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HomeMy WebLinkAbout1448A (8) � WORKERS'COMPENSA710N DECIARATION � I hereby affirm that I fwve a cenificoie of consent to self }1 .insure,or'o cenificate of Workers'Compenw�ion Insuronce,o� �d.+e.ao ' U a certified co IF1l�QOI(SQC.SBOO,LU{]C.) . CEBCB�REV.1187� qpp�ICATION� FOR PERMIT � � PolicyNo..�.651@ompany,yst_ 7?IIYI(� i ❑Cen�Red copy is hereby furnhhed. ,; � - SEVIIER - SEWAGE DISPOSAL � i �Cartif�ed copy ii filed wirh the county bui�ding inspec��on COUNTY OF LOS ANGELES BUILDING AND SAFETY de�26�86 I Dare Applicant T. Freeman FOR APPLICANT TO FILL IN CONNERION DATA . . CERTIFICATE OF EXEMPTION FROM WORKERS' eumm�w ..., COMPENSATION INSURANCE � n�ocess s*nnaa otrtH (This section need not be compleled ii the work invo�ved by the i�iirr MANMOIE REFERENfE ' ��R permit is for one h�ndred dollurs(3100)or less.) I cenify rha�in �he periormance of the,work for which�his PossSsr. �YPEOFCO��T� �tr+Gt�+F°au permit is iss�ed,I shall not employ any person in any manner Y� [uaB r.i. M�.ro r�. w as to become subjec�to ihe Workers;Compenaotion Laws. (�j(1e11 (} m.iru.Np. joe r�+o�. 0 Z�� OwNER ' . . . . M411 TPUNK PFRMIT NO. RWO PERMIi NO. Du�e ApplicoM nooa[ss PO B07C•• NOTICE.�TO-APPIICANT: I(, af�er makinq �his Ca.ti(ica�e of � ��T� TEir�O arrionvrt wwi�rtR EFSEMENI RECORD.INSTR.NO. DnfE � �piion, you should become subjett to ,the Workars' LfG�L penwlion povisions of the Labor code,you must forthwith o[xaiorioni toTr+o. Nwy.pe sT.wioer�ric ._�nply with s�ch provisions or this permit shnll be deamed fEVOItCtI. � BLOCK TRACf STAIE ENCQWCHMENT ' GCENSED CONTRACTORS DECLARAiION � r.q.or�p�s. vEaMrt rao. S�ZE OF l01 NOW ON tOT I hereby affirm rhat I am licensed under provisions of Chap�er �� V(commenting wilh Seclion 7000)of Division 3 0(the Busi• gunoaaGS p��q�5 neu and�rofessions Code,ond my license is in full force and � effect. � �pniTQ�ctpR CONNECTiONCH�RGEFEE license N�mber�%dSL37 Lic.Class � (,'�, ��Eu R[iMBUQSfMfNT i[F �„ � Con�roc���'PAl11AT Dote R/7�/f3� nTv /�t8 OIDaEL. D�SLRICTNO. GROUF MAP PRp�E55FDlY 0 ❑I am eaempl onder Sec. of Ihe L.A.Co. ��E��r.q_ p °C" ( � � � � v 8V' Cln$$ � �+0. DESCRIPfIpJ pF VYORK fEE � Plumb�ngCodeond/or5ec. ofthe pNA� ay VALIDATION W 110VSE SEWER COANJECTING f0 00 D�iE I L�fl y B.8 P.Code for fhe following reason � w°��c seweR $FMIC TM1K.SEEP�(�R7 OR pNA� 6' PITS AND/OR DRAINf1ElD ' {/� �t� IqUY SfYIER CONNECfING i0 s� � �. - PRIYAIE DI YS1EM � $ignOlVfB CONNKTADDITIONn.IOlW.OY � � ' OWNER-BUILDER DECLARATION 'N�K TO NOUSE SFWER . Jf lOW E R %,DRAiNiiElD 1 he�eby affirm that I om ezampl irom Ibe Controctor's Litense EXIN.,�[5$000(,DQYW(lL,M/.NNOIf ^ law for�he follawing reason�Secton 7031.5,Buisness and Pro- arert,rtcvaic oa ns�r+ooN Nous� � �� 4 Q$A ' 'ons Code): SE'NFR d+a5aO5M srs�FM .,�i,o�owner of ine properiy,or my employees wiln wages as f�' ' ' � � � the�r sole compenwfion,will do�he work ond ihe�trvtlure is not intanded or offered for sole(Section 7044,B�siness � ^ •2�,Jr� and Profess�ons Coda�. OWNER'S Permit s 1� rj0 ❑I,as owner of the property,am exclusively controcting wirh AUTHORIZATION TOTAL FEE � `-' �C 7•`r''�� IICE�SCd COIIhOC1015 10 COIISI�VCi 1FIG�J�O�B[I(S@C�IOII JOAA, 1 MA�E AT TNIS DAiE A CONiRI�C7 WIiM THf MEREIN NP.MED CONTRAC704 TO o 8 2 9-8 6 Business and Professions Code). cavNect rHc aeovt ocxe�eeo exanr+c oweiur.�ro rvrt Pv�ic sEwta. CONSTRUCTION LENDING AGENCY ► I he�eby affirm Ihal fhere is a construction landing age�cy SIGNEDTHIS � DAYpi 19_ � for the performaoce of Ihe wmk fo� which ihis permit is ��ROR - OWIfRSAGfNT issoed(Sec.3097,Civ.C.). nnpctss lender's Nome lender's Address I certify Ihat I have read ihis opplicotion and state�hot Iha � above informotion is correct.I ogree Io comply wilh oll County ordinances ond Slale lawz ragulating Plumbing and Sewers, and hereby o��ho.i:e�epresen�aiives of this Co�nty to emer � upon 1-obova-mantioned property for inspeclion purposes. � � ' p ,�.,Q.�e-swrv ��?�G/I"� Signalure of Permiltee Dote SEE REVERS[iOR EXHANATORY LANGUAGE ' �n 7 ' . -: '...'' :._ +4 � o�r� i'-., w C� �_j � � . . � 'i � ' n �:f' ^ n v z 7 - . 1 � � � 1 � F 7 Gl�, � �) }��� (� � . , . ,I ; I 'i � - :_ �';z .^, i � . i ..^ 5? �n O�r � 'O �- � � � ' , :; }-� 1' ❑ r.�, �.�� ;; 'O . � , , I i , • -;��, �,� ��"' r �>� � � . T',• ` :' � u, � r ^r < : . 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