HomeMy WebLinkAbout1593A � � WORKERS'COMPENSATION DECLARATION �
I hereby.offirm that I hove o ceriifiwle of mnsem m self �
. 'insure,or a certificate of Workers'Compenwfion Insurance,o� �aneeso
PoliMcylNo. h re o5 P.�n�.�a`�.,F�� ���RE�.B,B,> � APPLICATION FOR PERMIT �
. ❑Certified copy is hereby furnishad. � . SEWER - SEWAGE D15POSAL _ . � �
❑Cert�fied mpy is filed wirh the couny build�ng inspection COUNTY OF LOS ANGELES ?-BUIIDING;AND.SAFETY �
depart a t.! / � ��
Dare,9��l�npplicant T����Yl ArA/ � FOR APPLICANT TO FILL IN - CONNECTION DATA . -
I CERiIFICATE OF EXEMPfION FROM WORKERS' euno�nic sranaw otvrH
COMPENSATION INSURANCE ApORE$S
(Thh sact�on need not be completed if rhe work Imolved by rhe A hMNlplE REfERENCE ��R
permit is for one hundred dollars(=100)or less.) �°UUT� w
I cer�ily that in the performance of the work for wnich �his CR�Ogssi TYPEOFCONNKTION t[rv�THFapm �
V. CURB P.L M.L.TO P.t.
permit is issuad,I aholl not emplay any person in any mannar p�� q p �/
. so os to becoma subjeti to the Worken'Companwrion Lows. owr�e CO.IMP.NO. JOB NO. {J�G O J '
��� TkUMf PERMIT NO. ROAD ffRMIT NO. "
Dafe Appliwnt AOONE$$ t �
/�^ �� AFFI�AVIT WAIVFR EASEM[Ni RECORD.INSf4.NO. DAiE
NOTICE TO APPIICANT: tf, oher moking ihis Certificafe of aiv Tei.ra. ��
� l'�vmption, you should become subject b the Worken' itiµ �
� �pensation provisions of the Labor code,you must forthwith orscnivripa �orr�o. � nwr,qe st.wio[wr�
...mply with such provisions a this permit shall be deemed
� revaked. � . etOCx iksci STAIE FNCROWCNMENT
� �' LICENSED CONTRACTORS DECLARATION �'+�.a Ws. OER1N1T`'p.
. SiZE Of lOT nqw p.��pr
. I hereby offirm Ihat I om licensed under provifions of Chapter ��� .
� 9(commencing wifh Section 7000]of Division 3 of the Busi• g�iipi�5 j aAac[5
� ness and Professi �d�my license is in full fwce and
affacr.� O/ CONiRAROR CDNNFC�IpN CHAR[�F(E T
d
licenseNumber ,��f Lic.Closs `, (� �qE� RFiMBl1R5EMENTFEE Q
- COlf�fOCtOI �! MWI��/'M� �OfB � �Y_Q++ � CITT � iEl.NO. I DISiRICENO. GROUP MpG PRpCE55ED8Y V
BC PG Z
❑I am ezempt under Sec. � of the LA.Co. ��ry�� �u� ,Q O
V
Plumbing Code and/or Sec. of the NO � ��� O� K �E DA E� VALIDATION i
9 , IAUSE SE WER CONNECTIwG TO p �`L�_�J
Pll&IC SEWER / Z
B.8 P.Code for the followia reason gp���i�NR.SEEPAGE DIT OR
vif5 ANDiOR D17AiNF�ElO ��l
. _. . D019 11DUSE SEWER CONNECT�NG TO BY
- PRIVI1iE D15NSFl SYSIEM �
$igna�ure CONNFCT AODITIONAI&DG.OR ► .
OWNER•6UILDER DECLARATION `^'�To�+ouu s�w�R
oveartow s[[vnce ort.aeRi�u�eio
I hereby affirm tha�I am exempf f�om the Con�roctor's license exTr,,ce5.5vOa,uQrwn�,+ro�rn�o�[
CLaw for the following reason(Secton 7031.5,Buisness ond Pro• u�a.R[r�ia at�e�rooN�ause
'�OnS COdC): 3FwER OR D�SPOS4 Sv57EM �1 5 9,3 A
�.�I,as owner o(the proper�y,or my employeea with wages as
�heir sole compenwiion,will do the work and the slruUure'� . �t' ° •-• � �
is no�intended or offered for sala(Section 704d,Business
and Profassions Code�. OWNER'S Permit S Q I A o C��Jr�
❑I,as owner o(the property,am exclusively controctin9 with AUTHORIZATION TOTAL FEE �
licensed contraUors�o construct�he project(Seclion 7044� � I HAVE AT TMIS DATE A CONiRACI WITH ME NEIIEIN NAMEO CoraR�aoa to . ��n'7'�`��
� Business and Professions Code). � corarxcr rue neov[pescqieeo exisrnue owEuiNc to tHe vueuc stwea. +
CONSTRUCTION LENDING AGENCY � .I� Y�(/_ � � . �S�'�I 2�F b
� I heraby affirm Ihaf fhere is a conslrucfion lending agency SIGNEDTHIS �AYOF �En1 19(L ,
for'ihe performance of the work for which this permit IS ' �'NfR�R
� " issued(Sec.3097�CiV.C.J. OWNERSAGENi
AOONESS
� Lender's Noma �' •
• Lender's Address �
I cartify that I have reod this application and srote Ihat the
�� above information is correct.I ograe to comply wi�h all County .
ordinancas and S�ate lows reguloting Plumbing ond Sewen, �
and hereby authorize representatives of Ihis Counly lo enfer � .
upon the obove-mentioned proparty for inspection pvrposes.
cbdaw��u.manv 9�-a-A-b
� Signature f Permittee Dale , SEE REVERSF FOR EXPIANATONY IANGUAGE �
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