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HomeMy WebLinkAbout1457A ` � 1NORKERS'COMPENSATION DECLARATION I hereby af(i�m ihol I have a cer�iiito�e of coaseat ta self , ' }'� ins�re,or 6 certificote of Workeri Compensot�on Insurance,or ]6A6J7D � o«,�;f,��o thereo((Sec.3&I0,la6 C.) CE 808(REV.IB31 qpp��CATION FOR PERMIT Policy No.7��510 Company S't� Th�n� � ❑Certified copy�s hereby furnished. . SEWER - SEWAGE DISPOSAL �Certified copy is filed wirh the counry building inapecr�on COUNTY OF LOS ANGELES BUILDING A�1D S�ffFETY de r meM po�e � ZE) 8E)qPP�i�a�� T. FTeBm&II FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' �iipi� . COMPENSATION INSURANCE �ooaess STATION o[riH (This secrion need not be compteied H�ha work involved 6y the i«�utr Dia yai �N�F RF�fRENCE �° � ' pe�mit ia fw one hundred dollars(�100)or leas.) � R ""v�5, 3 lvan Glen `""°``«°""'b" �"�TM'uo", I.certify thnt in Ihe perlormance of the work ior which this � �RpyS ST, r. ��q6 p�, M.L TO P.l. permit is iss�cd,I sholl nol employ any pe�son in any monner P�� p w as fo become subject�o the Workers'Compenwtion Lows. p,�a Anden G CO.IMP,Np, Jps Np. O�a/ Do�e APPIicoM a�oo�R[ss PO Boa..3329 TRUNK iERMIT Np. RWO pERMIT N0. NOTICE�TO APPLICANT: If, after mo4ing �his Cerfificate of • AFFionvrt WAIVEY e�S�ro�Ni RfCpRO.irdlN.n0. DaIE ��,� Covina ,E�.� 818 6 — ' ��piion,,you should become subjecf lo the Workeri � pensotion provisions of fhe Labor code,you must(orthwith pescreiviiow toi rio. Nwr.q�sr.w�oewr.� 2...nply with soch povisions or fhis permii sholl be deemad L revoked. � etoCK TAACT vl STAIE ENCF04CY1MENT , � � ULENSED CONTRACTORS DECLARATION ' r''o a�ocs. �°Mir N°. 512E OF LOT NOW ON LOT I hereby offirm thot 1 om licensed under provisions o(CF�opre� �a 0(commenting with Sec�ion 7000)of Division 3 of the Busi- pwtou+�s 171 oucc,�s nesa and ProFecsions Code,ond my license is in full fwce and �1�. n T eI{BCI. CONiflACTOR 1'y p.ema.n yQyB t• CONNfCTION CMAOGE FH LitenseNumber 474887 �;�:c,ass C3$ „��u 8225 Beehewood Dr. ��MB���M� � Con�ractor T. �'I'@@p1al'1 po�e 26 86� o�STM�R�. �,o ^"wv motFss�o er d ��TY Alta Zoma- h�.� 1 so— 2 1 BK ,� o ❑I am exempt und�r Sx. of fhe LA.Co. nATE p u�. G� V UCENSENO. ' p� Cl/55 a NO. DESCRIPf10NOFWORK FEE PlumbingCodeond/orSac. offhe DATE� p � �qUSE SEYrFq CONNECf�NG TO Z�Y_ VAIiDAT10N 8.8 P.Code for the foliowing reason °�'«�R 0 w SEVTIC TANK.$(fPAfif PIT O9 FINAI n' �o�e VI15AN0/pRpRAINiKLD BY Z . 'q115E SEWEN CONNECiING TO VRiyATE OISWSAI YSfEM ' � Signawre . ca�m[a,woirqraai e�n�.ors � OWNFR-BUIIDER DECLARATION - �^'�ra�s�s�`�'ER • OVERFIOW SEEi.4GE%1.0R11INfIFID � . I here6y affirm that I am exempl from Ibe Contracfor's license F%iN.CESSVOOL,DIIYWLtI,MANNOtE law for Ihe following reoson(Satfon 7031.5�BUISf1C35 O�d Pf0- Al7ER,I�VAIR ql AlANppN Np�Sp � `jons Code): s�wtw at oisoos�i srshrn � :� [1`.z'�A "r�i,aa ownar of ihe p�operty,or my employeas wifh wages as their sole compensotion,will do the work and�he structura n e s • e � � is not intended or offered for wle(Sec�ion 7044,Business � and vrofesaions Code). OWNER'S Permif s 1� �j0 I • s 2 7,5� ❑i,as owner of the properry,am axclusi'valy convod�ng wirh AUTHORIZATION TOTAL FEE 27 IlfEtlS6d COfl�fOC�0/5 10 COI151lVCI tI1G PI0�9Cf�SBC11011 JW4, 1 HAVE Ai iH15 OATE A CONIRACT W17M THE HEREIN NAMf�CONiNI{10R TOO e rt o%7�j�j � BUSif1�53 Of1f�PfOfe5310n5�OdG�. CONNFCT iHE ABpVF DESCRIBFD F%ISTIMG DN4Ll�NG TO 1NE PUBLIC SEWfR. CONSTRUCTION IENDING AGENCY / (� � O H.G Q—8 6 � 1 hereby affirm thal thare is a construction �ending agenty ��1EDTHIS I�? DAYOF 19� tor the perfamance of 1he work (or whfch fhis permil is d++HEROR � , OWNERS AGEM �,�0�� ��' issued(Sec.3097,Civ.C.).� A�SS �"�.�—��Q��F�^�Y lender's Name �J� � lender's Addross � I certify that I have read this appllcotfon ond sfote that the o6ove informotion is correcf.I agree to comply wirh all CouMy . � otdinp�ces ond State laws regulaling Piumbing ond Sewers, � ond hereby a�thorize representaiives of rhis Counly Io enler u�e-mentioned property(or inspection purposes. ' . ���_�� Signol�re of Permillee Dofe SEE REVERSE FO�FX►IANATORY IANGUAGE ' . . , . . . . ' . . �C�; r n m r ,;,�, r S.; �� 7 � u ' �!i j•f 1 T� N V y �; � . ' , , I � ' � ' . . � - - �:T �m .� xn ��n n . � . . � � i � . . . ::� z�� �% �� �,'� �� C '�C ' . . . 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