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HomeMy WebLinkAbout1455A (8) . WORKER$'COMVENSATION DECIARATION I hereby affirm �hat I have a certificoie of consene�o self }1 ,insure,or'a certificale of Workeri Compenfnlion Insurance,or ]dn6<3D . I� Polcr"No����f(Sec.3800��:�.�d CE8091REV.1/B3� APPLiCATION FOR PERMIT � y Company ❑Certified copy is hereby furnished. � SEWER - SEWAGE DISPOSAL� � � �Certified copy is(iled with rhe coanty building inspacrion COUNTY OF LOS ANGELES BUILDING AND SAFETY departmenl. oai� 26 86 qppliconl T. FTeBm3I1 FOR APPLICANT TO FILL IN CONNERION DATA ��CERTIFICATE OF E7(EMPTION FROM WORKERS' p�,ip�r�c , � COMPENSATION INSURANCE , (; ADDRE55 STnnora o[vrH �This settion need not be tompleted if Ihe work tnvolvad by the i�i�T� �i$ �,N����� o°°E p ' permit is for one hundred dollars(SI00J or less.) I certify thol in Ihe performance of the work for which fhis cQos�ssst. �Y������T� �Er+GTMFko� ' lY Y. CUR! P L. M L.TO P.L. permit is issued,1 shall not empluy any person in any monner ' so os io betome subjed b rhe Workers'Compensation Laws. - P�'�'1O' Q oW�a Anden G �o��.�. ,��. . . �Nll iRUNK PfRMIT NO. RO�D RRMIT NO. Dme �� � . .qPPlicont noor+ess __ AffIDAVII WAIVER EASEMENi RECORD.IN51R.N0. Unif I NOTICE�TO APPLICANT: If, ofier moking �his Cenificate ot nn. • TE�r.�p ' ��ption,,.you should become zubject to �he Workers' LEGeI ' ' penwlion provisions of the Labor code,you must forlhwith pEsca�vrior� �oi NO. Hwy.pt 5T.wipEr+iraG �„�np�y with such provisions or this permit shall be deemed � ' revoked. • �acK TRACf S1AiE fNCRO�CMMENT � ' LICENSED CONiRACTORS DECLARATION r'o.a&°cs. ffRMiT r�o. I here6y affirm�hof I om licrosed under provisions of Chapter sizeotiot raworaioi , 9,(commenNnq with Setlion 70WJ of Dfviaion 3 of�he Busi• B iuio�s � 1 aaqc.�s nesa and ProFessions Code,and my litense is in f�ll iorce ond @fI6C�. �pJTRA�IpR reeman CONNECT�ON CHARGE fFE lice�:e Nombe�474887 • ii�.aa�� C� �ooness 8225 Beeehwood I�• ���uRSEMENT f4E y, T. Freeman Dme 8 26 B6 orsmKrw. eeouv MNP rvoeesseoer a Contraetor an [�'t8 ZOIDB' *ei.r+a f eK r� V STAiF UC �a ❑I am exampt Under Sec. of the L.A.Co. u�Nst nq. 88 ctnss d. �+0. DESCRIVfION OF WORK fFE Q -PlumbingCodeand/or5ec. oflhe FiNA� VAUDATION ~ 1qU5E SEWER CONNFCfING TO DATE ,)�/�7 �(J/ 9.8 P.Code for�he following reoson °O&i��'"�" � ! �' q�d uV+ V71C TANK.SFEPA�P17 OR y. . � PI75 AND/OR pRPINFIEID fiN4� y �O�Q HIX15E gWEi CONNEC7ING 10 B� .�. PRIVAT[D�SPOShI YSIEM "" . Si9lWIUI! CONNECf ADDITION�IlIDG.OR � OWNER-BUILDER DECIARATION woqK to Noust 5[wEa I hereby aKirm that I om examp�from the Comrottor's license cziEwF�ass Pi,plpYWFI�IAMAN�MpIF � Law for the following reason(Secfon 7031.5,Buianess and Pro- utea,a[vnic pt neu�pora Hous� �: [t 5 5 A ��ons CodeJ: sewEc at oisrosnt 5rshrn -� ��i,a�owne�of rhe propeny,or my employees wirh woges as h• • • • I V � rheir sole compenwrion,w�ll do the work and�he strvcture . is not intended or offered for sale(Secrion 7044,Business I ••2'j.5� and Profesctons Code). OWNER'S Permif s ZO 50 ❑I,os owner of the properry,am exclusively conrracting wirh AUTHORIZATION TOTAL FEE ° " "=7�J�� l litensed conlrocfors to tonslrutt 1he projecf(Section�OAA, I HAVE AT iH15 pATE A CONIRAC7 WIiH iHf HERFIN NAME�CON7RACiOR TO 8usiness and Profess�ons Code). ca+Necr r�aeov¢nesce�e�o exrsnn�c owewr+e ro r�rueuc s�wea. 0�.2 9—�6 CONSTRUCTION LENDING AGENCY , 1 he�eby aHirm that thare is a conslrucfion lending ogency SIGNED THIS DAYOF 19� , for the perfo�mance of �he work for which �his permit is �'^�^�q� . OWNfRS ACENi Issued(Sec.3097,Civ.C.�. AODFE55 tender's Nome . tander's Address � I certi{y�har I Fwve read ihis applica�ion ond state thot the above iniwmation is correct.I ogree to tomply wiih oll Counry � 1 ordinonces and State laws regulating Plumbtrg and Sewers, ' � , and hereby autho�ize reprosentarives of this County to emer - . , . upon t e obove-mentioned property for inspection pvrpous. '' . �-���1��-��- .�l/�� . 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