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HomeMy WebLinkAbout0902A (4) ' � WORKERS'COMPENSATION DECIARAT1pN� � � � . I h(:eby=t�K�.rm thot I have a certificote of consenl lo ael/ � }l iniure,or a certifimra of Workers'Compenm�ion Inwronce,or '6"w�o U a cenified mpy thereof(Sea 3800,lab C.) �, - �Eeog�aE�.,;g;, APPLICATION FOR PERMIT Policy No. Compony , ❑Cerlified copy is heraby fumished. � SEWER - SEWAGE DISP05AL . ❑Cerrilisd copy�s filed wirh rhe counry building inspeciion COUNTY OF LOS ANGELES BUILDING AND SAFETY department. � � . oo�e Applicont FOR APPLICANT TO Flll IN CONNECTION DATA - CERTIFICATE OF EXEMPTION fROM WORKERS' g�mpr� COMPENSATION INSURANCE �ooc[:s , srr�naa o[nH �This sadion need no�be completed if 7he work involved by the i����Y �NNOLE REFERENCE �,�R permi�is for ona hundred dollals(;I00)or less.) � I certif Ihoi in rhe erformance of the wark fw which this �'+E�"ESr ivv[orcaaNecu01+ �ry�TMFROM y (> CFO55 Sf. Y. NW6 P.4 M.L TO Y l. permil is issusd,I sholl not employ ony parson in ony manner so os to be me s bject to�he Workers'Compenaation Laws. owra[a w.v.w.r+o. � ioe i o. - / ,� FWII TRVNK PERMIT NO. 0.0AD PERMIi NO. pote w ^2 �3Applitont ��. ^°°"Eu NOTIC TO LICANT: If, after mal' this Cer�ificata of AfRDAVIf WAII�EN EASEMENT xecaro.nvsm,r�o. o�te � . 9 CITY iEL.NO. EHem tion, you should become subject to �be I Workers' IEGAI Compenwlion provisions of fhe lobor tode,you must fonhwifh o[xnivr�da tOTr+O. Hwv.Oa 57.wioewraG � comply with such provisions or this permit sholl be deemed rEVOlted. ' ' 8l0[K iRACT S1AiE ENCNOACHMENi LICENSED CONTRACTORS DEQARATION rq.°F�°�5. cepMiT r�o. SIZE OF LOi NOW pJ lOT I hereby offirm thot I om licensed under provisions of Chop�er �� 9(commencing with Section 7000)of Division 3 of'�,the 8usi- evno�r+ps � nukGes ness and Profassions Code,ond my license is in full force und C+flCf. �r �pNiRACTOR CONNECTION CHARf�[fEE Licanae Number J Lic.Closs � V � �pp�ss 6 �lf a[iMeuas[ r+r�ce Di51RICiNO. GROUV MAP PCOCESSEDBY 0. Contracror �'-DYre crtr �y i.wo. sK vG '�N V ❑I om exempt under Sec. of the L.A.Co. �I�E1r�r�o. � �Q'r Q�ys C� '� /� , _ l eC u�� DESCRIPf10NOFWORK ifE 0 PlumbingCodsond/or5ec. � ofrba ���Py VAUDATION ~" � WVSF SEWEA CONNFCiING TO DAiF � PUBLiCSfWFR B.8 P.Code for ths follow�ng rsoson s�vri ANK.SEEPAGE ilT OR . . � S pw, vrts�r+o.oa ow�nrt�ew wr�ra N Dara �qust SFw[p Ca+r+trnrVC To BY ��y.,� 2 ' i CPIYAT 1 SYST M S19f10�U!! ' CONNFCT ADD1710NA1 BIOG.OR ► OWNER•BUILDER DECLARATION '' wO�+K to NouS[srw[a I heraby affirm rhat I am exempt from tha Gon�rac�or's License F�N.�[E$$pp�,piYWFll��1MN�lKKE / Law for the following reawn(Secron 7031.5�BVii/1e35 011d P!O- �IiER.REPA�R OR ABANOpV/qt15f {lSSiOnS COAR�: . ' SFwE4OR DISVOSAI SYSTEM � ❑I,as owner of the property,or my employees wuh wo9es as � � �O 9 Q 2 A their sole compenw�ion,will do the work and the strocture . #• •�''�'� Q is not in�ended or offered for wle(Section 70�4;Business ' and Profeuions Code). OWNER'S Permit E �U �$� I • �2 7�rJ Q ❑I,os owner of the propeny,am exclusiwely conrroctinq with AUTHORI2ATION TOTAL FEE 7 S� � � •2'],5�� �icensed contraUors�o construd the project(Sxtion 7W.1, i M�VE AT TMR UAiE A CONTRACT w1M illE NEREMI NM1ED CONIPACiOR TO 6us�ness and vroteu�on:Code). ; coNractr rHc neove nexRieeo exanniG owtwrae ro THc vueuc s[w[x. � � 0 fi 2 4—$Jr CONSTRUCTION LENDING AGENCY ' � � . � I hereby offirm Ihat thare is e construclion lending ogency SIGNEDTHiS OAYOf 19_ for the performonce of rhe work for which this permit is �"�p� iuusd(Sec.3097�CiV.C.�. �. OW�45AGENT AODRFSS lender's Name lender'e Addreaa I certify tha�I hove read�his applimtion and sta�e���hat ihe � � . obove informa�ion is wrrect.I agroe ro comply with oll Counly � ordinances and S�a�e lows ragulo�ing Plumbirq ond$ewers, - - . and hereby aut wize repres atives of thia Coumy��o enter opo t e�bav �•me ned �ty for inspection p rposs `� � - , K� y;�Q/T/.f(i � ✓ . iynoWro of Pe�mittee � . 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