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HomeMy WebLinkAbout1452A (8) , -WORKERS'COMPENSATION DECLARATION . I hereby offirm �hat I have a certificote of co�sent ro eelf jl insure,or a ce�tificaie of Workeri Compen�olion Inauro�ce,or �6^bizo U o certified copy rGhereo((Sec:3800,�ob�., �E�9�a�����a�� APPLICATION FOR PERMIT �. PolityNo.�.68.a]_Q..Comqony 5't� Fllrid ' ❑Gertified copy is hereby(urniahed. � .. • SEWER - SEWAGE DISPOSAL �Certified copy is filed with�he co�my b�ilding inspec�ion COUNTY OF LOS ANGELES BUIIDING AND SAFETY depor menl. ' " oar� 8 26 S6qpplicant T. F�eem3T1. FOR APPUCANT TO FILL IN CONNECTION DATA , CERTIFICATF OF E%EMPTION FROM WORKERS' eunonac � � �- . COMPENSATION INSURANCE � �oowess Sr.+rroN oevrH (This section need not be completed if�he work involved 6y�he i�iiTr MANHOtE RE�ERENCE l�Q � permit is For one hundred dollars(=100)or�ess.) I cert�f tMt in �he erformance of�he work for whith this ^�'°REST ' . rrffocco.w,tCnora ¢rJGrHfaOrn Y P CQO55 ST. Y. CURB P.l. M.L TO i.l. pe�mil is issued,I sholl not employ ony pe�son in ony monner p�� so as to become subject lo Ihe Wo�kers'Compenwtion laws. �ER �nden G �o������ ���� �d��I M41L TRUNK PERMIT NO. RO�O VERMIT NO. I Dote � �� Applicont ADo�si PO BOX-� Z I NO710E�T0 APPIICANT: If, afror makin �hi5 �GffifiCOle Of Aff10/NI WAIV(R E/SEMEN7 RFCORD.iNSiR.Np. DAtE I, 9 nrv COv�IIa Ta.ea, 818 fi�]— 1 � �'Ynp�ion,.you should bacome subject�to ihe Workers' . IEG�I �penwlion provisions of ihe Labor code,yo�must lorihwith pES�a�vf�pr� tO7N0. Hwr.pw 57.w�oFN�MG �_,nply wi�h such provis�ons or this permit sholl be daemed C C , tBVOkGd. � BIOCK iRA�I J�[71 STAfE ENCR04CMMENT I ' LICENSEO CONTRACTORS DECLARA710N ao.a aocs. �R'"�T�''�� ' 92E Of lOT NOW pN lpT � I hereby offirm Ihat I am licensed under provisions of Chopler � �� 9(commencing with$ection 7000)of Division 3 of�he 8usl- euitoirvGS [w�acES nass and Prof.ssions Code,and my license is In full force and �y effec�. d�] �] cpri1QARoc �l"eQman C��Bt� CONNECTIpN[HA4GEFEE litense Number r•���• �i[.��OSS C34 q�qE�r REIMBURSEMENT FEE ce��.a«o,T. Freetnan oa�� 8/26/86 • A1ta Loma. ,E�.� o�s���*�. �«,P MAP PROCESSEDe� a ��,Y 714/980-4429 !� ,F ,� o ❑I am exempt under Sec. of�he LA.Co. ilt�Nsc nip 88 n�u V eG NO. OESCRIVfIONOFWORK fEF Plumbing Code ond/or$ec. of Ihe FINR� O • wusc s�wER cor�rxcriNc To onre VALIDATION �,a��«�R i oo �t_�r-��. � B.8 P.Code(or fhe lollowing reason� �u . . SEGfI�TANK,$FEp�GE Vii OR iiNA� ' Vrt5�NO/OR DRAINf1ELD N Da�e equSE Sewta Corweetir�c to eY — Z %lIV�tE DiSM)SY v5}EM '� Signofure . towrrtcT noort�or�wi uoc.orr � OWNER•BUILDER DECLARATION Wo�To"Wsc s[w�R OY[fil0'N SEEVPGE R7.pRA�Ni�[lD ''C!� 1 hereby affirm tha�I am e�empt from the Contrac�or i liceme E%iN..CESSPOOL.ORYWELL,hUNllplf �� �:.-1 C Fl law for the following reason(Secton 7031.5,Buisness and Pro- atEa,cFv�ia Oc nBnNoOra rause ' `�ons CodeJ: s�wee at oivov.i svsrtM �• • • • � O __��,ae c.,�ner ef the preper!y,cr ny cmpioyees wirh wogas as I� •2�.5 0 iheir sole compenwtion,will do the wo�k ond the sv�ctvre is not inrended or offered for wle(Sedion 704t,Bus�nns Permit S •� �2 7,5�_ o�d Professions Code). OWNER'S � ❑I,as owner of the property,am exclusively contrac�ing wirh AUTHORIZATION TOTAL FEE 0&2 9—8 6 17censed contrac�on to construct fhe projecl(Sec�ion 704d� �qAVE AT iN15 OATE A CONTRAO W17H 111E HERFIN NMAED CONTR/.ioa ro Buslneu ond Pro(essions Code). comr,�cT n+e neov¢oe5ca�eco exisnn+c owetuwe To Tut vux�c 5[wEa. .CONSTRUCTION LENDING AGENCY , I hereby offi�m thot rhere is a tonstroction lending agency SIGNEDTHIS � DAYOf 19� for fhe performance of Ihe work for whith �hia parmit is p�RS��M�� �/,r'����K� isaved($ec.3097,Civ.C.J. AppRE55 lender's Name , Lender's Address I certify�hot I have read this applicotion and s�o�e�hm�be � - above Inlormotion Is co��ec4 I agree lo tomply with oll County ordinances and Srofe laws regulaling Plvmbi�g ond Sewers, , and hereby oo�ho�ize rep�eaentatives oF�his Counly lo en�er ' upon t�en�ioned propeny Io�inspeUion purposes. � ���.� �,�-.��G Signalure of Perminee Dote SFF REVERSE FOR EX►LANATORY IANGUAGE , �' , . � � � . y� �1�; M z� �� 4 . . . 'rt�: a�L� z.� " °n 'c_+� z � e � �'a�' :O T�� 1 c� N 6��� 4 2t • I t 1 �� r� °'" 's.•" �i -p ' . . �,, . 1 :o.� � c a ;� . .�+ . ', ' , ' i , �n j r �n 'V in O . . � ' ' ! � T, ��� ., C`-' � ' . '.i ' � , _ NZ �,y ta; n �,� � . . -. , ' ,, s`�U�° ''.D _ ''` • a^ : . . �1 . . ' , .yt I t " , � ' . .. . ` ' � '�. . � ro • . ' ' ' ' ' ',` .'11 ` •.1 '. .�,` �� � ' . _ . 1 � . � . "�' ' � . '' . •1 �i � ' . _. O � ' . � ' V. -__. . ,�fl` ,.� 'I�` ,�� � P , . . � � � ' ' ... ', • '.' i '� n , �, .. , . ' , , ' . ' "''. 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