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HomeMy WebLinkAbout1461A � WORKERS'COMVENSATION DFCLARATION - I hereby affirm fhot I hove a cer�ificote of con»n1 to self. 11 insure,w o cerlilica�e of Wo�ken'Compenso�ioe lesuranca,or 16n6�7D . � 11 a«,�����d� �hereof(Sec.3800,lob C.) CE809�REV.11Bl1 APPUCATION FOR PERMIT � Policy No. �8 1Qompomn.�t. r'�1111f1 ❑cs.,�+�ea'�o�v is hereby fu.n�ahad. - SEWER - SEWAGE DISPOSAL �e«f��i�d�oPy�s f�ied wi�h�he co�nty building�r,sPea�o� COUNTY OF LOS ANGELES 6UILDING AND SAFETY de �men1 oo���26 86,,�,;�o�, T. Fr@@�lAri FOR APPIICANT TO fiLl IN � CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' e�,inpnvc - COMVENSATION INSURANCE - ^uoc�si STATia� o[mw (This section need no1 be completed if the wwk involved 6y the i«Ai��Y MnNHOLE RFFERFNCE . L�q pe�mil is for one h�ndred dollo�s(5100)or less.) ��5� ,rv�orca+�craN �,.�rH�ean I carlify 1ho1 in Ihe performance of ihe work for which this [rt05557. v. NRB PL. MI.iOP.t. permit is isdued,I sholl no1 employ any person in any manner o so as to become svbjeU to the Wor4ers'Compansotion Laws. p�Q Anden Grp co,ueo.r�o. � ioe r o. �2"� Doie , � . .APPlimm � A�oo�rs�ss PO BOS". 2 iRUNK GFPMIT NO. oOAD RGMIT IJ�. NOTICE TO ACVLICANT: If, ofter mokinq �his Cer�ificate of �iTY �i� .AF��wvrt wAiVER [as[n�tNr kEC04O.MSIR.NO. OATE ` �p�ion, you should become subjett �o the Workers' LEG�L ensati0n provisions of ihe lobor mde,you musl forfhwifh pFSCcir7iprv lOTNO. HWv,pq 5T.WIpENING comply wilh such provisions or ihis permit shall be deemed re�oked. ' " ' � etocK TRA�T STAiEENCROACNMENi RRMIT NO. ' ' UCENSEDCONTRACTORSDECLARAiION 9ZEOFlOi r�owor+ioT I hereby"affirm thol I am licensed under provislons of Chapter 9(commencing wi�h Section 7000)of Division 3 of the Busi• avip�r�cs i a��ac[s nese ond Profassions Cale,ond my license is in(ull force and effect � coNra>aou Freeman OII CONNEpION CHARGE fFE LicenuNumber 474as7 ��;�.�,a,s : c34 nopaess 8225 Beeehaood Dr� ���VRSEMENTf(E �, Co�tracro� 2'. Fr@2ID8I1 Doie 8/26 86 A,i T� � orsra�crr+o, c�+air �+,�v woccsseoer d I CITY�y ya y0m8' iEl. '� � � � ❑I am e�empt under Sec. o(�he l.A.Co. ii�Ns�r�p. tiAss a K NO- DESCRIVTIpNpFWORK RE O Plumbin Code ond/orSec. of�he F�r�A� 9 NWSE SEwFY CONNECTING TO �� onre Z�� $ VALIDA ION v 8.8 P.Code for rhe following reason °U&1��"'ER W i r�K, [vnc.�vrt oe d PITS AND/OR ORMNFIEID FiNAI �•��� N ' �1e MOUSE$EWER CONNECTIIJG TO BY ����� ? . ' VRIVAIE 01 Y T M ������i . Signoture caar�cT�ooirror�ni�o�.04 ; OWNER-BUILDER OECIARATtON W�K T�MO�SE$FWE4 ' pJFRi;OW SEEPAGE FIi,C�AiNiIELO I 1 hereby affirm�hot i om e■empt from rhe CoNrocror's licensa Ex7N.,CESY'OOI.ORYwE4.M�NHOIE ;"� [1 6,� A ��w for�he following reoson(Secron 7031.5,Buisness ond Pro• ureR,kErnik ae nenraoora�+oust � ,..,�ons CodeJ: s�v.�a oa oisvosu srsnM #. • • • � O i 1,es ewner of r1.e prvperty,r.my eTpl�yees wi:h woges cs ! � their sole mmpansation,will do the work ond the st�vtlure . I • •2 7 rJ Q is no�inrended or offered for wle(Secrion 7W4,8usiness . = I ond Profe:sions Code). OWNER'S PCrmit f Q �$"Q • o 0 2 7,5 0 c� � ❑I,as owner of ihe p�operty,am e:clusively conhatting with AUTHORIZATION TOTAL FEE J�� litensed tontrodors�o tonstrutt fhe project(Sec�ion 701d� 1 HAVE A�THI$DPiF A CONTRNCT WIiH THE MEREM!NpMED COMRA�ipR TO 0 B 2 9-8 6 Bw�ness and�ro/essions Code). corm�ct rHc awve oFxv�eeo¢xisnr+�ouvewr,e*o Twe v�euc s�vrta. ' , CONSiRUCT10N IENDING AGENCY /�/��� � I hereby affirm fhot ihere Is o consiruction lending agency S�GNEDiH15 � DAYOF `w`� 19� � for the periormance of Ihe work for which this permil iE ��R� , � OWNFR$AGEN � issued(Sec.3097,Giv.C.). ' npoacss lender's Name . - ' lender's Address � I certify Ihof I have read�his applicotion and s�ate�ho�the � , above Information is corrxt.I agree to comply wi�h all Counry ordinoncea and S�o�e laws regulating Plum6ing ond Sewers, and hereby authorixe representafives o(lhis Counry�o enter . upon�e above•meniionad prcperty for inspection purpous./�/ � _ i �oO�x.w ��LG/.�L " SignotureofPermitt e Do—�e —��� SEEREVERSEFORE](PLANATOIIYLANGUAGE . � �� y�. �2 £ . �q � `Ti �': Z r . " � . � - .4� �a }�., q }ti 7'� `. ' . . � . . ' ^' ^ v�ji y++ ` ,T c �', '� .. .. . , C�7 n.-. n�� . ' ' . ' ��_ C�G,n U C�`r ...`� '� � . � . � `1 .'' _(��j. �Q Z;,r iO-. O . . 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