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HomeMy WebLinkAbout1126 (5) I WORKERS'COMPENSAT�ON OECLARATION '. � � � � I�her�4y ai8rm thot I hova a certificafe of mnseN 10 self � ' �ineyre,or o certificale of Wwkers'Compensmion II15u�OMe,O!�� - 16A6�]D , . .. . - - o cer�ified copy thereof(Sac:3800,Lab C.) «°����.e,e"� . � ....: . : .APPLI�ATION FOR PERMIT � � Policy No. ' Company �� � , ,,. . . _ ❑Certified copy is hereby fomishad. • � ' . ; ..- SEWER_` SEWAGE DISPOSAL . _ �.Certifed copy�s t�led wi�h the counry bui � c��o COUNTY OF LOS ANGELES BUILDING AND SAFETY dey�r�tm�e�L��,,� � . . �me�npplica�t ��! FOR APPIICANT TO FILL IN . CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' eunar.� L� / . . � � �� COMPENSATION INSURANCE - - - . nooass � STAiION� � OfPiH � (ihis section need not be completed if�he work involvad by the i���i� � - � �y,N�a¢REr�r�[- � � �°� permit is for one hund.ed dollon(5100)or Isa.) t.EANEST . t� � � rrvcoFta�ctqr+ �pqTH Ff10M I cert�fy that in the performonce of the work for which ihis � cRoss sr. ' � r. cuee o.�. M.t.ro v.t. permit ia issued,I sholl not empYoy ony peraon in ony mannar / � P�� ao os�o become subjeU ro the Workeri Compenw�ion laws. pw�a �+'LL CO.IMP.Np, JOB NO. � � • . .. . . lMll •� •. G', � ... TRl/NK PERMIT NO.' ItOAO PERMIT NO. Daie Applimnt noo�ss G NOTICE TO APPLICANT:-If, aNer makin this Certifico�e of- � �{/� 3�— A��io��it wnirFa e�Se�Nr RECORD.INSiR.NO. DATE Q CITY 7E1.NO. Esemp�ion, you sFould become subject to�the Wwkers' ��� Compensafion provisioes of the labor cods,you mwt fonhwi�h- pescar�iot� � - iorNo. � � - Hvn.oa st.wio[nuNc , comply wirh such provisiona or this permrt shaH�.be desmed . , flVOksd.' ' - - . D�OCK ' iRACT STATEENCROACMMENT ND.Of&DGS. PERMIT NO. � LI[ENSED CONTRACTORS DECLARATION � sae ov�or: Now orr ipr I haraby affirm that I om licensed under provisions of Ghopter� - �� , 9(tOmmencinq with Section 7000)of Diviaion 3 of fhe Busl- , Ouito�NGS' d�RGES nesa ond Professions Code,and my licenss is in full twce and � - � !HlCf. 7 �7, ' [ONIRACTCR ��• CONNECTION CHARCE ffE �. LicenseNumber 4V' Lic.Clau � y- . ��u � ��� QO l RFIMBUNSEMENTf(E O � COMfaCI tC //) Di5iM10E Np. GROUP MAP PROCESSfD 9V V ' `' CIfY� ('/ � TEl.NO. _ / ^� BK PG ❑1 om exampt under Sec. of the LA.Ca iI�E�ep.Zt/ � �L,iss Z � tV 1/� C� � Plumbing Code and/or 5ec. of�he niO' ��KR�PTbN OF WORK �E nNu � y W� M7VSE SEWLR CIXJNECfING T0 . . DA1E � � � VALIDATION 0. - B.�8 P.Code for tha following reaeon PVBLIC SEWER w . s�vr AWf.SEEP�GE PIT OR FiNa - 2 .. Y�16 AND/OR DpA1NFIflO - DotO •. MOU$E$EytER CONNERMJG TO BY . wi E a svsr S �L $ignolure�- - CONNECi ADDIiIONAt&OG.OR � � � � OWNER-BUIIDER DKLARATION W°�T°i'°�s�S�w�R NFl W SEEP PIT,pRAINflEID � I hereby affirm thai I om exempl from the Conhatlor's License � exrr�..ct55roa,oRrwtu.MnNNa[ � ,. _ . . . . ... � �,.� Law for tha following reoson(SeUon 743I.5,Buianess ond P�o- uhn,aeveic at ne�r+oor+Housa� feasions Code): . s�wm oe oisrosni srste,�t , _ � . ��Q ❑I,as owner of�he property,or my employeea with woges os - �heir sole compenaation,will do Iha work ond the sMucWre -�� ' � ' "' � ' � � " " - � 5`,�D � is not intended or oHarod for wle(Section 7044,Business _ and Profesalona Code�. � OWNER'S Permit S � ('���_ ❑I,as owner of�he p�operty,am e�dusivaly ton�roUinq with AUTHQRIZ/�TI�N TOTAI FEE 4 . Y �� liCensed contracfon�o cons�rucl the�ll0�9C1($eCfi011 7Q04. - � � �H�H[AT iM5 DAiE A ODNTRACT WITH ME ME4EIN NM1E0 COMTRACTOR i0 � - � Busineu ond Professiona Code). covr�tt tne naove oescRieeo ex�snwc oweiur�c to Tr�Puaue seweR. . CONSTRUCiION LENDING AGENCY ' � -�- ��- - � " . � � - � , � " " � 1 hereby aHirm fhal there is a conslruclion lending ogency SIGNEDTHIS DAYOF ' 19_ ' for tbe performonce of the work for which this permit iz� - °wr�Ra+� . - ' . .�_ . . � . _ . _ - OWNER$AGENr i35UCd�SCC.3OYI,CiV.G.�. , ...... �ookess ._ . .. . ... . . . Lender s Nome lender's Addiess . . . .. . . . . . . ".. . � . . . . . . ' . � I certify thot I hove read this opplicofion and a�ate that�be � � � above'nformation is cw�act.I agroe comply wi�h oll County . .. . . : .._ .. . .. . . � .. . . .. ordi ces and St ulat' g Plumbing ond Sewere, � - � on reby aufh i e entaf es of fhis Counly lo enler . . . .- ..: --.. ... . . . . � . o th a ve �o op , fortinapeUio purpotes. � ' � � nalure of Permittee DaM �� - �SEF REYERSE FOR EXPUNATORY LANGUAGE , .�:.._. . . ... ._..� . _'.._. — �...-.,r."ti. . , . . . . ._� . , ,\' . . � .. . . . -`, . . . . . '� , � � . � . .. .. . . - , ����1��� . . SaQA1�_ ._ . .. . . . . _. . _ ' � i . . ._.. . _. - - ' ' ��. � a1BQ'� ` � . . � , .. . . . . . . . ._ _ ,. . .. I, OOSBa3 9[t�3 d0;�.7�d�S�� � � ' , . .. _ .. . . , _ _ ' �'aapmt�dear:►me T . , , ', . 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