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HomeMy WebLinkAbout1456A (8) � � WORKERS'COMVENSATION DECLARATION - . , I hereby a/firm tha� 1 have a ce�iifico�e of consant�o self �insure,or d'certificate of Worke�s'Compenwtlon Insaronce,or 76A6RD ' i� j a cenified co y thereof(Sec.3800,Lob C.) �E e�9�°E�.,,e�, . APPLICATION FOR PERMIT Policy No. �B ZOCompany �u'f'.. Fi111(� ❑ee.+�i��a��v ia hxeby fumiehed. '- SEWER - SEWAGE DISPOSAL � �cen�f��d�oPy�e f�ied wi�h the counry building�m��ro� COUNTY OF LOS ANGELES BUILOING ANO SAFETY deportment. oo�e $/?6/.$�4ppl�ca�� T_ FTeem2ri FOR APPLICANT TO Fill IN CONNECTION OATA � . , � CERTIFICATE OF EREMPTION FROM WORKERS' g��ipi� . COMPENSATION INSURANCE �ooacss srnrror+ oEvrN (Th�s�ecaon need not be comple�ed i(the wwk involved by the MpNNpE pEpEpENCF . �R permil is for one hundred dollor:(SI00)or leas.)� tOUt1ry R rEAREST 7YVF OF CONFkCT10N ��7�{pRdyy� 1 cer�ify tho�ln�he performance of�he work(or which�his �rtass sr. r. curte P.l. M.L.TO P.l. permil is issued,I sholl not employ any penon in ony manner P�� v��i so aa to become subjecf�o the Workers'Compenw�ion:tows. p�q �d co.o.w,ta0. �oe r+o. � d " ' ' � ��� TRVNK PERMII ND. ' GOAO iERM1T NO. pnle ' Appliconl �. ' �� A00REu - . NOTICE TO AVPLICANT: If, ofrer makin this Certifica�e of A�ria�wr wuvEe E MENT wtcoco.naSTa.rJo. o.�t[ g' CITY TEL NO. � �ion, yo� should become subjecr to the Workers: nsolion ro��sions oF the tobor code, ou m�st lorrhwirh ��a� P Y oFxeivr�OFt lot No. Hwv.oa 51.w�oFwNG c..mply with suth provisions or this parmit sholl be deemed � revoked.� ' � " � � � &OCc TNACT SfATEENCQOACHMENT � LICENSED CONTRACTOR$DECIARATION . v[aMit rro. S�ZE O�lOi NOW ON l07 I hereby otf�rm that I am licensed under provlsions of Chopter ��� 9(tommencing with SeUion�7000)of Division 3 of�he Busi- . eunortacs anxts ness and Profesalons Code,ond my license is in full fwce and BRBCt. 7 �7 � C0�1TR4ROW BgID CONNECi1pNCHAYp[F{[ LicenseNumber�I���1 u�.eia5s � C34 pppREu p22J Beechwood Dr• RFIMBURSEMENTRE y . �1�. 8�26/86 �i5lqiCE NO. GRWP MAV PROCESSEO BY O COIIIlO[�D�T• CieP.m� DOI! CITY �.�� BK 0( V ❑I om exempt under Sec. of fhe L.A.Co. ��Ny r,q �iAu /� O ��PlumbingCodea�d/w5ec. ' oflhe �� DESCR�vr� wORK �e ��Hq` V . wvs�s�wea eo�cr�r,c ro 1 OO on� 2��2_ VALIDATION 6 B,B P.Code for�he(ollowing reason �u&��s�u�R . SEOTiC iAN[,SEEVA�YIT 04 � VI YITS ONp/�Q ORAIl�f1ElD FINAL - ' Z �OIB IqUSE 5[WFR CONNECTING 10 Bv � - � PRIVAiE DISPOS�I SvSTEM � Signature coNN[cr�minowu&oc.oc � � OWNER-BUIL�ER DECLARATION �+'omc To Nous�s�wea 1 hereby offirm fho�I om e.empr from the Controc�or's license E�NF�CESSVOOL.DR%YNtILAMAN�1101F Law for tbe foilowing reason�Secton 7031.5,Bulsness and Pro- aitrt,rttr�iR oa�Bnnoor+wus[ , �� 4 5,b� • �ons CodeJ: 5[w[R oa aioosui srsnM � owne•ei�Ae��F�•�•, ploYees wi!h:voges o: H • • • 1 U �heir so�e compensotion,will�do�rhe work and the strocrvra is not inrended or offered for sole(Sedion 7041,Business 1 " '2�J� � and Profess�ons Code�. OWNER'S Permif f ❑I,as owner of the property,om e.clusively contracting w'�th AUTHORIZATION TOTAL FEE •" e'�,J n� IIClf15�CI CO!)f!O[IOfS ID COIISIIVCi�FIC PlO�BCI(S9C�i0I1�QIA, I HAVE AT TNiS DATE 0.�pNiF��T WITN TME MERFIN NAMED CONIRAC�OR LO Business ond Professions Code). ca+NeCt ru[awvt axcieto ezisrn.w owtwwe to t�+[vuauc sew[rt. � ��.2��8 6 ' CONSTRUCTION LENDING AGENCY I he�eby oNirm Ihat there is a consfru[tian lending agency SIGNEDTHIS � DAYOF 19_ ► � � for Ihe performance of the work for which Ihis permit is O�FRqi �_/�_ _� , issoed(Sec.3047,Civ.C.). a�psnctr+i �� - --= . . ADDRESS ��P-� ' �� ✓ lender't Name lender's Address - . I certify that I have reod this applicofion and slale Iho1 Ihe obove inlormation is co�ract.I agree to comply with all Covnty . o�dinonces and Slale laws reg�la�ing Pl�mbing and Sewers, � and hereby authorize represanrolives of this County to eNer � upo�h obove-mentioned property for inspec�ion p�rposes. 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