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HomeMy WebLinkAbout1466A � WORKERS'COMPENSATION DEGLARATION I hereby affirm that I hove a certificole of consent to salf _ , � � {� insure,or o certifico�e o(Workeri Compensoiion Insuronce,or 7dA6J�o II dce�tified ��fi 5i`o+,s«.�°°s�.�.�d CEBOB�eEV.I/03� APPUCATION FOR PERMIT � � ° Policy No. Compony � ❑Cenified copy is hereby furnished. • � SEWER - SEWAGE DISPOSAL � �Cerrfed copy�:filed with�he counry building i�sp«ro� COUNTY OF LOS ANGELES BUILDING AND SAFETY deparlmeM. ' � - .' . Da�e 8 6 86Applicanf T• �Fr@BII18T1' FOR APPLICAN7 TO FILL IN CONNECTION DATA � CERTIFICATE OF E%EMPTION fROM WORKERS' g�iip,r.X, , COMPENSATION INSURANCE �� �ooc¢ss st�na� otrtH (This eection need nol be completed if the work involved by the .d MnNHpIE REfERENCE ' ��4 permil is ior one hundred dollars(SI00)or�ess.) �°GUT� I cmli Iho1 in Ibe rformance of the work 1or which this �'�ST . irROFCOruNECiqru ��,p�pppp, fY , P� C405S 5T. y, CURE V.4 M.L TO F.l. permit is issued,I sholl no�employ any perso�in any monne� P�� / C so os to became subject to�he Wwkeri Compenwtion tows. aWr.�[x Anden G to.��.�a.r�0. ioa r+o. [ �s-p ADDRE55 PO BOI.. (� TRUNK iERMIT ND. ROAD PFRAVT NO. Daie ' � � ApplicaM ' avrio...w� W�IVER E1l5EMEM RFCORD.IN5T4.NO. 04TE NOTICE TO APMICANT: If,.ofter moking this Cerlificote of ��iT� f�'t�.ZOmB t¢�.ra.$18 96 � 1 ��mpron, yoo shoold betome sobject �o the Workers' IEGAL ensalion prov�s�ons of the labor code,you must fo�thwi�h pp$�RIAION - LOTNO. NWY,dt ST.NAOfN11J0 c,..�piy wt�h such provisions or this perm��sholl be deamed � revoked.- � ' etacK TRnR StA1EENCR04CMMENT • LICENSED CONTRACTORS DECIARATION p{p�pGS. YERMIT NO. I he�eby offirm that I am litensed under provisions of Chop�er sizeorior r�oworaiot us�oc 9(tommencing wilh Section 7000J of Division 3 oi fhe Busl- aWID�aGS Si Res. O1�aG[S � ness and Profeuions Code,ond my license is in full force and BfIlCf. � �1 7 ('pryTRA(TpR CONNECTIpN CNARGE FEE - license Number� 4 1 4SS 1. Lic C�ass • � C34 p�E� ff�MBUYSENFN7 iFE d T. FTeem8210me 8/26�86 ' oisre�ar+o. ccwv nua raocesscoer O Cootrodor prv Tci. � .� � v I� � ❑I'am acempt untler Sec. � of�he L.A.Co. i,�ENs�na. nAu � �� Plumbing Code and/or Sec. of the "1O. �KRivrior�oF wORK �e FiNA� V iaus�s�v+ec caw+Ecnnc ro Q O °"'� 2'S`�7 VALID TION w 8.d P.Code for tha following reason °�����R 6 - . SFPTI TANR. EVRGF NT OR Z FITS AND/OR ORAINFIEID FINAL Da�e �5E SEw�q caVnrtCriMG ro BY � - . PRiYATE DISPOS4 SvS�fM � Signolure - cpaN[ci MDitiON�t&oc.qt � OWNER-BUIIDER DECIARATION 'MORK TO HplSf$EWER . UIERfIOW EPwGF P17,ORaINFIElO I hereby oHirm thot I am eaempt from Ihe Controcror's License E%TN-,CESSPOOL,DRYwEIt,M�NHOIF law for the iollowing reoson�S�C�OtI 7O3I.S,BUISI1G55 OlICI Pf0• Al7ER.REP��R OR ABI�NDON MOUSE t)ons Code�: stwec or+wvosa srsrtrn _1f��1 nwn�.of r6.�.rnFp��Y.e•r�y emp!oyees wi!h:vo�es oe ^1 /���r their sole compensation,will do the work and ihe structure is nat intended or offared for wle(Section 7044,Business �• • ° • � � and Proiessions Code). OWNER'S P¢rmit f '� ❑I,as owner of the prope�ty,am extlustvely contracfing wi�h AUTHORIZATION TQjAI FEE pf( ,j � ' °2 7•5 O licensed contraclors to conslrucl the projetl(Section 7044, I HA4F AT TNiS DATE A COMTR�Cf WIiM ME HEREIN NnMED CONTNACTOR TO s � d�]'l,C O BUSineSS Ond PfOfB5510n5 COdEJ. CONNER TNE ABOVE DESCFIBED F%ISTING DN4LUNG Tp TI�%1BLIC SEWE4. G i � � CONSTRUCTlON LENDING AGENCY oJ� �t� � ► D$2 9-8 6 1 hereby af(irm Ihal the�e is o consfruclion landinq agenty SIGNEOTHiS DAVOF � I9 for �he performance of the work for which this permit is °W"�ER°R OMmECSAGENT iss�ed(Sec.3097,Civ.C.). ADDRE55 lender's Name lender's Address 1 certify ihat I have read�his applica�lon ond stoie fhat ihe obove informotion is cwrect�aqree�o comply with oll Covnty , ordinonces and Stole lows regulo�ing Plumbing ond Sewars, � a�d hereby au�horize representotives of rhis Co�nry ro enfer upon e above-menlioned property for 7nspec�io�n+pu�poses.J/� � � ����iL7C�I1�[� �+/C.(i/�+� ' Signolure of Perm"tlx Oole r SEE REVERSE FO�L%rIANATORY IANGUAGE . , . • .. . " . . �� rr c�r h! =x: cC) ' - � ' � � • .� j ' o n z0 •-y �; p� ,� � � ' ' >:� �� o; 7 : . i _� i j � i � � - Z;; �V z, xy <�� n r . . � � � . 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