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Home My WebLink About1459A (8) � WORKERS'COMPENSATION DECtARATION � I hereby af/irm tha� I have a certificote of ca+senl fo self . _ . {� inaure,or O'cartifico�e of Workeri Compenao�ion Insuronce,or �bA6a�o � •�I a certified,c�oj�y,,t�he�re�of(Sec.3800,�ab�., . . �EB�e�aE�.,,e�, �APPLICATION FOR PERMIT � " Policy No.��lUCompany_ S't. Fund ❑Certified copy is hereby f�rnlshed. - SEWER - SEWAGE DISP�SAL � I �Cerrfied topy�s f led wiih�he counry build�ng�napecron COUNTY OF l05 ANGELES BUILDITjG ANQSAFETY deparlmenL - po,� B ZE) 8C)Applicanl T. Freeman FOR APPLICANT TO Fltl IN CONNECTION DATA � CERTIFICATE OF EREMPTION FROM WORKERS' e�.mo�Nc COMOENSATION INSURANCE . ADDrtE55 s*anon o[►rH (This sec�ion need not 6e completed if the work involved by the � M4NMClE REfERfNCE UOPE° � pe�mi�is for one hundred dollors(SI00)w less.) � � ��TM ' ' L 4 I cenify ihat in the performance of the work for which fhis ��ST _ TYr�°Fca+r�[c�a� ur.�tMFa�' CQO55 5T. Y. CURE P.4 M.l.TO P.l. permil is iss�ed,I sholl nof employ ony person in ony manner so as�o become su6jecf to the Workeri Compensolion Lows. o,,y�p °��'"1°' Ariden G co.uv�v.r,o. ,oe No. o pofe ... � Applicanf � ' �DDaE55 �O BOE-- Z iRUNKRRMITNO. ROA07fRM17Np. ' AFFIDAVIi WAIVER EASFMFNT RECOR�.INSTR.NO. DA7E NOTICE TO APPLICANT: If, af�er moking�fhis Cerlificota of �iTv rFi.uo. ��np�ion, you should become subjec� to �he Workars' � tEGM )pensation pravisions of ihe labor code,yau must forthwith ptS[eivriprd LOiNo. Hwv,pt Si.wioFNiriG c..�np�y with such provisions or this permil shall be deemed re'vo4ed. � � ' � � � s:otK TRACT STAIEENCROACHMfNi . � ��5_ VEaMIi NO. " IICEN5E0 CONTRACTORS DECL4RATION size oF ioi r�ow or�ior I he�eby�offirm�that I am licensed under piovisions oi Chap�er ' , 9 commencin with Section 7000 of Division 3 of rhe B�si- �� ,,SiII • ( 9 ) aunon+cs Re9 a�rsc,�s ness ond ProFessions Code,and my license is in f�ll force and , effeu. p � ta+rancroa ji'Te@ID8I1 OA8 t'i COMNECTIpN CHARGE FEE ��087 LiC.CI053 ��4 QEIM&JR$(M[Ntf[E � (ICEnSB NUmbCI ' A�E� m f7. �On11OCiOl1. �eeman oote �8�, 6�/86 �ITY llit8 ZDID�.�+o� oisrai[tra. caouo BK MAP � Wp�ES$(DBY y .� ❑I am exempt�nder Sec. of the L.A.Co. iIt�TNy rp 88. RAu f d 0 -PlumbinQCodaond/orSec - oftha �� FSCRIPfIQfJOFW�RK ffE FNAI . ~ �uus�s�wea cor.Necnr+e ro on,e q,/ VALIDAT ON w B.8 P.Code for the following reasan � �°��c�1°4R Z— Y— . YPi1C TANK.SEfiAGE%T OR HNAL v �� Z PITS ANDiOR ORAIKIEID � Da1e FqUSE SEWEN CONNECfINCs TO �Y � " V41YA7 1 V T $19t101UIR - CONNECT ADORiONAt&DG.OR , OWNER-BUILDER DECLARATION W�r°�aus�s�m'ER ovEe�iow savec�v�T.oa•na��o 1 hereby affirm that I am exemp�from�he ConfraUor's licensa EXiN.,CESSi00l,DRYWELL MANMqE � Lnw for the following reason(Secton 7031.5,e��a:5 a�d P�o- u*�q.�o.�o�.��o�� :1 4 5 4 A J�(on5 COdl�: SEWER OR D�SpOSAI SYSIEM �,ae awner of the property,or my employeea wilh wages as r'�r• • • •.� � Iheir sole compenwlion,will do Ihe work and the slrutlure is nol inlendad or offered for tale(Seclion 7p14,Business � o �2�],5� and Profess�ons Code). OWNER'S Permil S 10 �jd ❑I,os ownei of the properry,om axcivsively controcting with AUTHORIZATION TOTAL FEE ° ° o G 7,5 Q U licensed contratlors b consrrvct tbe projeci(Sectron 7We� I NAVE AT IHIS OAiE A CONT44CT WIiX iNE HEREIN N4MED COMRACf04 i0 B�s�ness and Protess�o�s Code). ca+�ca TMe neovc axR�e�o EXrsntic owew�+c ro��Pueuc sewER. 0�2 9�8 6 CONSTRUCTION LENDING AGENCY , I he.eby offirm that fhere is o conihuc�ion lending agency S�GNEDTHiS � DAVOF I _ �or the performanca of the work for whith this permit is a�R°R OwNfas aGENT ISSVld($9C.3097�Civ.C.�. pD�RF55 Lender's Name � lender's Addreu I tertify that 1 hove read this applicorion and s�ore tha�rhe � above infwmalion is corract.I agree to comply wi�h nll County , ordinances and State laws raguloting Plumbing and Sewers, ond her�by aulhorize reprezentatives of this Counly to enter � . upon ihe above-mentloned property for inspection purposes. 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