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HomeMy WebLinkAbout1454A � WORKERS'COMPENSATION DFCLARATION � I hereby affi�m tho� I have o tertifico�e of consent lo self . 11 ' ,insure,or'a ter�i(imle of Wor4e�s'Compensotion Insuronce,or ]6A6!]D II °.°N�;';��°p Y,h°�°°f«°.'e°°,�°b�., "B°"'"`",,87 APPLICATION FOR PERMIT " Policy N�6ti510 Compony .5't. FI111d , ' ❑Cenified copy is he�e6y furnished. � � . SEWER - SEWAGE DISPOSAL �Cer��f�ed'copy�s f�led w�rh the county 6uild�ng�nspecron COUNTY OF LOS ANGELES BUILDING AND SAFETY de rmenl � �� oo�e � 26 86,,�,i;�o�, T. Freeman POR APPLICANT TO FILL IN CONNECTION DATA .. . ,CEqTIGICATE OF EXEMP110N fROM WORKERS'. ��ipi� . COMPENSATION INSURANCE � �no�3S 12 Feathe MOOf� sanoN oevrH (Thia section need not be compleied if�he work involved by the Dia HAL' 'N4NHq[R[i(R�I.�F l�R ' permi�ii fa one hundred dollars(f100)or less.) �«°'uTY ' I certify,ihot in the perfo.monce of the work for which�his �¢pusT rY����� ��T��� S lvan Glen �. ��R, P.L MLTOPI. permi�is iss�ed,I sholl not employ ony person in any monner °�,� v so os�o becoma subject�o rhe Wakers'Compansotlon Lows. owra[a Anden G �o��"���� ��� � �, Da�e -� ' ApplicoM � ADDRE55 PO Box_.3329 TRUNKPEAMITNp, ROADRRNUTNO. NOTICE TO APPLICANT: If,.aftar making ih15 ClAIfiCOi! Of ��n,- AFfIDAVII W�IVER E�.SFIAFNT RfCORD.IN51R.NO. DATE � ption, yo� ahould bacome a�biect to the Workeri COQiTla TEi.r+o. 81a 6 � �enwtio� ovisions of�he lobw code, ov must forthwith ���� _ Pr Y o[sceivr�oN '�m No Hwv.dt st.vnoENMG �,,,nply with such provisions or rhia permit sholl be deemed c flVOkp�. &OCK TFAC7 Vl � SIATEFNCaOACW�ENT � UGEN$ED CONTRACTORS DECIARATION � r,°.or e�ncs. ffpMiT�o_ SiZE Oi LOT NOW ON lOT I hereby affirm�bot I am licensed under provisioaa of Chap�er �a _ 9(commenting wi�h Sxtion 7000)of Division 3 0(�he Busi- euno��5 S'�A @ oucocs nesa and Professions Code,ond my license Is In full fwce ond . ' QNO[I. .. ' CONTY��TO4 m COn1NECfIpN CMAR'G[F(( , t�cenae Number 474887 u�.ciau C34 �Eu 8 PE�MBURSfMENT iE }, C011�I0[�Or T• rl eAIDSnui� O � SO , � Di5T41�1 NO. GYWP MAV PRp«SSFD BV / 6/ CITY Alta Loma ,��.,,�714 980-4429 / BK PG )^''� $ ❑I am exempt under Sx. of the LA.Co. ilcti�st rp '� $$ �a�ss O �"� ! p� . PlumbingCodeand/or5ec. ofthe �� DESCRIPTIONOFYVORK ff[ F�Np� O I i.ous�s�wea cor+erccrn+c r° 1 00 onrt VALIDATION r"'j , B.6 P.Code fw�he Followinp reason °�K�'"�° �_�r—P,� . Pil ANR.SEEVAGE flT OR d PVTS PND/OR ORAl1�1E10 FiNA� N , DafB �DUY SEwER CONMCTmG TO BY ? . VRIYAfE DI$Op$11t S�$1FM • 5i911DIUf! . CdJNEC7.CW1T10NplµOG.pR OWNER-BUIL�ER DECLARATION woea ro Nous[s[wte OVERFLOW$EEYAGf RT,OR�INfIELD I hereby affirm that I am eaempt from�ihe ConKattor's License exnu,CF55vpp�,oerwtu,w�wqt[ ^� 4 S 4 A Law for the following�eoson(Sec�on 7031.5,8uisneu ond Pro- mr[a.a[P��R oQ�mooN�5e � � �OnS COde�: SEWER pt d5PO5AL SY51fM +�• r} e � • � O �I,os owner oF the property,or my employees with woges as their sole companiotion,will do�he work aod the srrocrure � ,• •2'].5 Q is not in�ended or offered for sole(Section 7044,Business cnd Piofessions Code). OWNER'S Permit S 10 .� ❑I,os o�+ner of+he p.operry,om e.ciusively controc+ing with AUTHORIZATION TOTAL FEE 2�] � p �c(�7•v O U licensed mnrracrors ro construct the P10�9C�(S@CilOfl�WA, �HAVE AT THIS DAfE A CONiRACT WITX TiiE MEREIN W�.MED CONiiACTOR TO , O U L 7"8 6 Bus�ness and Professions Code). corau[a rw[nqo�c o[sca�e�o ezisrx,�c ov�wwc ro rHc wx�c s[wca. CONSiRUCT1pN LEND�NG AGENCY � � 1 hxeby affirm thar there is a conshuUion lending aqenty ��DTHISV _DAV F I9� , for the perfamonce of the wo.k for wh�ch th�s pe.mu is �R ce ' - OWNER$AGEM issued(SeC.3097.CiV.C.). A�� � lender's Nome ' tender's Addreu I certify�hof I ho�e read�his applica�fon ond s�o�e thot�he above info.motion is correct.I og.ee to comply wi�h oll Co�nty ordinances ond Slo�a lows reg�loting Pl�mbing ond Sewars, ond hereby ou�ho.ize representa�iven of th�s Coumy b en+er � u e obov m mioned proparty f°�Inspetii�o p�urf�sas. � � �� � ���(�Ap�iYYIG,ILI ��la!k�o SignaWroofPermitlee Date . 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