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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 . 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