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HomeMy WebLinkAbout1462A (8) � .WORNERS'COMPENSATION DECIARATION I hereby offirm �hof I hcve o certifimte of toasent to self ! iniure,or u certificate o(Worken'Compenwlion Insuronce,or �6A6RD i� i ocerfifiedy�y,(6yqq((Sec."3800,1c1.�.,�d CEA�BIREV.1/871 APPLICATION FOR PERMIT � Volicy No.�0071 V Compony �z � � ❑Ceniiied copy is hereby fu�nished. � SEWER - SEWAGE DISPOSAL � �Ce�+ified copy is f�led with ihe counry building inspection COUNTY OF LOS ANGELES BUILOING AND SAFETY l department. ' � � oore 8 Z6 86Appliconl T. FreeRlBn FOR APPLICANT TO FILL IN CONNECTION DATA , CERTIFICATE OF EXEMPTION FROM WORKERS' �qpn.K, .COMPENSATION WSURANCE, - �ooc�55 STATION oerTN 1 (This section�need not be tompkted ii ihe wwk involved by the i��in, MANNp[REiERENCE u°°E R ! permit is for one hundred dollors(:100)or leas.) I-cerufy�hai in rhe pe�fo.�„a�ce of�he work fo.which rh�s C�us57 . rrr�orca+r+ecno.+ �[NGiNfYOM . S IV8t1 Glen r. cuRe ri. M�.7ov.�. permit is issued,I sholl nol employ ony person in ony monner P�� � so os to betome sub�ec�to the Workeri Compenw�ion lows. pwr.�R �1'lden �����"^��,q� �"�� ��-8 . ' � 'w'�� TRUNKiERMITNO. RO�D4FRMITNO. Dote -� � Applicont ^�u NOTICE TO AVPLICANT: If, afler makin �his Cerlificote of aFriw.wr WAiVFR E/SEMFNi wEcoRo.irasrn.r+o. unrt 9 CITY TEL NO. � piion, you should become s�bjett fo Ihe Worke�s' �GA� �r �pensa�ion prov�sions of�he Lobor code,you mus�forthwiih p¢xainrior.i ioTra. 'O NWY.ORST.W10fNING cortrply wilh s�ch provisions or this permi�sholl be deemed C revoked. � � eiocc TRACf p ST/.TE FNCRO�CHMfNT ' � � 'IICENSED CONTRACTORS DECLARATION ' r�°.a�°cs. v�pMit rq. I breby off�rm fhot I am licensed under provisions of Chop�er sit¢ovior rawonior 9(commencinq with Sec�ion 700p)of Division 3 of the Busi- e iuio�s $�II cM�x.�s ness ond Professions Code,ond my license is in full force ond _ I efTeCl. oo�'/ (+ CONTR4CT0R COr+NECTION CHARGE RE :, LicenseNumber���VVf LI[.CIO51� � C3�� A�RE� 822 R[IMBURSEMENTiEE a I COnIlOC�oIT� li'eCIDHTS DOIB B�J�/8[] � �tg TOID.�I.�. — D�STqiC7N0. GGOUV BK AV.P � P40CESSEDBY V atr �� ❑�om eyempt under Sec. of fhe l.A.Co, iKer�is[rq. a�ss la �°� O • Plumbing Code and/or Sec. of the �� ��R�PT�ON OF WORK rte Fir�ai V wuscuw�aco.�.�cr�r.icro 0� onr� �_�_ VALID ION 6 B.8 P.Code for the following�eawn � °UB1����Q CTI TANK,SEEv�G(RT pR �� N PIIS ANp/OP DRAINFIEID FINAI . Z . ��e rqUSF$fw[P CONNECTING i0 BY ' , � iRN111E DISPOS�I SYSIEM f $i9nO�Uf! CONNECI AOOI7pNµ&OG.OR � ' OWNER-BUIIDER DECLARATION . w�+K'o�ousc s�`veR OYERiIOW SEEVAGE PIT,DRA!NfIElO I hereby affirm Ihat I am exempt from the Conlmctor's Litense EXTN„CE551'OOL.DRYN4lL,MANNOIE � . taw for the following reason(Sacton 7091.5,Buisnesa and Pro- nirta,atowia Oa�ewNppri�nous[ � , `'(ons Code): xwEa oa wsrosu srshM :^1 4�i 2 A ; .� os owner of the F'oFertY,cr my emplo•ees�vi!h::�o es as �heir sole tompensotion,will do�he wo k ond�he ahvc�we . $�° ° ° • � � j is noi�niended or otfe�ed for soie(Section 7We,B�s�nesa permif f � ( � •2�,5� ' ond Profeu�ons Code). OWNER'S ' ❑�,as owner of the property,om e�clusively controctinq wi�h AUTHORIZATION TOTAL FEE a � e 2 7,,�r l�� i licensed coMractorf fo consfruct Ihe projeN(Sedion JW4, �MAV[AT THIS DATE A CONi4ACf wITM T11[11(RFIN NAMED COMIRACTOR TO Bus�ness and Professions�odeJ. <oN�cr THe neovE ocscRie�o FxisnNe owfuir+c To tnc vusuc 5[weR. � oa29—ab CONSTRUCTION LENDING AGENCY , � I I hereby aH�rm thm rhere rs a consrruction lendtng ogency S�GNED7Hi5 DnvOF��i9 ► ; OWNE4 OR j for the performante of the work for which this pe�mit is . p�y�oS��M Issued(Sec.3097,Civ.C.J. . Ap�RESS Lender's Name � Lender's Address I ceHify�Iwt I hove read fhis applicotion and s�a�e that Ihe obove infprmation is tared.I ogree 10 comply with all County � � ordinontea ond Stale laws�eg�lating Plumbing ond Sewers, ond hereby outhorim representalivea of this Counry lo enler upon e obove-mentioned property for inspection purposes. � ��, ��� � �/��L/�'� �Signo�we of permittee Do�e ��� SEE REVFRSE FOR E%MANATORY IANGUAGE , � ' . . . . . y`+ c+7, n y mf1 � , ' � � � ,�'�, � �" C O . . . _ ' ; I 1 1 � 1 j p n D(1 Dx� ,}n VS �� �2 . � � . � . 1 ' O _ cji <�. rl' �n '.. S ' • ' i C)7 V v (S .V' (�� L � ' . '• i !, . _ ^, 7�y '"u. � iin AD -iJ - l.' I , ]�-" C � ❑ r� U 'C ; � i' ' � ' : � . :i t,' �n�n 7•` f.3 .7 . . � �c ;:� "'o '�: u Q . . � . i T� �•� . . '. � . . � � � � ..—.. �,! SC,D Na, .o Oc� ^y C . . : . ' ' �ulAi' SA � ' �� � . .. , � i : "" —" " I � i I ; N� , � I I � ' N � . .. . m � ' ' � � , _J. . ._ . . , n � � i i � , _ � , 0 _._ __ . _ ,' i . � l . , , � j .'. . 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