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HomeMy WebLinkAbout0917A (4) WORKERS'COMPENSATION DECLARATION - . I hereby affkr!� �hot I have a certifico�e of cooseM lo self - i .t�surc,a a certi4cfila of Wo�ken'Compenw�ion Insuronce,or'� �a�e.ao . � �� � � ace�tifiedtopy�hereof(Sec.3800,1obC.) . ceaosiaev.ire�i APPLICATION FOR PERMIT � Policy tJb. Compony ' � ❑Cerlified copy,s ti�«eY f�,���tied.�. .. SEWER - SEWAGE DISPOSAL i ❑Cer�ified copy is filed wi�h rhe counry b�ilding inspection•. COUNTY OF LOS ANGELES BUILDING AND SAFETY deparlmen6 . � I oo�e hppl�cont fOR APPLICANT TO Fllt IN CONNECTION DATA � CERTIfICATE OF EXEMPTION FROM WORKERS' eunonac � . COMPENSATION INSURANCE �REu �T�� �°m (ih�s section need nor be compleied iF the work involved by ihe � M4NMIXE RFFEffNCE ��e permil is For one hvndred dollars(f100)or less.) - �«"��ry � � ° � 1 cerlify thar in Ihe performonce of tFe work for which Ihis c�ao�ssr. �%' iYv[p�OrwE�Tq� �E�'rN�¢OM permil i5 issued,I shall not employ any person in ony monner Y� CURE v.4 M.t.TO v.l, so as to become subjeU fo�he Workeri Compe�sai on lo'ws o,,y�a � � co.�Mv,rio. Pio�g'o. I '��� 1WUNK FfRM1T NO. ROAD PERMIT NO. / ADDRESS IZ W Da�e�ApPlicanr . NOTICE TO AVPLICANT: If, oftar m �his CMifica�e of� nFFiw�� w�ivcc cnse�rui uECoao.insta.no. wh . g CITY TEL NO. Exemp�ion, yo� sho�ld become s ject �o tha Wwkers' lEGAI Compensotion provisions of�he Lobor toda,yov must forthwith oexairnori ioT rao. Hwv.ce st.vrio[wrac comply with s�ch p.ovis�ons or rhis pe.mit shall be deemed revoked. e�oac iCFCf STRiE ENCQ04CMMENT � UCENSED CONTRACTORS DECLARATION ' r+p or eiocs. �pMit No. ; SRE OF l0� NOW dJ lOT 1 hereby alfirm thot I am licensed under provisions of Chapter u�a , 9(commencing with Section 7000)of Division 3 of Ihe Buzi• aunwr+GS oi�aG[s - ness and Professions Code,and my license is in full force and effect. �Tq�Rpq CONNECTION CHARGE FEE , L'I[lnSR NUmbGI � L'IC.C�OlS ,�pppEu � � REIMBUPSEMEM ifE y �, COn1rO[�or pole CITY � �1.�. DiSTRICiND. GkWP BK MSP � PROCESSFDBr v , C ❑1 om eaempt unde�Sac. of the L.A.Co. �i�N��. ci�ss � Plumbing Code and/or Sec. of�he �� DESCRIPfION OF WORK � FINAI�O � � V w�s�s�wea ca.Nca�r+c ro on� VALIDATION �u PUBLK SEWER d B.8 P.Code for the(ollowing reoeon �[pp�TµK,$FFpA(aF pR�q FINAI Z vns u+o�oe oc,u��o �1Q Hd15E$EM'ER COrnECiING T0 BY � � RIWiE d5 S�'S�EM S191W�UlE CONiECTA0O1TiONAIlIW.OR � � � - OWNER-BUIIDER DECLARATION `"�`TO"a���° I ovEaclow SE6o�G[qt.puativielo � 1 hereby offirm fhat I am eaempl from�he Conlractor's License FMTN.,CE55POp„pQYN[0.,MAHNp1F Law ior the following reoson�Secton 7031.5,Baisnass and Vro• uTtA,atP�ik at ne�NDoni�qu5e I!S OIIS COdO�: - - SEWER OR WSPOy1l WSIEM • I,m owner of tha property,or my employees wi�h woges as �� hei�sole compenwtion,will do Iha work and the s�ruttura is not intended or offeied for sole(Section 7044,Bvsiness j and Profess�ons Code). OWNER'S Permit s ►O �0 9 1,7 A ❑I,as owner of the property,om excluaively contracting with AUTHORIZA�ON TOTAL FEE � o . Q licensed contmc�ors�o consirutl the project(Section 7W4� I NAVE AT THIS DAT[A�pNTR�Ci W17M iME MERFIN NAAIED CONTRI1CTpf tp �� •2�,�Q Business ond Professions Code). cw�x+[cr rNt neove oescRie�o ezisrmie owewr+e To TH[vueuc s[wea. CONSTRUCTION LENDING AGENCY � . • � ��2 1.5 0 i� I hereby affirm thot Ihere is a conslrVC�ion lending agenty ��1EDiH15 DAYOF 19._ ► Q Q 2� —8 7 for �he �`"�"ER� . periormonce of �he work for which this permif is o��A�NI . is:ued(Sec 3097,Civ.C.). p�� . , lender i Name � - lender's Address � I ter�iiy thae I have read this opplication end state tbat Ihe - - above toformmion is torroct.I ogree to comply with oll Coomy � ordinances and Sble laws reqolating Plumbing ond Sewers, '. - ' and hereby owhori:e rep.esemoYves of thts Coonfy to enter '� � u n the a6ove-mentioned prope�ty fw inapeqtion purpo� / � � ' l v:, 7'�7 igr� reo ermitt e o�e � SEEREVERSlFORf%KANATORYIIWGUAG[ / /i 1 - 7, ' .. Ns' � z.�� c� f .' . ... .�. „� ro^ �: ��n vn 47 T ' . � <f io �'' � Q '���.: c D � , • - � �, . . ' . � i '- � 8 z �';, ' C•r o'� -."�o ' . . i � � v� z�, }r `� �� �, � . �.+ - � I �1 � � • �i �i.�. ()^� TN %: . �' 1 1 ' "'f i C C S,�,•" ��• O � ' . � . . • ' . i ' . � : . . . 1 , ` . , �q �,r �n r. 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