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HomeMy WebLinkAbout1458A (8) �� WORKERS'COMPENSATION DECLARATION � . - 1 I hereby offirm that I hove a cerlificaie o( consent�o self _ �' {{�� ' in5ure,or a�certi{icote of Workeri Campenwtion Insurance,or �e�bato •�� Polc''No.'������f(Sec.3800,yqb:.)��d CE808�REY.1/8l� APPLICATION FOR PERMIT . _ " � Y com��Y Sr ❑�e.��f�ed copy is hereby furn�shed. . � . SEWER - SEWAGE DISPOSAL � I �Certified copy is filed with ihe co�nry building inspect�on COUNTY OF LOS ANGELES BUILDING AND SA�ETY departmen�.� � � � oaie e/26�86Applimnt T: Freeman FOR APPLICANT TO fill IN CONNECTION OATA � � � CERTIFICATE OF EXEMPTION FROM WORKERS' eunwr+c STRTION otrn� j ' COMPENSATION INSURANCE �� ��ss 11 @AtYI � (Tht�secr�on need no�6e comple�ed if the work involvad by the i�iiT, r.v,Nwoit retrtyerxi �R � pe.mit is for one h�ndred dollors�5100)or less.) ��ST trrE a cONHERqro S 1v2I1 Gl eri ,.. ��� P` IEN['iTM iRpA1 j I ce�tify rbo�in��he performance of rhe work for which thiz �¢p�st. rn i.ro p.�. l permil ia ifsued,I shall not employ ony person in any manner so as�o become s�bject fo�he Workers'Compansation lowa. �r,�[e Anden G co.iMo.r�o. �oe^o. d�'� r � �. N`°'�� TRUNK�fRM171q. ROI�D OERMIT ND. Date - Applicont �oocess NO110E TO APMICANT; If, af�er making �his Cer�ificate of C17Y aFrio�vir w�rvee fASEMEM �cam.iNsra.wo. ontt . F��ption, yoq should bemme subjecl to,the Workeri COoina TEt.trO.8 8 � ensotion rovisions of the Labor code, ou must fwthwith �E� P Y DEXR�P110N lOtNO. IMn.pRST.WIDtN11JG w�nply wi�h such provieions or this permil sholl be deemed C � fGV04G(I. - " BLOCK TYAC7 p S7ATE ENCROACNMENi � � �� LICENSED CONTRACTORS DECUIRATION NO.O�&W5. �F4M�T NO' sae a�or wow on ior I hereby aifirm�haf I am licented u�er provisions of Chapler , 9.(commencing wiih Section 7000)of Division 3 of the Busi- a�uiio�s Sing• R89• cN�x�s � ness ond Professions Coda;and my lironse is in full forte and y i effetl. COr�rc�CrOk Freeman Ci0 Y CONNECf10NCHARGFfEE licenseNumbe. tl�]ef.$$'/ lic.Closs (,;,3d^,! �u 8225 Beechvrood Dr� REIMlURSFMENTiEE p�, � CoMroctorT• FTeBmelTl pO1e 8/26/86 ' � o�sTQicrra. c�eouv waw vuoc.�sseoer O : - Orr �ta, m �.No � � V � ❑I am e■empt under Sac. of the L.A.Co. �i�T�r.�p_ [uu �a 0 � NO. pESCRIPf10NOF WORK fEE F" I Mumbing Code and/or$ec. of fhe �WAI V 1qUSE$EWER CONNKTING TO DATE Z_�/� VALIDATION w ! B.8 P.Code(or�he(ollowing reason �1°"���R d ` $[iTIC TANK.$EEPAGE%T OR N � P175 AND/04�RAINFIEID F��'y'� �. � DOIB Iq�S[gW[R CpNNKfIN(:TO BY - � . YYIVAiE p$POSAL V$fEM ..Signa�vre � ca-weCT�uorta�i xoc.o¢ � OWNER-BUILDER DECIARATION W�i����R 1 hereby offirm�ho�I am ezempt from tha Contmctor's�icense E%�NF�CESSi1701,ORYWEt�L^MI.N�MIXf � �1 4 a 8 A law fo�the following reoson(Secton 7031.5,Buisness and Pro- uitw,r�ania an nn�NoOu�Wse i;• • � • � � � �bn5 COdlJ: SEN4R OR DIS�OSAI SY57FM ._,-�.a�owner of fhP propwrty,e.my��„pl�yees wi!h w�ges as 1 • ^G�.J U �' their wle compenwtion,will do the work ond the�trutture , � is not inlended or offered for mle(Seclion 7044,Bosiness � ° •�7�J�i� ond Profauions Code�. OWNER'S Per/nit S 10 50 ❑I,os owner ot the property,am exclusively contraUing wi�h AUTHORIZATION TOTAI FEE �8.2 9��'b ��Cl�SQfI COMfOfbfS 10[O�SilUC�IFIO FNO�lCI�SlC�10t1 JOCd, �HRVF AT TMIS DATE A CONTRACI W11N illE MEREIN NAMED CON1N ao ro � B�siness and Professions Code). cor�Nea rNe�eove ocscaie�o czrsnnic ov.Fw�c ro T�Pueuc s�vaa. CONSTRUCTION LENDING AGENCY , I hereby oHirm ihal fhere is a conslruction lending ogency SIGNEDTHIS � DAYOF _I9_ � (or Ihe performonce of Ihe work for which Ihis permit is O�+ERpt issued(Sec.3097.Civ.C.). owr+tas ac[ ADDRE55 2 lender's Nome Lendei a Add�ess 1 ce�tify tho�I hove reod this application ond stoie thol the � obove informo�ion ia ca�ect.I ogree�o comply with oll County ordinantes ond S�o�e laws regulating Plumbing ond Sawers, � ond hereby a�fhorize represen�aii�es of rh�s County to en�er �upon he obove•mentioned property For inspaction purposes. � i �� �71ray[� �/�� . . . S�qrwWre of Permitfee Oo�e G SEF REVERSf FOR EXKANATORY IANGWGE � . .. � c�r � Z N C Z =^�L. • � +�� a r •:T 'tn L�n o T S . pm 7' . ._ . , , ''o n z� O'9 y �D `�' O � , �. r C U r " � � , i. , � � � - C,7 0`=i i n #�n � �1 ,a o� z,� ;,� p e $o �, , . � � %�=� �;� �� ?.`;^ u,� Q , • , �� h� � �,� ,. 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