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HomeMy WebLinkAbout1589A �WORKERS'COMPENSATION DKIARATION . ' I hereby of{irm fhot I ha�e a certifica�e of ca+sen� �o sel( I insure,or a'certiiicate of Worken'Compansolion Inwronce,or ��eaba7o , ,� � PolkyfN��Cosmpan� `�b�'�,�,w� �EBOBIREV.1/BJ! APPLICATION FOR PERMIT ❑�r rtified copy is he�eby fu�niahed. � SEWER - SEWAGE DISPOSAL� � Q'Ceri�fied copy�s Filed wirh�he counry build��g��apecuon COUNTY OF LOS ANGELES BUILDING AND SAFETY d rr en� �/ ��� APP���a^� ���'Try fOR APPLICANT TO FILL IN CONNECTION DATA . CERTIfICATE Of EXEMPTION FROM WORKERS' p�i�pi� � � . COMPENSATION INSURANCE � � �oorttss D srnrioN otviH (This section need not be compleied if the work Involved by ihe i�i�T� .^ MANNOIE REFERENCE - VPPER permit is for one hundred dollora(SI00)or less.) , � iv�'' ��R — I certif tFwi in the erformonce of the work for whith this �°'�sr —_ l , rvceorca+r.�KiwN ���F� Y P C40551T. j �/V/{/ Y. CURO PL M.LTOP.L. pe�mit is issued,I sholl not employ any person in ony ma�ner so aa�o bacome subject to�he Workers'Compensation taws. / °��'�� Q y�� . , owNEa [y� 1 CO.ivs.NO. 106 NO. � . � , M41L O � iRUNK KYMIT NO. ROAD VERMIT NO. Date � Applimnt ADDRE55 c NOTIGE TO APPLICANT: If,;ofter moking this Certiiicoie o( ntr rEi.r�o — (�� "� AFfIDPV1! WAIVER EASEMENT RECORD.INSiR.NO. DAIE � -�ption, you should become subjeU �o �he Workers' ensation rovisions of Ihe labor code, ou must forthwith ���� P P Y oescaictiow iot ruo. Hwr.Oa sT.wiotNnae i...nply wilh such provisians or this permit sholl be deemed / IlVOkBd. BtOCK iRA[T m/ SiNiFENCQOACHMENT LICENSED CONTRACTORS DECIARATION ' ^'�.a etas, ffRMir r�o. SIZE Of LOT NOW ON LOT I hereby offirm fhot I am litensed under provisions of Chapter �� 9(commencing wilh Sec�ian 7000)of Division 3 of�he Busl- eunomws i p�axc,�s ness and Profesaions Code,and my license is in full fwce and BfSBU. CONT4A�'fp4 CONNECTIpN CHnRG[F{E License Number�7/�7 �I�.��pi5' c3y pppqE55 E � q[IMBURSFNfN(i{E d ConlroClorT�'��fAiM� DOfG �_��T G C�TY '1'�► TFL.NO./I �J� �. D�Si4KTN0. GPOUv ,MpD VROGESSED6Y V BK �C h ❑1 om exempf under Set, of the L.A.Co. ii�ErnSE r.q �i u {O ,��� � ' PlumbingCodeand/or5ec. oHhe �' �xp��TIqJOFWORK �cF rwn�� V:,• O w�s�s�wen caJ.�cr�r�e ro oa DATE Iz� Z� VALIDATION 4 B.d P.Code(or ihe following reason °p�����R SF IC T4N[.SEEGAGE RT pR FINA� Z VITS M1D/OR DRAINFIELD D01G MpUY SEVIER COMHfCTING TO BY ' GGIVA7E p5PO5LL 51'STFM Signature . Wrrtact noorciawt e�pc.ort � OWNER•BUILDER DECIARATION `MOkKT0110U5E5fWER OVERfIpW$FEo�GE ni.DY�IHFqID I heraby affirm�hat I am exempl Trom the Contrador's License . [xrv.,assot70�,perweu,nv.alloic Low for the following reason�Secfon 7031.5�BUISl1QE5 ORf�Pf0- N�ER.RFP�IR OR AB�N001�HOUSE ' '1o�s Code): s�v.ea av wsnos�i svsreM �1 5 8�9 A _.�I,oe owner of the property,or my employees wi�h wages es �• • • •� C I the�r sole compenso�ton,will do+he work ond the structore �� ia no�infended or offered(or sole(Section 7044,Busineas � � • °2'].S� and Profese�ons Code). OWNER'S Permif t � ❑I,as owner of�he propnry,am exclusively contratring with AUTHORIZATION TOTAL FEE • • •2�.5�� litensed contractort lo construct Ihe projecl($eclion 70a4� �NAV[At THtS D�TE A�ONiYA�i wliH iHE HEREIN N�MED CpViRACTOR ip Business and Prafessions Code). Co�+N[Cr rNE aeo�t p[SCRietp existu�c oxfwrrG To tH[nuetic stwer. . O 9�I�2�B 6 I CONSTRUCTION LENDING AGENCY p{ ► I I hereby aff�rm ihat there �s o consrroc�ion lending agency SIGNEDTHIS onv iqor for the performonce of Ihe work for whith this pe�mil is �"�R� OWNfRS/•GFM i iss�ed(Sec.3097,Civ.C.). AODYE55 Lender's Nama . � Lendei s Address � ' I cartify�haf I hove read this opplicotion ond sto�e fhat the � above Infwmotion is corrotl.I agree to comply wi�h oll CouMy � - � � ordinancas and Stote laws reg�loting Plumbing and Sewers, �' and hareby a��horize represematives of�his County�o anrer � upon fhe above•mentionad proparty for inspet�ion purposes. � � . ��,� �a-�� . Signatura f Permlltee � Dote SEE REVLRSE fOR EXKANATORV LANGUAGE ' � ' . . . . • . �' . . . . . , '.' .. .. ' ;G� rv Nr. m Ds,; rnn M . i' ' o�� D}�i }.� Zo �O . ' I'. ' . . ' . . i ZO )n >D Un �7 � . . .. � ' . ' � ' . �" �7z �^'° CJ N� 7n n , I . �' 2� �D oz pr � 'tl i � �i y • � : ' i ' � � . , ' �Cf C� c�iif ❑ Zr f� S � . �_,� ' ' . � T�y ^'"t ��} � "' G�. � � , , j: � - . � . . .. . �, T �T H'� 'O C'n �� G ' " ' • �O " `^° .s '" D � ' �'._'_•• .. . . . } N . N � , , ' ` . , ,�1 ` i ❑ ' � ,� � � ; .' . , � 7U • � ' O . ' N ."" 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