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HomeMy WebLinkAbout1449A - WORKERS'COMPENSATION DECLARATION I heraby affirm tha� I have a certifico�e of to�sent ro self , � , inwre,or a cer�ificate of Workers'Compenwiion Insurance,or 76A6<1D . i�l a<er�lfied copy rhereof(Sac.3800,�ab�., CEB09;REV.1/677 APPLIGATION FOR PERMIT � Polity No.Z6851(lCompany S'f'� �j�]'Ifj ❑Cenified copy�s ti«�b,.r�.��.h�. _ - SEWER • SEWAGE DISPOSAL � �Ceprtp�fier�d cyopy ia filed wi�h the counry b�ilding inspection , COUNTY OF LOS ANGELES BUILDING AND SAFETY pa�e�/ZO�/gE) APP���o�� T• FT@8II18Il FOR APPLICANT TO FILL IN CONNERION DATA CERTIFICA7E OF E%EMPTION FROM WORKERS' ymprK, CAMPENSATION INSURANCE ' �ooit[ss sianari o[nN (This sec�ion need not be completed if the wor4 involved by the �w�y.qiE q[�Ea�r� ��p IOULiTY � perm��is for one hondred dollors(5100�or lxa.�„ nE�qcst rvrta cor�wxcran ��iN�� I ceri�fy�hor i�rhe performonce of tMe work!or which this �ipssst. r. cuae 74 M.LTOP.L. permil is iss�ed,I sholl nof employ ony person in ony manner p�� so as b become subject to Ihe Wor4ers'Compcnsoiion taws.. oww[e Anden G - �o.��.No. ,o,�. p�-fr/ Daie �ApplicaN �"�oo"aess PO BO7L— Z rau�x v�anvi no. ao�o ccru+rc ruo. ALiIDAV1I W�IVF4 E�SEMEN( RFCORD.INS�R.NO. DAiE . NOTICE�TO APPLICANT: If„alter making Ihia Cerlificate of �itv .�.�t$ Om9Np� F�- ption, .you should became subjett to the Workers' � �pensation rovisions of the labor code, o�m�s�forthwi�h �GA� ' Zl P Y DFSCRiVT10N LOTNO.-� HWY.pq 57.WIDENIlJG �_.nply wi�h such provisions or}his pe�mil sholl be deemed c revoked.' ' - aiocK TRACT p� SiAiE EIJ�ROA�MMEN7 � ��UCENSED CONTRACTORS DECIARATION rq,pF&WS. VERMIT Np. SIZEOF lDT NOW dJ LOT I hereby�affirm�hai 1 am licensed onder p�ovisions o1 Chapter �a 9(commendng wftF Seaion 7000)of Divisfon 3 of the Busf- euimincs wu�s ness and Profess�ons Code,ond my license is in lull iorce ond �f{�1. CONTqAROR CONIJFCTIpJ CMAFG[FEE tice�se Number 4�l�88�Lic Clou'�� (7� ��u CFIMBURSEMENT ffE y Conrractor T. Freemanoa�e��fi�f�fi ' o�sra�crr.�o. cao�v ,w�v auocesseoav O �— atr i.ra. /v eK vc �+ �`"'� 47 887 "` � °� I am exempf onder Sec. of the L.A.Co. ii�Ns�rap, a�iss O r+o. DESCR1VfION OF wORK RE PlombingCodeond/orSec. ofihe P1NA1 VALIDAt10N � WUSE$EY/ER�ONNFCTING TO � D4TE WpuC StWFR p B.B P.Code for the following reoson i[puaK.yfP�Gt Arpe FMn� Z_ �`o� Z DOIB PIT$M!D/OR pQA1NFIElD By _ �qUSE SEwER CONNECTING TO � NlIVATE DISidSAI SYSTf $i91101UlO CqJNfGT AOpliipJN�&DG.OR � OWNER-BURDER DECLARATION +�"ro"°°s[sew�R , ' OYfQ�IOW SfEPAGf Rl.ppI,INF��D I hereby offtrm�bm I om e■empt f�om the Contraaor's License E�7N..CEiSPOOL,DRYNlELI,MANMOLE Low for the following reoson(Secton 7031.5,Buisness ond Pro• attc,qev�ia dt,�a�rlopa wous[ ona Code�: s�wEo ce wsros��svsr�M �1 A G.9 A '.,�,as owner of fhe property,or my�emplayees wifh wages as ' ' iheir sole compensation,wil�do the work aod Ihe strudure �• • d • � � is not intended or offered for sole(Sec�ion 7044,Business � � ond Protessions Code�. OWNER'S Permif S I ++2�.Jr� ❑I,es owner of rhe proparty,am exclusively conrraUing wilh AUTHORIZATION TOTAL fEE litensed conhac�ors fo cons�roct the ro'ett Seclion 7044, �^ °L�,5�� P I I 1 MAVE AT THIS DI.iE.4 CONTlACI WiTW TM[H(F[IN NAMED C0r11R�ROR TO Bustness ond Professions Code�. corar[cr r�naovt cexaieeo txisTrtaG ow[ui�ro rwt w�ic s�w[a. • 0 Q 2 9—8 6 CONSTRUCiION IENDING AGENCY ► I hereby oHirm Ihot Ihere is o conslructlon lending agency 3�GNEDTHiS � �DAVOF 19_ For the performonte of Ihe work Ior which this permit is d'�'NFR ok OWNFRSA T �SSUCd�$@G.�9���IV.�'.�. AO�RESS Lander's Nome Lender's Addreu I certiFy Ihot I hava read rhis applitoiion ond stare�hof ihe obove inlormo�ion is correct,t ogree to comply with oll Counly . ordinonces and 51ate lows regulating Plumbing and Sewers, � cnd hareby outhorize represenlotives o(this County to enler - � upon Ihe above-menytioned preperry(o�inspaclion purposes. � � ��r� �7�Ji_Q-=. �/3.t,��� SignoW.e of Pe�miuee � �Dara SEE[EVERSf FO�fJ(►IANATORY IANGUAGE � . .. . I . _ .... , , ' ;�� ac �^r �.^, Xr' Co � . . , i . � v n� r n f� �" `,-. -f f . 70 �n � C�; � ' . � � T e �� �-. Sii () - I ' � . , • ��,: �Tyi Oto S7 OY " � ' . , j ' � • � , �,� f�c O"' �t� p•'� [i 'L1 . . , � ^; �� S'�., I U(i O . . . . --- ,r','� }i N,� �u �,a ^; � ' ' ' : �E7 ..�� ;� ;$ ; i- � . � • i----...---j i !'• � • , , j � v+ : ' . y 1 , ' '' � . I �I _—�"� . . � ' ' ; ' � � � . . � : _�:� �, . U _-''- --; ; . i ' ; � . . , Y : . � � � : �. � � � . — - ' � . i , �; : . . � , � , . � 1 ; , ---- i '� �,, t R q: .. . JI . 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