i— � ! � COMPENSATION IivSURHNCE .�"ca�s5 i7h�s aecron need no•be comnfe�eo d�he v:ork mvolved 6y the 7�T� 'pn D �rc.,�u_r uf�[ePN^ l,=n`F oermil:s?or o.^.e 4undretl dol!a�x iS100`or IP.55'. .�)-�'—Y�. 11j.fL.illlCl___�_—� _� . .y. �.F !O'N!q _ —_. __ �4� �r: t � h�a4r:� /.�.. -Yar.C�-^^yN•C-',^,Y . i <c�t•ty o' he pe�formon:e a d•.e work�nr wh:c� if•is ,k�;q;s- (�_,' " .� .� .i�n";so'r pr-m�r is�ss�en, !snch^ot�=mploy a�y perscn in any monner --"—` ��1'� V "„`� ° •�.` �^_, .—.—.'___��--- _— ....... .,...�...�_ ......... so as ro be<cme>ub�co:o ihe Wnr4crs'Comoensaao�+Lows. p��F� ���� C� _,�p .rn�;; ,. /d��p-� � � ^�p ... ..._ �4... _ A':`:h.i� ���____ '1�<cFN\"\U Ra'.�CFtGV'tG o����-----A,:, .� PO BC?X 4 . NOTICE 70 APP:ICAN'. �.....^..,. ..��.,.� .. ^�,...,. ..,, �.. � �� 87.8.�11� 1_.-7',r,e�a r.+yr�.:r�.' arcr,ec m=T¢�r. ;;.r . ,; , . , �TA ,�.i•rnnhnn ynu sho„Id nerome s�c�ect 'o �Fe Workers' �--- � 11#�no U :�](?n5(Y'i7f�?�OV�S�O•`5 Of Ih0 lobor rode,you R1J51 ip�1hW�IV• ':�:•. , _ .. ... . _ . ._......�.... :;15(2�'C� -J�'�;' 1;."::R�'WIDENIIJG�� ..�npiy witl�, su<h urovis•ons cr Inis perm�t snal� bc dnemea ��� ___ . . •evoker.. =.C:< 'tA:' __��.__ ti'.•rL\:2JACHly\ENT:-.:�.: . . . � � L�CFNSED CONiRACTORS D'ECIARATl0�1"'� � � '`�• '�'r=�s �'P�^- - - - '�.7t�� :r �C4_c:�.^t —__— . �O ..w ..<.:.., E hereby o`firm�hc�� �_. •.. � •�.P,�v•�,ons o°Chap�r.: a�� . . ._ . . Sing Re� . .... ,...,..,�. 9 jwr^mcrung with )wisior 3 of•ne 8,�s�- �,�_+iy;;;. ;r�:.ec'»5 ness ai�d Proress•ons Codc ond�n�I�<ense�s�•i iuit?o•ce and — ��_--'--.—. .. �.....�� ,•°,.-�,�-^•'�"�""""� effa.r :a�•..C'rt FREEI�'lAN CONS 2• �,�'�F":1�;�n;r;r r,-t .,...�...wv_��.c � 474887 C34 --- — " a ..,:..._ �.. icon.cN.�n,nr ._'--- ._l,< Claas----'— r..ce[•d, � :f:,,i,.a=•v�n•_; ..,.. 8225_._£s.€�S�nos_�r,� ---- - .< < ......,.. � o e�.,,,a�:,�-_k'ree�an._u���_�/20/s`3�-- , _Alta I,oma^--'Z�4.L�8S�'-.4�29 f.�'kl:�\Q ::Ri)JP ..1.� :VP':eeiC 5Y u ry� x �y I �h Pc 2 ' _ nm exempt unoc�Se:____ cl tFa L.A Co `ic[us=,�^�!.t8� !.q5•_�i�[�- ,� I I o PlumhmgCodeanr..or5r.c.___'_'_ `cf,f,e �- DFS:B.^"O�OF:90eK - --'1—�—_ _ � .. :)l.:E ifrrc3.'.^.�Vr^:\G T:. . .. :.�-�' W e.&P Code for rhe iol'io�vmo reasor__ , •_�;`�•'�`' . I_1?I Q�_ �� �0-Z"+�g� �VALID ION _,_„_„, d .^,f:.'��C.�..�:,^,�:•�� � .r'- � _ �ale�_ _ `nNi...G f..l.\.�S'; __ T :V:, � i '. ... .., r `"_____ /�r. 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T'� i i�:.:I . !.•,a"CiF+OSaI. :'F•.^ � $�9ii�•UIC'__'__"�.._ ��..u.�....�...........^e.w�R.x:,.:�.�:�n� ::".\=�i.��'�:'C\A 9.:u(:R _�_y.'__ ___ �_�_J I � (� CWNER-BUILDER Df.CiARATiON o.:iai'��a.icF c.v,.K _':FF�IG;',4k'>nGF�li "'nA^.F:l:: �_ 1;� .�'.��v YS I herr.bv afi•rm•hu��om r,xemp��.oM•na Canvro:�c�'x u�..rsc 'x�•, c�.;s:.�o_;c�nEi� en•.-.^,_[ - a`o•'k•e ioi�owing rs�sn��;SeU:n 7031.5.Bwsnoss ond Pro- -'� '.iri ci-�,e;x n5:.�x�a:icis_ ---� ^"^'.ior.sCodei :.:a:�t;ior,:�a pvsr:v I� *;e � c o 1 !� _ . as ovenc�o+�ne property,or my employees w�th woges as - t*= �2 7 u;;1 :tir.r solc conpenso'un:,will do the work and fhe strvcture � is not i••i�rded o•offered for sole(Section 7044,Business = ---� � ,_, ��_.�r�.r�� . r.n;,aro;ass�ons Ccco: iZNlNER'S Permif ,�I-�Q ' � � � i ' �s owrie�o+!he orn,r.�i�y,am ecr;d,:vcly coNrr,chrg w AU�HQ�I'YA�1(O�„� TQTA�FEE� (i v,C�"Q�J licr.�s�d rorttroc:ors ro rors�•.,c':ne Pro�rr�;Sec4on 7C4a� i Hnve.ai*w5 on*E�,r:;nTaa:'':,if'.,:i�4[4 w:�['+.7;••+,:4: �.. � Bu1i�•FSS(�n(J�r�{fSDiORG CVt1C� CONNE[':THE A801�E Ct;:i 3`f.=t 5'�i i7.:_h;�Ti;:F!�l-,:�-';:�L � CONS?RUCTiON:END:NG AGEIVCY p � 6� , i F;o•c•;;y nf��.m d;�y •.�t.rn �s n rnr.s�ruUion lending agency SIGNEDTHIS DAYDF d� 19a� ior Ihe vr.�(orma�re oi ihe work for which +his permit is nwNPaOa ��� (ii.�e/'i r,Hra,..n.n -�' Ll.i.i[Z'?'�..—.—_. �swed�Sr<.3C97.C:�v C� --- . ' c:`l:F'ty �.� ' � ' ' n Le-de�'s Nome• -�—' � �_. . ___—_........._..�....�,_....�.._n,.....: „ -_' "T• �c•�dcr's Address - _,.�. .. . � ��- . " - . ..- . . � � . � � I rertiiy ihot I�hnve reod ihis applicahon ond sfafe inat tbe � ahooc inicr;r;ai�cr�is torrecL I agree b comply wiih a�l County Orj��(����f5 ar.d$r�'e lows rcgi,lo"�y Pi�,imbi^c a�id Sewers. or:d .'^.creny nut4orue ropresen'a�rves uf:�.c Cn.iNy�o entc� ,�pon!nP nb�vr.mPr.����er!propci'y+o� �"sner��o:,n.,rpnsr.s _o-�C^M Pe�`�;�,•,,v�_G^—.--.�'—c�.�-� �L Sicr:;�ure o,.errn•!•ee :�'i± SEE RiVERSE FOR E%PiANATORV LANGUAGE � ,..._.�...._.._.......isaaP�aR'SNO7E3 .._.._� .�,._ ���!�4FTd.�Lr`IY.�Y�.!#lJ�G:.la�!'i:'.��.}.'�: ....._:,..�.:...q.,�,..at.4::,-�.��---„".'� .' , ._..__=.___�.=�. .: ��`�.,..-.e...�: , . , A,QPROVs4f.S _._ ! nn� iE � INSFxGTOR'S S�GNATURE �„rriL;ixiir.�.::h�..i t.:�n¢..�:�,>.t.ue:,x'r.�..•'o�:aeacxnr`n -------- ----—-—�._«_.... ., NEW HCliS'YWER � �� [:'s.�n:w L•r_w-fo:�.:ye'?aiicf�ing re:;�ur.jar::t'�r..a v3Y.5, ,\.r--:' ._-•:n —�— .. 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