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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 � $igna�ure CONNFCT AODITIONAI&DG.OR ► . OWNER•6UILDER DECLARATION `^'�To�+ouu s�w�R oveartow s[[vnce ort.aeRi�u�eio I hereby affirm tha�I am exempf f�om the Con�roctor's license exTr,,ce5.5vOa,uQrwn�,+ro�rn�o�[ CLaw for the following reason(Secton 7031.5,Buisness ond Pro• u�a.R[r�ia at�e�rooN�ause '�OnS COdC): 3FwER OR D�SPOS4 Sv57EM �1 5 9,3 A �.�I,as owner o(the proper�y,or my employeea with wages as �heir sole compenwiion,will do the work and the slruUure'� . �t' ° •-• � � is no�intended or offered for sala(Section 704d,Business and Profassions Code�. OWNER'S Permit S Q I A o C��Jr� ❑I,as owner o(the property,am exclusively controctin9 with AUTHORIZATION TOTAL FEE � licensed contraUors�o construct�he project(Seclion 7044� � I HAVE AT TMIS DATE A CONiRACI WITH ME NEIIEIN NAMEO CoraR�aoa to . ��n'7'�`�� � Business and Professions Code). � corarxcr rue neov[pescqieeo exisrnue owEuiNc to tHe vueuc stwea. + CONSTRUCTION LENDING AGENCY � .I� Y�(/_ � � . �S�'�I 2�F b � I heraby affirm Ihaf fhere is a conslrucfion lending agency SIGNEDTHIS �AYOF �En1 19(L , for'ihe performance of the work for which this permit IS ' �'NfR�R � " issued(Sec.3097�CiV.C.J. OWNERSAGENi AOONESS � Lender's Noma �' • • Lender's Address � I cartify that I have reod this application and srote Ihat the �� above information is correct.I ograe to comply wi�h all County . ordinancas and S�ate lows reguloting Plumbing ond Sewen, � and hereby authorize representatives of Ihis Counly lo enfer � . upon the obove-mentioned proparty for inspection pvrposes. cbdaw��u.manv 9�-a-A-b � Signature f Permittee Dale , SEE REVERSF FOR EXPIANATONY IANGUAGE � y,�w dnmo� v� �,� '9 'o� �' ' �� �� ,�'w �'3`�'� ,� � ��..$�� � � �' Z �eo � �• "�8�'M3�'�• �d .'" ..$ �,�•� - i - \ O � •� � sR� .x� � � o,� b' � � . �;'i O. � ',�" $`� 4.�M ir ,� � � �� " .- . � �'�,� C�: .$ � � ',g �,�.� � . ��� �e 4 , �ad�� �yS ���s �C�.�,�•� , % , �. c � ' ,�33 �'� � � ^'�' � ' �� �. , � . V - � ���� ��s� �k� $.�„��� �. . � , Q . ��� x ��o�a �� ��y � y .�, . . . tx �. � s �.n�"$���������� �'y. 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