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HomeMy WebLinkAbout1465A (8) � WORKERS'COMPENSATION DECIARATION I hereby affirm that I have a certiflcoie of tonsent to ielf }l ; insure,or a'cenificate of Workers'Compensation Insurance,or �n..6aso U PolkyNo.`°P�eosm��Y°°s�:`�'�und� . CE809"`Y."°" . qppLICATION FOR PERMIT ❑Cxlilied copy is hereby fornished. � � . SEWER - SEWAGE DISPOSAL L]Cen�fied copy is f�led wirh the county building��spaceon COUNTY OF LOS ANGELES BUILDING AND SAFETY de�°r ment. Dare V 26 86Applicant T. FT@BID811 FOR APPLICAN7 TO flll IN CONNECTION DATA . CERTIFICATE Of EXEMPTION FROM WORKERS' �npm� COMPENSATION INSURANCE nooxtss siATior� o�°�N (This section need not be complefed if the work invo�ved by the �a B� MANHIXE REFERENCE ��R permit is fa one hundred dollors(SI00)or less.) ��A��TY 11A4E5T TYYE Of CONNECTION �[1.1GTH FROM I�cenify that in�he periormance of the work for which this �RpuST. v. CUR6 v�. �rn.t.iov,�. permii is iss�ed,1 shall not employ a�y person in 6ny manner P.C.NO. so aa to become sobjecr to rhe Workers'Compenwtion Lows. owr�[a � co.i�+v.Np. �oe No. �y �`�� TRUNK PERMIT NO. ROIN PFRMII NO. Doie ' APPlicant a°°REu NOTICE TO APMICANT:.If�_p{iB! moking �his Certificote Of ���, AFfIDAVII WAIVER E�lSEMEN� RFCORD.INSTR.NO. DATE '�ption,� you should bemme subjett �o the Workers' COQ�n$ TE�.r�o. � nwlion rovisions of Ihe Labor code, ou must for�hwith ��'°� P� P Y oEScaimiou LOTNO. HWY.qiST.Wlp(NING comply with such provisions or this permit shail be daemed � revoked.' � ' � eio[K TRA�f SfAiE ENCRO�CHMfNT ' �' ' 'LICENSED CONTRACTORS DECLARATION� rio. eiocs. vcaart rao. � sae a ior riow aa ior I here6y offirm that I am�icensed under provisions of Chop�er 9(tommenting wi�h Section 7000)of Division 3 of the Bvsi- �ioir�GS SIIl • �e�• o�a,kc.�5 nes�ond Profeesions Code,ond my license is in full force ond effacr. �pNraaooa re ]�8n CONNECTION CHARGE fEE li[en5e Nvmbe�4'I4BS7' Lic.C1osi�,ti�A ADDRE55 � REiMBURSENfNT f�E � � T• lieem�Y 8%26/86 DRLRiCTNO. GRWv Mnv PNp(,E55EDBY a CoMroclor Dnie ��7y �tra Tl�ma- rELr+o714 980� 2 � � V ❑I am eaemp�under Sec, of the l.A.Co. ilcc�rasE nq. 47488 1 ciass �+ 4 r� � � Plumbing Code ond/or Sec, of the �� DFSCRIPTION OF WORK �c RNAI � 110VSE SEWER COIWnECiING TO DAiE VALID ION ���«,�R ov z-l�-a 7 � B.8 P.Code for the following reason $(PTI�T�NK,SEEOAGE R7 OR pW, PIiS AND/OR OR.�INfiEIU FINAL N Dete �qUSE SfwfR CONNfCinV(Tp B� Z ' � ' �iYnTE DiSt�OSM v hM � Signo�ure mra�tt nnortior��i�oc.oa � ' OWNER-BUILDER DECIARATION W��TO MOUSE SEWER OVERf�OW EPAGE VIT,DRAiNfiEiO 1 ha�eby affirm fhal I om exempl irom Ihe Conkotfor's license E%TN.,C[550pp�,DRYWEIL,MVNHIXF Law for�he Fallowing reoson�Secton 7031.5,Buisness and Pro- urea,xtvnie oc�aeNopri�se . \;OnS Code�: YWfR OR DI$PpSN M51FM �1 4 6.5 A � u11,oa owner of tne proper�y,or my empioyees witn woges os Iheir sole compensation,will do the wmk ond Yhe slrodwe . �+• e • • � � is not intended or offered for sole�Section 7044,B�siness and Profess�ons Code�. OWNER�S Permif f / Q ❑I,os owner of the proparry,am exclusively controcting with AUTHORIZATION TOTAL FEE 'd � •�G 7�5� IiCEfISCd COfIf�O[IO�S f0 COnSINd tltG PIO�Gd�SCCtIOtI 7W4, �qpyE pT TMI$DATE A CONiRnCT WITM TI#1�EREIN NAMfP CONTRAQOR TO •� a Z�,J�� Business and Professions Code). ca+Nca TH¢nsov[oe5ca�aco ez�srn.�c uweu�r+c To rre ausuc seweR. CONSTRUCTION IENDING AGENCY , o�.2 9—8 6 I hereby affirm thol fhere is a construction lending agency SIGNEDTHIS DAYpF 19_ for the parformonce of the wo�k for which this permit is �'�R�R its�ed(Sec.3097,Civ.C.). owr�wsnc.[N ADDRE55 � lender's Nama . lender's Address 1 tertify thal t have reod�his opplica�ion and sta�e�hat the � • above informotion is correct.I ogree to comply wifh oll County - ordinancea and 51ate lows regulating Plumbing ond Sewe�s, and he�eby au�horize•representaiives of this County eo enter vpon e obove-mantioned property for inspec'on parposas. - ���U ��o ..,v�/2L/�'� Signature of Permittee Dal � fEE REVERSE fOR EX►IANATORY IANGUAGE � � ;,: . . • . " . . 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