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HomeMy WebLinkAbout1467A � .WORKERS'COMPENSATION DECLARATION . � I here6y offirm thoi I have a<ertificote of consenl lo sel( �' � }1 insure,or d certifimte of Workers'Compenwtion Imurance,or 16a6�7D U Po��YN�`�°�eosm��Y°°s��C�LL �EBO9IREY.1/831 qpp��CATION FOR PERMIT I ❑Cerfified copy is hereby furnished. . . , SEWER - SEWAGE DISPOSAL . �Certifled copy is fi�ed wirh�ha coun�y build�ng��eP,cr�on COUNTY OF LOS ANGELES BUILOING AND SAFETY �; �a�e�r 26'SGqPP���e�� T. FT@8m8II FOR APPLICANT TO Flll IN CONNECTION DATA . CERTIFICATE OF EXEMPTION FROM WORKERS' ��ia� � COMPENSATION INSURANCE � nooa[ss 5*nnora otttH (This section need not be mmpleted if the work involved by 1he MqNNaE qEpFpFNCE uvr�R � permit is for one hundred dollars(E�00)or less.) . �OC�uTv i rE�a�si rrvt oF cow+tttaN �cr+ctw v� ° I,cen�fy+hm in�he performonce of�he work tor wh�ch th�s cRoss st. r. cuxe P 4 M L.TO P.l. permi�is issued,I aholl not employ ony person in ariy monner so oa�o become subjed�o�he Workeri Compensoiion lows, oy�,r,ER P'�'�� !� I Anden G ro.��.�o. ,��. ' � � .. A�ff� PO OX-� iRUMK PfQMIT NO. ROAOOEQMIT Np. ' Da�e � Applimnt � AFFIDAVII WAIVER EhSEMENI RECORp.INSTR.NO. DATE NOTICE TO AVPIICANT: If, ofter making �his Certifica�e of �in. �,t�.LOjpg TEi.rip. 818 ( � � �ption,, you should become subject lo the Workers' iE�i penw�ion provisions of�he labor tode,you must lor�hwith pF5[qipT�qJ - tOTNp. ' pWy.q(ST.WIOENING camply wilh such provisions or lhis permit sholl be deemed , revo4ed. ' oiocc TRA�i $IqiE ENCYOACHAIENT �, � �5 PERMIT NO. �UCENSED CONTRACTORS DECLARATtON 5¢eoFioT raoworator I he�eby affirm Ihat I om li�ensed under provisio�s of Chopter �� 9(commencing with$ection 7000)of Div�ston 3 of Ihe B�si• euno�wGS �up�5 ness and Profe�sions Cade,ond my license is in fuil force and effecf. cpnrtancrac ma, n conuxrnon+a•ac,[r�c LicenseNumber 474887 ltc:Class C34 nooaEss 8'Z'l�j Beeehwood Dr• REIMBURS(MENiF[E y T 1 $Q� 2 o�sraKi r.a, caoua rMF PkOCE55E0 BY � Comrx�or T_ Rrawman Do�e 1��7F.�R(, urr /�ta JJOIIIB' TEL.NO. gK � � ❑I am eaerript under Sec. of Ihe L.A.Co. ��N�r.p �iAu lf7 � ' -�PlumbingCodeand/orSet. ofthe ^'�� �xRiPfiONOFWORK �ce ��N�� O ' �w,s�sewea ca+�a��ro �7 DAtE � VALIDATION �"' B.8 P.Code for ihe following reason ����Nk�S[FVAGE%T pR O V �" d FRS/�rJD/OR 02�iN��EID fINA� N Oafe Mp�$E 5FW[R CONNECiING TO BY Z . ' DfINATE pSPDS�L SYSTEM ^ Signolure CONNECr�oortiONµg�p(',.pq . OWNER-BUII�ER DECIARATION `MOCK TO MOUSE SFWER , ; GYENIOW SFEYP�E VIT,DR4iN�IELD � 4��^ I hareby offirm thol I om e.emp�irom�he Comroctor's License FYTN,CE$$Ppp�,pRYWEII,/�MNMOIF .�± Y1 l�w for fhe following reason�Secton 7031.5,Buisness ond Pro- ur¢a,a�r�ia at�eeraoaa'ausc - �(ons Code): sewea oa oisaosu srsrern � u�l,a3 owner of fhe properfy,or my employeas with wages as $�° •' • ' O Iheir wle compenmtion,will do the work and the shudure _ � • e 2�].5 p � is not iMended or offered for sale(Sedion 7044,Bvsineas � � and Professtons Code�. OWNER�S Permit s Q •-+ n C'],5 n� i ❑I,as owner of�he properry,om exclusively tomrocting with AVTMORIZATION TOTAL FEE � ,5 Q �I[lflSQd COfIffOC�OfS f0 COl151fUC1 ti12(N0�8C�(SQ[�1011 1OII, 1 HAVF AT THIS DATE A��NfQA�T WITM TIIE HEQE�N NAMED CONT4A�TpR TO 0&2 9-8 6 Businas ond Professfons Code). cor+Nea rN[neov[orscRie[o txisTirac ov.[uvie to tH[a�euc stwta. , CONSiRUCT10N IENDING AGENCY = 1 hereby aHirm fhal there is a tonslrutfion lending ogency ��EDTHIS� � DAYOf 19� � for the performonce of the work for whith fhis permil is b++�+ERp1 , F OWMERS AGFM isaoed(Sec.3097,Civ.C.). ADDRE55 Lander's Name LenJer i Address I cmtify�har I hava read�his opplicorion ond s+oie thot fhe above Info.moi�on is correcL I agree�o comply with all Go�nty ordinances and Stote lows raguloling Plumbing ond Sewers, and hereby au�horiza represeMotives of fhis County lo en�er " . opon I obove•mentioned property for inspeUion purposes. /� - - 3 5����rJI./2r�i��fL G,�15�i . ; $ignofure of Permittae Dole SEE REVERSE FOR E%KANATORV IANGUAGE � r -� - .� . , . . . . . , , . � - � �, w 4^ ,^Y. � �:�, c c : � ' ' 1 � , , �, ��, = � c� � r , ' I � I I � ' '• T F! m.� �j C�n �r T � I ' , 1 . r ' �:, � a GV � b. � c . i �� �' r4 �T' ��r Q> • -U � � �� �„ �x �O i� << 'v ' � , � , � . . :, ',c r�„ '� T . . i T r •a ; 4; ; � � � ---"� ,,: �n � �� �'� i< < • I I - � • , b O �'� � rr- .- m i �----.• ' ' li 1 ; , . � -' I i � -•j'. N ; '• . . O I I ; i i i \ (, .. , . � � . � , ' � � ; �' -, i _ �` a -� . m . j ' �n -' . - -. ---i � i 1 i � ,i n , - ' . , . ` . 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