HomeMy WebLinkAbout1590A (9) � +rv�ncKa �umYtNSATION DECLARATION � �
I hareby,offirm that I have a ceriificaie of consen�fo self .
. 'insure,or a cerfificote of Workers'Compensotion Insuronce,o� �b1e'7p �
-0�a.�;f;�,�o �, of Sec.9800,L b C. CEBOB�REV.B/el) qpp��CATION FOR PERMIT �
Pa���rNo.yZ�Company ��F�+v� �� SEWER - SEWAGE DISPOSAL
❑Cer�ifiad copy is hereby furnishad. .
❑Cartified copy�s f�led V.i�h ihe county building inapenion COUNTY OF LOS ANGELES BUlLPING'AND SAFETY
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��a�APP���o��—/1��'�--��`�N FOR APPLICANT TO FiLL IN CONNECTION DATA
CERTIFICA7E OF EXEMP710N FROM WORKERS' ��i°i� •� �
COMPENSATION INSURANCE nwacss SUTION OevtH �
(This secfion need not be completed if�he work involvad by�he M4NHOLE REFERFNCE �� � U�ER
permil is fo�one hundred dollars(SI00)or lesa,)
�oc4utt t c
I certify fhai in fhe performance of�he work for which ihis �RasssT �,,N cra�occoNk[cnori �r.�THF�an
Y. NR8 i.L M L TO P.t.
permil is iuued,1 shali noi employ any person in o�y manner P.C.NO. /,� GJ
sa as to become svbjec�fo the Wo.kers'COmPlIISa�iOn GdwS. �R CO.1MP.NO. JOB NO. /V�D�
��� TRf1NKPERMITNO. ROADPERMITNO.
Dote Appliton� a�u
NOTICE TO APPIICANT: If� Of�01 makin���his Certificole Of' AFFIDAYI7 WAIVER EASEMENi RECOA�-INSIR.NO. DATE
g CI7Y 7EL NO.
' �p�ion, you shoutd become subject to the Workara' tE�at
pensaiion provisions of�he labor code,yov must forthwith� cescaim�ora LOT NO. HWV.pRSi.WIOENiNG
��„mply with s�th provisions or ihis permit sholl be deemed ^�
f9vOkld. � � 6LOCK TGACT / S7ATEFMCROACHM[NT
' �.a& GE4M17 NO.
�� � LICENSED CONiRACTORS DECIARATION sze oc ior rqw pm ior�
I hereby offiim iFwt I om licenud undar provisions of Chapfer ��
9(commencing with Sectiori 7000)of Division 3 of fhe Busi- eviioiHGS �qq�s
ness and Professions Code,and my licenu is in fuU force ond .
. BlfeCt. CONNER�ON CHARGE iFE
CONTRACfOR r
License Number�17Y�7 Lit.Class �'
//���Y_ I /} Q ADWtES$ � RFIMBURSEMENT FEE O
COf1hOC�Of Tn`j��/ DO�R y��`�il �/ 'L �bTRICT NO. GROUP MAV PROCESSED BY V
1��'��"�-_'"� S CITY � 7EL.N0. �I� Z
BK a'i ZO
S7ASE L1C, '�
❑I om exempt under Sec. of 1he l.A.Co, ucEus¢NO. � a�55
" PlombingCodeand/or5ec, ofthe �'�O� �5 RIPTIONOFwORK �e FiNq� � �j 'i
NOUSE SEWER CDNNFRING TO � R DAiE �l Z�^�I VALIDATION y
B.8 P.Code ior the following reason oueuc sevrtv ' V � N
SEoiIC 7ANK.SffPAGE PIT OR fiNAL Z
i1i5 AND/pQ pp4M��E10
Daie �5[5[wER CONNECIING i0 BY �
' raiv�re oisons�i sv rF.v�
Signar�re � corr�cr Aoomonui�oc,oc �
OWNER-BU4DER DECLARAiION �K to�aus[s�wEx
OYERFIOW SEFPnGE PIT,ORAMFiEL�
I hereby affi�m�hat I am exempt irom the Cantractor's license E%TN.,CESSAOOI.DRri+FLL.MANMIXE
�nw for the following reason(Sectan 7031.5,Buisnass and Pro• ur¢¢,cev.ia oa nannoor�rrous� � � � �
��OnSCOdEJ: SEWER04DISPJSAl5Y5(EM , ,
1 �is9aa
.J I,as owner of fhe property,or my employees with wages as �
their sole compenso7ion,will do thx wn.k••nd!he shuctur� � }j�� � � � Q
is no�iNended or oHered for sole(Section 7044,8usiness
and Professions Code). O�VNER'S Permit . s d y .- - � . i�•�.2 7,5 a
❑I,os owner of the property,om excl�sively contractinq with AUTHORIZATION TOTAL FEE C 1
licensed tontroclors lo constivcf fhe project(Section��4d, I NAVE AT THIS DAiE A CpNi4ACT WIM TNE HEREIN NAN.FD CONIRACiqi TO � ����'J O�'',
BUSin055 Ond P10I25510114 CO(�0�. CONNECf iHE ABOVE�ESCRIBED EXISTING OWEIIING 70 THE%1glK SE`�/ER.
CONSTRUCTION tENDING AGENCY " C3�� ► Q���`8 6
�I hereby oHirm thal lhere is a cons�ruclion lending ogency SIGNEDTHIS DAYOF 19p� "
!or the per{ormonce of the work (or which Ihis permif is ��R� ���
i55Uad�$e[.3097,Civ.C.�.
OWNERS AGENi �
ADDRE55
Lender's Nome �
Lender's Address - � ��-
I certi(y fhm I have.eod fhis opplicorion and stote fhof fhe � .
above informafion Is mrreU.I ogree lo tomply wi�h all County ' ' � - I
- ordinon[es ond Siafe laws regula7ing Plumbing and Sewers, � �
and hereby ou�horize representalives of fhis County fo en�er � � �
upon the obove-mentioned proparty for tnspecrion purposes.
���,�,�,�,K, q—a—�G i
Signofureo Permdtee Date SFEREVERSEFORE7(PIANATORYIANGVAGE j
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