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HomeMy WebLinkAbout1460A (13) � WORKERS'COMPENSATION DECIARATION � I hereby offirm tho� I hove a certifica�e of to�sen� fo self � ineure,or u cerfificate of Workeri Compenw�ion Insurance,or �6MeTD a Fe�lified co y ihe�eof(Sec.3800,La6 C.) CE8091REY.1/831 ,APPLICATION FOR PERMIT Policy No. �6851Qompany S't. F1111d ❑CertifiEd copy i�hereby furnished. - . SEWER - SEWAGE DISPOSAL �Cerrified copy is iiled wirh rhe county building inspect�on COUNTY OF LOS ANGELES. BUILDING AND,tSAFETY deportment. � oo�e�/26/86Applicant T. Freeman FOR APPLICANT TO Flll IN CONNECTION DATA , CERTIFICATE OF EXEMPTION FROM WORKERS' ewipraG . COMPENSA710N INSURANCE A�u $1AT1� ��H Qh�s secion need nor be compleied if�he work invol.ed by ihe Dig BAI ' MANHOIE REifRfNCf i°°E R permil iE for one hundred dollors(5100)or less.) ����� - � I cenif thol in�he erformonce of the work for which Ihis �A°�ST TYYEOF�ONNEC�ION �r.�TM�a�n Y P CwOSS ST. Y. CUR6 P L M 4 TO P L. permil is issued,I sfwll not employ ony person�in any manner p � �O��` c. so os lo become subject l0 1he Workers'Compensation Lows. p�rr�R �'1d8n �p-�Ny,�.q� JO6 pp, Dole APPlicant . . �oo�ae55 PO BOB_. Z TFUNKPERMITNO. ROA�PERMITNO. NOTICE TO APPLICANT: If, ofler moking Ihia Cerlificote of Ciiv OQ a AFFIOAVIT wsivER E�SfMfNI RECOWD.INSiR.NO. DNiE TEI.NO. � ' �plion, yo� should become subjecl fo fhe Wo�keri LEG�I pensation provisions of fhe Lobor code,you m�s�for�hwirh oescxwrroN _ iorNo. 6 �y.pesT.vnu�N�r�e comply with suth provisions or�his permit sholl be deemed C lGVOkC[�. ' BLOCK • TRACT p S�AiE ENCQOACwMFNT • � IICENSED CONTRACTORS DECLARATION w.pv etocs. ccaMir rio- siz[a ioT raw ora ior I�hereby'offirm tho�I om licensed under provisions o(Chnpter ��� 9(tommencing with Section 7000)of Division 3 of ihe Busi- Bu�tD�r�lGS Sin Re�• O��nGFS ness and Professions Code,and my license is in fvll force and - eI}DC�. � CONTAA�TpQ CONNECT�On1 CN/•QGF�EE litenieNumber 474887 -u�.ao�� � e34 ���ss 8225 Beechwood Dr� ���UKEMENTf(F �, �OMfOC1D� T_ Freemanome 8�26/86 �iT�ta Z�]�'d ' TFL.NO 1 8�•• 2 DiSiFi�TNO. GROUv MAV vROCE55EDBY O STAfE . IIC. � ] BK GG (� ❑I am exempt vnder Sec. of the L.A.Co. ���E�r,p. �i�u �� ns � PlumbingCodeand/orSec, oHhe "1O � R� iON wORK ffF i�NA� O � "O1�5EN1E4 CON"`�"`'��O 1`T 00 D�TE ' VAIIDATION c�'i B.8 P.Code for the following reoson "�B"��"�R Z�20� W SEPTIC T�NK,SFEVAGF GIi pR fiN<l �" VI15 AND/OR DRRINfIEID N Dale ��gWER CONNKTInK;TO eY ? . - PRNATE DISPOSAL SYSTEM SignOtVfQ Cp�HFCf,�.DDnpN<l&OG.OW S . OWNER-BUIIDER DECLARATION M'OOK 70 MOUSF SFWER pVF4F�OM'SEEPP�PIT,DYsiNiiEtD 1 hereby aHirm ihot I om exempl irom the CoMroUor's litense fxTN.,Cf55P00t,DRYwFtL.MANNqF Low for Ihe(ollowing�eoson(SeUon 7031.5,Boisness and Pro- areR.kEvnie a+aenNoorv Nous� '1 �Off!COdl�: SEU'ER pR DISPOSAl5Y5iEM �� µQ O A �f 1,as owner of the property,or my employees with wages os their sole mmpenwlion,will do the work and the s�rvtfure . �° �• • 1 � is not inlended or ofiared Ior sole(Seclion 7041,Business and Profe:sions Code). OWNER�S Permit f 1� 5� �n •'�'].,rj Q ❑I,os owner of the property,am eKclusively contracring with AUTHORIZATION TOTAL FEE 27 50 . litensed tontraUors to construct the projed(SeUion JOAA, I HAVE AT THIS DI1TE A CONTRA�T WI1M fME NFRE�N NAMED CONiRACiOR 70 , s� ���'r O U BVSi11lSS Oflf�PlOfBS5�0�5�OdC�. C0�INECT THF ABOVE DEKRIBFD F%ISTING ON4l11NG TO TI#RIBLIC SEVlE4. � CONSTRUCTION IENDING AGENCY ► 0�3.2 9-8 6 I he�eby ONirm Ihot Ihare is a construclion lending agency SIGNEDTHIS �� DAYOF i9� for the performance of tbe work for which Ihis permit is °�+ERoa ONRJFRS AGENT issued(Sec 3097,Civ.C.J. A�f� � lender's Name � lender i Address I canify thot I have�ead�his opplicorion and state rhat rhe above informotion is correct.1 ogrea to compiy wirh oil County � ordinonces ond S�o�e laws regula�inq Plumbing and Sewers, and hereby au�horize representativas of�his Co�nry to en�er. �upo he obove•mantionad properly for inspaclion pu posas. / ��P�r�.s�-��`�Lf��o Sig�atoro of PermiNea Da�e SEE REVERSE FOR EXKANATORY LANGUAGE :� � • - : - .- : . . � Q o N� m j.� �� m ' ' . . � • � a n z•r F� �� c� '-z � ' i � �� yx �� �� � T'. � = ' _ .. ��; �'� �_� � ;;� ��' � r . � , � : ... _InIC�� �„ ❑ r<� cii '9 ' ; c� 7 ' I ' , ; _. � ;,;�, ,>.} n. �:; ., � • . , . 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