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HomeMy WebLinkAbout1450A (8) . WORKERS'COMPENSATION DECLARATION I hereby oHirm �ha� I have a cerrificme ot consen� to self � � �- S'► insure,or d certifica�e of Workers'Compencotb�Insuronte,o� �6"6i�o . U Po��"'fN��,g'ti�.�`O��SK.3BOO L bC. CEBC9�REV 1/831 APPLICATION FOR.PERMIT y ��Company .��• �Cl �Certiiied copy is hereby furnishad. � SEWER - SEWAGE DISPOSAL � Certffied eopy�s rned w�rh�ha counry boilding+r,sP�croo COUNTY OF LOS ANGELES BUILDING AND SAFETY deppo meN oo��"Y26 SC qPP���o�� T. Freeman FOR APPLiCANT TO Flll IN CONNECTION DATA CERTIFICATE OF EXEMPTION fROM WORKERS' ��ipi� � COMPENSAiION INSURANCE . nooee5s stnnow otvrw i (This section need not be compleled if the work Involved by�he �.WrJNIXE QEfERENCE �q � permit is for one hundred dollars(5100)or le:s.) �ap�ITY i y rc�v�sr �rr�or conN[cnon �H('.TN iRQ4. I tertify thai in�he performance of rhe work for which lhis taosssi. y r. Cuu! 7L. MLTOP.I. ' permit is issued,I shoil no�employ any person in ony mo�ner j so�os to become subject�o the Workers'Compenwfion Laws. oW�R °����� Anden G �o.��.No ,o�� dZ& ; ��� TOUNKPERMITNO, R04DffRMITNO. Da�e� Applicant �Dd+E55 AFFID�VIi WNIVER EASEMFNI REC04D.INS1N.NO, pA1f N0710E TO AVPLICANT: If, after making Ihis Certificate of �iTy Covina �����8 8 � �-y�ption: yoo should become subiect to �he Workers' i ` Fpenwlion provisione of 1he tabor code,you must fonhwith pFxa m�ipni _ tOi n10. Hwr.qt Si.vno[NiNG � _rply with s�ch provisions or this pe�mit sholl be deemed laVO40f�. BIOCK TIIACT SIRfE ENCROACMMENT tICENSED GONTRACTORS DECIARATION ra a�ocs. `ER^"�T�'1O. I hmeby affirm ihot I am licensed under provisions of Chapter SiZEOFIOr r+OwpuiOt 9(commencing with Section 7000)of Division 3 of iha B�sl• e�uit 1�5 Sin • RP.B• ness and Professions Code,aad my litense is in full force and ��5 j� effect. �. cp�rp��rpa CONRIFCTIpN CH>Rf�iFE � I License Number 474887� ���.<�a:s C34 ' ,�,ppRF55 VG L Beehc wood IJr ff�MBURSEMENT fEE } .I T Freeman�,e S/ZOISO Di5TR1�TNp. W10UP M�P VYOCESSEDBY 4 c������+�� • ��TM Alta Loma,F�.� 1 80- ' 2 � � o I / u I ❑I am e■ernpt uniler Sec. o(rhe L.A.Co. l,ciNs�rao. - unss `J � iv0. pESCRIVfIONOFN/ORK HE Plumbinq Code a�d/or Sec. of the ����p��,,,,��T�r�c To on"Te VALIDATI N v �� B.8 P.Code(or the following�eason z�IE� .6 �y G 1 �NK,5(EIAC�E III pl iINAI �' PITS AND�OA UqAIPi1Et0 y� �O�! 1qU5E SEWEY CONNKTING TO BY Z WIiVA Y M � Signoturo coNruR.wo�T�pUle�oG.Oc . � OWNER-BUILDER DECLARATION wpRK TO NIX/5E SEWER - WERFIDW SEEiAGE PIT,pRAINfiEID � I hereby oHirm thot I om exempt{rom the CoNractor i limnse E]tiN,CESSq�OI,DRYWEtL.fMNMIXE j low for the following reason(Sectan 7031.5,Buisness ond Pro- xiEa,xFoniR qt�r�oprd wOUSE '�1 4 5.0 A ' '•ons Code): i s�wEe oc wsvos�t sxsn.�n I ,II,as owner of the property,or my employees with wages os i'' • ° • � � � the�r zole tompenwtion,will do the work and the shut�u.e , is no�iMended or offered for wle�Settion 7044,B�si�ess � � '�G 7�5� and Profess�ons Code). � OWNER'S Permit S 1Q Q Q 2 7,u 0 U ❑1,us owner of the property,om ezclusivaly conlraCting wilh AUTHORIZATION T�TAL fEE � � . licensed comroc�ors to tonstrucr�he project(Saction 70d4� �HqyE qT THI$pAT(A CONTRA�T WIiH IHE HEREIN NAMfD CONTRFCiOR TO 0-P 2 9-8 6 Business and Profassions Code). eoraratt Tw[neov[ocscaiato txiun+o ovrtwrae ro T�rueue sewta. CONSTRUCTION IENDING AGENCY SiGNED THIS � I hereby offirm thot there is a construclion lending agency DAYpF 19 ► I for the performance of the work for whith thia permit is ��ROR � OWNFRS AGEN7 issued(Sec.3097,Civ.C.J. pDURE55 ' lender's Name . .I Lendei s Address � I cenify thot I hove read this applicarion and sroie�hol the � � o6ove Informotion is corracl.I ogree to comply wirh ol)Co�nty ordinances and�State lows requlaHng Plumbing and Sewars, � ond hereby au�ho�i:e represento�ivn of�his Counry�o enie� upon he obave•menrioned preperty for inspecfion purposes. �� y ���� �'���� � Sig�ature of Permillee Date �— SEE RfVERSE FOR E%HANATORY IANGUAGE ' , . r . . � r,g My r(„' zF: �n � - • ' . i• i � ' � �I a n yn rx� �" ;n �'i 7 i i w _'�-' O m'T ��{ O-. ryi (1 ' , ; • ; F;I m rs > £�� �- �. '- z �• or , . • - ; . • ; ;m T�� ,: .� Y„ o� � � . . ' 1 �� (tc �u TN i`-' O ' . • � ' ' , • ; ; i � ^n ,� � a , , 1 . .. ; v•� K;�y N� '� �„ ^* �C . . 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