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HomeMy WebLinkAbout1464A (13) ' WORKERS'COMPENSATION DKtARAT10N ��� � 1 hereby affirm thot I have a cenificate o1 coneent to eelf ins��e,or e terlifi[als of Workers'Compenwtion Ins�rance,or 76A6l1D , '� a«�,;+;�so rhereof(Sac.3800 Lqb C.) CEBO81REv.li8J1 APPLICATION FOR PERMIT " Po�icy Nc7b� �.� Company $Tr• �'11I1d ❑Cerlified topy is hereby fu.nished. .- SEWER • SEWAGE DISPOSAL � �Certified copy�s filed with the counry building inspecrion COUNTV OF LOS ANGELES BUILDING AND SAFETY departmenL L' � Dote,�/?6f 8VApplicanl T• Fl @eID3II FOR APPLICANT TO FILL IN CONNECTION�ATA . CERTIFICATE OF EXEMPTION FROM WORKERS' eunpm�c COMPENSATION INSURANCE aooaEss sratror+ otvrH (This aeciion need not be compieted if the wwk involved by tha i�iitY MnN�E RE�ERENCI i°PE R � permit is ior one hundred dollors(S700)or Iess.J �a BA� rE�xcsi na�a eo�+aawa �r+crH Faoen I cerfify thoi in �he performance of the work foi which Ihis ceosssT. .�l 198t1 Glen r. cuce v�. M�.tor.i. � permit is issued,I shall not amploy any person in ony monner o_�.�_ �Q�� m as to kxcome wbject to�he Workers'Compenwtion Laws. pW�R Anden G CO.IMP.NO. JOB NO. ��� PO BOY"�J27 TRUNKVERMITNO. ROAOPEQMITNO. ! Dole ... . .��� ApplitaM ADDCE55 � NOTICE TO APPIICANT: If, ofier moking ihis Certificate of aTr nvwonwr w�ivec E�SEMfNT eecaeo-uura.rao. o�r[ � �npfion, yo� should become subiect fo the Workers' Covina ,��.�. 8i8 967-9 41 �pensolion rovisions of�he Labor code, ou must forthwith ���� b9 P Y OFSCRIPTION lOTNO. HWY.O45T.WIOENING camply with sucVi provizions or this pe�mit shall be deemed ZC C revoked. � � etocK TRAR JJ�Dl � ST�TEENCROACHMFM �� llCEN5E0 CONTRACTORS DECLARATION Np pF&OGS. PFRMIT NO. SRE Of LOf NOW ON LOT I hereby�offirm�thot 1 am licensad under provisions of Chapter ��� � 9(tommencing wi�h Senian 7000)of Oivision 3 bi the Busi- eunoin+cs CMARGES ness and Professions Code,and my license is in full fwce ond �w /� � e(IBCt. CONIRACTOR �epimpY V�nB�• ��NEC��ONCMARCfFFE � licanseNumber 4748e� LiGCIO55 ' C'�4 . AppqE55 V22J Beechwood Dr• ���URSEMEMFFE a 8/26/86 714/980-4429 °'S�""`"° �°°"" ""° �aE55ED8Y � co�+�a�+a�T. Freeman oo,� �,,;Alta Loma - ,E�.,�. BK � ❑1 om eaem t under Sec. of the L.A.Co. 57'°tE uc /d 'r� e! , P ucEns�r+o. unss � alombinq Code and/or Sec. of�he � �FSCRIPfION OF WORK �c R�,q� � V N�c�:ERca+.,ecTn+cro l � DATE Z_r�,y7 VALIDATION a I B.8 P.Code for�he following reoson 0 N � YVfIC TANK.SEE7I.GE%T OR � PiTS AND�OR OR�INFiELD BY A� Z �1p . MDUSE SEwER CONr�ECTir�G 10 � I . VRIVAff��SPOS11l5YSTEM $Ig(IO�UfQ CDNNEC.7 AOOITIONAI&DG.OW i OWNER-BUILDER DECLARATION worzc ro r�oust s�w[a � � OJERFIOW SEEPAGE RT.DRA!4F!El� q '1 I hereby oHirm thal l am exempt from�he Contracfor's licanse ExTN.,CES$ipp�,DRYWEII.MI1N1101F � I µQ�A law for fhe following reason'SCC}Otl 7O3I.S,BI115f1lSS Ofld Pf0- µiER,REPAIR�R A&1NpON hKKl$E � (O�S COd@�: 3EMIER OR d5oO5Al WS�EM D • o e O .-ult,os owner of the property,or my employees with woges os � e s 2'],5� their sole compenwtion,wil�do�he werk ond Ihe sfrudu�e is not inlended or oNarad fo�sole(Section 7Wa,Business � �` and Professions Code�. OWNER'S Pe�mif S Q ,j'(� � A �2 7.,�.�c=i ❑I,as ownar of the properry,am eacl�sively contradin9 with AUTHORIZATION TOTAL FEE (' IICQIISld COIIIIOCIO�S t0[O�S�fVCi 7I1C pfO�Gtf�SpCliOf1�OAd, �HAV[AT iH11 DAR A CONTNACT WITH TME HEREIN NAMfD CONTRACipR i0 0 S�2 9-8 6 BUSInC55 and PIO�BSSIOf15 CO[I2J. C0�INFCT TNE ABOVE OESCRIBFD FlltSTING DWEIIIlJG TO THE PUBL�C$EWER, CONSTRUCTION LENDING AGENCY /7�� , I bereby offirm rhm ihere �s o consnucnon lending agency SIGNEDTHIS � oava uti`� _tv_ for the per(ormance of ihe work for which �his permit is a+''NEaoa issued(See.3097�CiV.C.�. OWNfRSAGfiNT ADDRESS � lender's Nome � lender's Address I cer�ify�ho1 I hove reod this opplitolion ond e�o�e�hal the obove informo�ion is ewreet.I agree to tomply with oll County ordinontes ond Stote lows reguloling Plumb(ng ond Sewars, and hareby authorixe representotives of this Caunty to enter upon e above•mentloned properly for inspectian purposes. � ���� 7��•� �/�.�/�' . S�SignotureofPermi�fx Dole SEEtEY[RSFFOREXKANATORYIANGUAGE �� . - � . - , . ' � T r, p r �,.. ^ p�� �,n m . � a'�^ �iL Zv «; : � I . ' i ' � o n Dri �: u� - t. ' ; j � � I � 7C) 1x' fl ��' � �Z �'n ,� i .. S . � i � i . � . . in j� C1 0 � L G�i C � . . � _ � i ; . . :� yl T.. i n i fi '^ � • . i � j= T_ yN O �•� m �y . � . 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