HomeMy WebLinkAbout1592A WORKERS'COMPENSATIDN DECLARATION . � '
1 hereby,afiirm thot I have a cer�ifico�e of tonsenl lo self I
. 'insure,or a certiFicofe o1 Workars'Compenw�ion Insurante,ot 76A61X1
o cenified co fhereof(Sec.3800,Lab�.,�. F � �'�IR��8/81) qpp�ICATION FOR PERMIT
Policy No.�Compony � D . - l
❑cs��,r,�copy is hereby furn�shad. SEWER - SEWAGE DISPOSAL
❑Certified copy is filed wirh ihe munty 6uilding inspecrion COUNTY OF LOS ANGELES �BUIIDING ANP$AFETV
de t n 5
Do�e��Applicanl �� FOR APPLICANT TO FILL IN CONNECTION DATA
� � CERTIFICATE OF EXEMPiION FROM WORKERS' ewio�r�c R
COMPENSATION INSVRANCE noocE55 stnrior�t oEMr+
(Th�s section need not be completed if the work involved by the i naN�E REFEffr� �- � � o�R
permil is for one hundred dollo�s(5100)o�less.) ����Tr
NEAREST TYPE OF CONNECTION lENG7N FROM
I ce���iy�ho� tn the periormance of rhe wo.k for which rhis caoss sr. .s y, �pqg p_�, M.l.TO P.L, .
� permit is issued,I sholl no�employ ony persan in any manner p v C.NO.
so us fo become su6jecl to Ihe Workers'Compensafion Laws. owrxe i�/ T` CO.IMO,NO. ' J06 NO. (D} /
� � �'�� �O iRUNK 7FRMIT NO. ROAO VERMIT NO. '
Da1e Appliconl nDoeeiS
NOTICE TO APPLICANT: If, �oAer TOklfl Ih15 Certifico�e Of � /FFIDAVII WAIVER FAYMENT RECORp INSTR.NO. OAIE
( 9 nrv 1fl/+� TE�.�. �' —
�nption, you should become su6ject to the Workers' i�Ai �
rpenaotlon provisions of the lobor tode,you mvst forlhwith orscaianor� LOTNO. {�Wy,pq$T.WI�FNWG
�...mply wilh s�ch provisions or this permit sholl be daemed i
' �@vOkld. � � ' BLOC✓. TWACf StATEENCROACHM[NT �
LI�ENSED CONTRACTORS DECIARATION ryp.pf g�WS. PERMIT NO.
I hereby offirm fhat�am litensed unde�provisions of Chapter S12EOF107 r�owoy ioT
9(commencing wilh Secfion 7000)of Division 3 of Ihe Busi- e itoir.Gs anwc[s
' ness ond Profeesions Code,and my litenae is in full force and �
effect. ��TRARp� CONNERION CHARGE FEE .
License Number��lic.Class w /� qppqE� - REIMg�RSEMEM FEE 0 '
0.
COflilOC�Of���DOIB �`V^V �A DISTQI�t Np. GROUP MqP PROCESSED 9Y V
CITV TEL.NO. d sK vc 2
STAiE � LIC. �/� � Q
❑I am ezempt under Sec. of tha L.A.Co. i���Np, n� V � .
NO. DESCRIP710N OF WORK ffE
PlombingCodeond/or5ac. ofthe F�N"i VAIIDATION d
' F10USE SEwER COIJNfCiING TO {�n DATE p
8:�8 P.Code for�he foilowing reason PUBLIC SEWEC . V l/ •..Z --0 Z .
$FVTIC IANK.SEFP4Gf PIT OR FiNAI
%TS AND/pR IX1AtNF1ELD
DOtE NpUSE SEWFR CONNECfING TO 9Y
VRNqTE DISVOS4l SYSiEM '
Signoruie caNr�cr nooinowa�oc,oc D .
� OWNER-BUILDER DECLARATION wanc ro Housc seweR
WEffIOW SEEPAU[%T.DRAMFIElO
I hereby oHirm thaf I om exempt from the Controtlor's License exTr�,cessroa.oavw[u,nuHHae � - .
lnw fo�1he following reason(Secton 7031.5,Buisness ond Pro- AUFe,REvaa oR w6�.NDOrv HouSe � � I 5 9,G F
�•j011SCO(IC�: SEWEROR�I$iOSql5Y5iEM „. , . _._ '
, 11,as owner ef the properfy,or my employees wilh woges os .f�• • • � �
thair sole compensation,will do the work ond�he strvclure � ' � - "
is no1 intanded or oHerad for sole(Seclion 7044,Business �A�^z 7�.�.Q
ond Proiessions Code). OWNER'$ Permii S (O S
❑I,as owner of the property,am aKclusively contracting wi�h AUTHORIZATION TOTAL FEE � " ° •��,5��
Ii[BIISBd fO��10t101E 10 COfIS�fUC�(h2 PlD�BCf�SBf�1011�044, �HAVF AT THIS DAiF A CONikACi WiTN THE NEREIN NAMEO CONTRACfOR fD p yy
B�SII1B25 011d PfOI25510f15 COdBt. CONN[Cf THE ABOVE DESCR�BEO EXISTING DNFLL�NG i0 TII(PV&I�$EWE4. O 1.t7 2��,G
CONSTRUCTION LEND�NG AGENCY � � ► � -�
I hereby affirm ihol ihere is o construcfion lending ogency $IGNED7HI5 �AY F�_19�
for the performonce of fhe work for which rhis permit is °w�''fR°R . � _
issoed(Sec.3097,Civ.C.). owNeesac�r+r A
ADDRE55 K .. .
lender's Nome � ,
Lender's Address � '
I cerfify ihal I hove read this applicafion and stofe thot Ihe ' �
above informotion is correct I agree�o romply with oll Counly � �
ordinonces ond Staie laws regulal(ng Plumbing and Sewen,
ond heraby au�horize represematives of this Coumy to en�er � . . - �
upon fhe above-menlioned properfy for inspetlion pvrposes. .
��iu�w►e�- Q—d r�'G
Signature of rmiNee . Dote ' SEE REVERSE FOR EXPIANATONY LANGUAGE
� �� �
. - � � ; �4 4k�x (� � � �
>n vZ
T� � � � b
l�J� � � s G '��{ �,p�� G� �
� ' `�J , , �� 3�� vA ❑ �x Q�OO N �
. •�., �y �c��i � �a ,go � 70
� �Z �SD v`� �c2y A O
�` �"N eT� �� op b9 F �
, �O '° �'° � �
v� F ' fI�
Y 0 ❑
7 �
M ,
f� \
]OO �� . •� � D S�
V�
Z -i
� '
N ' ' " .i , � , N
• ' `� -� O
�
N
N
• � (Z�l
� �_, n
, , c
�
�_ .. '. . ' . " _ i '-
- � � .
� .
_ .� � � � �� - .
� _ •
- .. I . N
�I . i . � .- ._ . ., .. n
� 1
� " _' • ' �
. � � �
:J� - � O
- . _. -�
, • . m
� - N
I �
� _
bo ^ ° '"'�'4�er `a Sc.a-tn^�a " ° c.g ta C
• �. lb� ��' O�b..pa ��0o-a � �•� � � � � X�'� a, .
, ' ' � y� � �on�,xc, g � vr+'�x^ 7'6m � �'�n �•Q � � � �
t3 f'"9 �°' � '9 7.?.00 ��t.'',q.Z � C.���R � � $r,S`p t'"ae
�°� z
. (� � �p E,oa � � �ar� +a� ��,�'y����. � �-s �g � trJ
+ �� $�+ � �' �• � m
i ,,,,� � �$��3' ���� n � ����, ��. �
� � � � ��w� 8 � � M � � � �p� ��� s
_, � py _ �� � g��a '^»"o��• ��^����� !"
i ��OR "'�,, � g'�'N „ �� C
; . • � :, � ,� � .�'� � ���� n�� ` c n� � "��
� ,� «� ���a ���8 � ���°� � ;.� .
� �b
.� � �»��.$� � ��,�'�� •��� � ,rn-
i � ����� ��� ��. ��� ��
- � ; . ` . $'g�;-�"'*°" S n�c �,��'���.� ��2q E � .'
. 4 �� ��� E � ��
' ��'s '��4 ��'� 3 $ :px�.n�"� .$ �5' �'
. � . . . . .i� - �p. �p.i'�A �' � a il W�w� � Om O .
� ' • �� 6� 1r � �aQ� O ti.�•�� ya� 2. .
1 1 � �w e'�'! x y �"O
- . . " 4 .oQ'..m�o � � ��.�� �'�eo-cW . ��^a