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HomeMy WebLinkAbout1247A � WORKERS'COMPENSATtON DECLARATION � I hereby affirm fhot I hove o cerrificme of consent io eelf . +insure,or o ceriificme oI Workers'Compensouon Insorance,o� 16Add7D �j �1� o cenified copy ihereof(Sec.3600,lob C.) CE6CBIREV.7/831 APPLICATION FOR PERMIT � � aolicyN�WC6057d�,Po�yAiahland Insurnace Co. ❑ce.+�+��a�mY is hereby furnished. L SEWER - SEWAGE DISPOSAL � �Ce�lified copy is filed with the county building��spect�on jjnit5 433 4340�YOFLOSANGELES� BUILOINGANDSAFETY � deportmenl. pOe S�ZL�E�Ip�PP���a�� Amatore Plumbing FOR APPLICANT TO Fill IN CONNECTtON DATA CERTIfICATE OF EXEMP�ION FROM WORKERS' eunwnc 22915 Estoril Dr. sTAT�oN oertH . . COMPENSATION INSURANCE noor�ss (This section need not be tompleled if Ihe work involved by the ����n, D• B . AUNHOIE pE�fRENCE . V�q permii is for one hundred dollais(f100]or less.) 1 cerKf ihot in ihe erformance of�he work for which ihis �^�st irftacaw[cT�or+ �tr�crHrep,w Y P cQosssr. Porto Grande and Montefino „_ �,,,� p,�, M.�.IOP-L. permit is issued,I shall not employ ony person in ony manner so os�o become sub�act to rhe Workeri Compenw�ion Lows. pwr.�¢ Presle of Southern Calif. P���� [o.w,v.No. ioe�+o. - ��� 17791 Mitchell South TRUNKPERMITNO. ROADPFRMITNO. Dole Applicant ADO�u NOTICE TO AFPLICANT: If, aher makin this Certifimte of rvine . - A��oA��T w�iv[e E�SFMFN7 RECOR�.INS7A.N0. DATE 9 CITY iEL.NO. Exemption, you should become s�bject �o the Workers' LEGM Compensa�ion provisions of�he Labor code,you must forthwith pescaivrror+ ioT r+o. Hwv.pc St.wioer+naG �,ply with s�th provisions or this permit sholl be deemed iked. 9!OCK iVAR STRLE ENCV04CMMENT / IICENSED CONTRACTOR$DECIARATION ryp pF&DGS. GFRMIT rp. 512E Oi LOT NpW ON LOT I hereby affirm ihat I am litensed under provisions o(Chopter (,`OIl(�OS 9(commandng wirh Sactfon 7000)of D�vision 9 of the BusL �iipm�s a,�s ness ond Profeuions Code,and my litense is in iull force ond . effacr. coNranooa Amatore Plumbin i IIIC. ��NECnONCN�RGEFfE licenseNvmber 355068 lic.Class C-3�6 pppqE� 127 W. State St. WE�MBURSEMEMI4E � ��g�ore Plumbinq�� Inc. 8/25/87 • n ario - � Di5i4�CT NO. GRWP MAP PPOCFSSED BY O ❑TY TFl.NO. ' ,/� BK VG V ❑Iome.amp�underSec, oflheL.A.Co. i�Nscn�o. 3SSOGS q�ss C-36 `b "'~ �Q1��.e O Plumbing Code and/or Sec. of the �� DESCRIPTION OF WORK r�[ Fir,yi 3 PUlIK S�Fv�iER��NfCTn�.rP�00 ea 51 00 o�'E VALIDATION � 8.8 P.Code for the following reoson yrri 7MIK.SFEPpGE PIT di Z Pi75 AND/OR DRAINiiEID FINAI , Dol! p�75E SpwER CONNECTING TO B� � ' PRIYAfE D15P05�1 SVSTE ' ' Signolure CONNECt Moiii(Mln�&oc.O¢ , — OWNER-BUILDER DECLARATION WatK To�5�s�w[p OVERiLOW SEEP/�GF HT,DRAINFI��D I heroby offirm that I om e�empl from the Con�mUor's license [xiN..Cessooa,qerwtu MANMOIE , �� �h �p low for the fotlowing reason(Secron 7031.5,Boisnesa ond Pro- �uT[q.aevuR ow ne..ripoN rqus� . �� r� fessions Code): sewERa+wsros�i svs� Q - �1,o�owner o(the property,or my employeea wi�h waqes os " � ��� #' ' ' ' 1 � �heir sole compensn�ion,will do�he work ond the struct�re � �° •(��.Jr O I -/is not iNended or oifered(or sole[Section 7(W,Businese and Profeuions Code). OWNER'S Permif f 10 §Q s 6 •(��,S�� ❑1,os owner ol the property,om ezclusively contracling wirh AUTHORIZATION TOTAL FEE ((1 50 licensed mnlrocton to consMvtl ihe projett(Seclion 7O4d, �N4VE AT THIS DAIE A CONTII.KT WIiH fl+E NFRFIN IY.MED CONW�.CTOR 10 0 8 3 1 —$7 ' Business ond Profeu�ons Gode). ca+�[cr rw[aeov[o[xaieco[xrsnNc ov+eui�c To r�vueuc 5[wta. - CONSTRUCTlON IENDING AGENCY - , I hereby offirm thol there is o conslr�c�ion lending agency SiGNEDTHIS DAYOF Iv_ � � for the performance of �he work (or which fhis permit is �'"'�R� OWNFRS AGfNT issued(Sec.3097,Clv.C.). aooeess � lendar's Name Lender's Address I ce�tify thot I hove read fhis opplimtion and stote that the � obove informotion is cor�ed.1 agree to mmply with ail County • . . ordinances and S�ate lows reguloting Plumbing and Sewers, � � ond hereby ize reprex ives of this Counry�o smer �pon the a -menl' ned q rty fw insp lion purposes. � ignofure of P ine Da�e � SFE[EVFRSF FOR[XrLANATORY IANGUAGE � 1.rVli1� 1iii1,-^_`v_� . 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