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HomeMy WebLinkAbout1447A - WORKERS'COMPENSATION DECIARATION � I hereby,off�rm thot I hove o cenificote of consent io self .ins�re,or a certilicote of Workers'Compenwlion Insuronce,or 16�6/7D �� o certified Qy�hereof(Sec.3800 �ab�., �E8o8�RE�.��3� . APPLICATION FOR PERMIT " Polky No. v8 lOCompony St. F11Ild ❑Ce.tified copy is hereby furnished.. ^ � SEWER - SEWAGE DISPOSAL � � �]Eenified copy is filed with�he co�nry b�ilding inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY deportmenf. c� � . oo�e'8 C) cApplicant T. FTB@m811 � FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICA7E OF EXEMPiION FROM WORKERS' ewianic � � �ONIPENSATION INSURANCE ��u 66 Q8t sunaa oearH �This sectioo need no�be comple�ed if the wwk involved by�he ��im, a � ' M4NNOLE YEFERENfE °P°EQ permir is for one hund.ed dollors(5100)of less.) ��5� trreoFcorataar� �[wctHcaaM I terlify�fhat in the per(armance of Ihe work for which Ihis [xO555T. r�,Y1Q811 Glen y, �ap p.�, ML.TOV.L. permie is issucd,I sholl nol employ any perwn in any manner p�� ) `/ so as�0 6ecome su6ject eo the Workers'Companwlion Lows. p�yr.ica Anden G CO�1AAP��� �^p� I d y6 I . . M0.11 TGUNK GERAUT NO. ROM iERMrt NO. pole .. ,.. 'ApplicoM ADDCE55 _818 � — AFilOAVIT W4NER EnSEMEM ffCO4D.INSTR.NO. 04/E NOTICE TO APMICANT: If, ol�er making �his Cerlifita�e of �irr �iO4iIIeL h��r+o. � �plion, .you should,become subjxt 10 the Workers' iE�i ensotion provisions oi�he Labor code,you must forthwith p¢XR�riiord �OtraO. 1 NWY.qtST.WIOENING �.�nply wiih such provisions or ihis permit shall be deemed L flWOkl�.• . . .. . lLOCK TRACf p SiAiE ENCQO�CHMENT � � IICENSED CONTRACTORS DECLARATION Np,pf p�pp5. VERMIT NO. 52E OF LOT NpW pN lOT �hereby aHirm 1ha(I om licensed under provisions ef Chapler �� 9'(commencing'wi�h Sectian 7000)oi Division 3 of�he Busi• Bo�LDir+GS SZII • R88 cN�x,�s nass and Vrofessions Code,ond my licenu is in(ull force ond eflect. CONi4ACT0R CONNFRIpH CHac(�f� License Number 474887��;�.c�a.�� C34 ,,�u ���,��,�E � d Contr«tor T_���e R/9F/R� �,T;, �t8 �Oma.�+o. o�sra�rq. csouv m.w vnocesseoer V F�TE �i�. 1 a � � �p� ❑I am eaempf under Sec. of the L.A.Co. uCFtiSE r+0. 88� nn55 PlumbinyCodeand/orSec. ofthe ^p� DESCRIPTiqJOFWORK �e FNA� V R/�l C Yw[R���r NG ra UATF � � VALIDATION 6 8.8 P.Code for the following reoeon v�i IANK,$EFPAGE%T OR �+ VILSANO/ORpRA1NFEID FINAI , 'Z �O�! IqUSE YWEY CONNECTING TO er , ORIVA pISV05,LL SYSTFM S9�oru.e ���T^��r��.� � �1 4 4 7/{ OWNER-BUILDER DECLARATION W�K To�ou5e s�vha , OVEYFiOW$[EiK,E PoT,OR�iNFiEID I he�eby affirm thot I am evemp�hom the Conrracror s License E%iN.,�SSVOOL,ORYNRIL,NdNMOIE k• • • • � O Lnw for the following reoson(Sec�on 7031.5,Buisness and Pro• .ute4.k[vr,iq at,�.9�Npora rqus[ �ons Code): . s�wEa oa asrosu svshM . .�1,os owner of�he properry,or my empioyees wiih woges os � ° •2�•5� rheir sole compenwiion,wcll do rhe work ond the stroc�ura • A •2�,5 Q� is not intended or offered for sole�Seuion 704d,Business � ond Proiessions Code). OWNER'S Permit 5 0 a 2 9—$6 ❑1,as owner of the property,am exclusively tontracting with AUTHORIZATION TOTAL FEE '1 � licansed controUors to construd ihe Pf0�8C1�SC[ilOf1�O/4, 1 NAVE AT TMIS pATE A�pNtYA�(WIM T11E lEFEIN NPMEP CONiR�CiOR 70 BUSInlSS and Plof0551On3 COdeJ. CONNER iNE ABOVE DESCRIBFD Fx15TING DWEIIING i0 iNE PUBLIC SFWER. CONSiRUCiION LENDING AGENCY � , t he�eby offirm Ihal fhere is a construcfion lending agency SIGNEDTHIS � DAYOf 19_ for fhe parformance of the work for which this permit is , a'^�"'FRo° pWNERS AGENT issued�Sec.3097,CW.C.). �ooae55 tender's Nome lender's Address � I certify ibor I hove reod fhis application and stare�har�he . � - a6ove informotion is correct.I ogree�o comply wi�h oll County ordinantes ond S�a�e laws reguloting Pl�mbing and Sewers, and here6y outhorize rapresantativas of�his Co�nty to anter ' upon 1 e above-mentioned prOperty for inspection p�rposes. ���w �/�J�� Signolura of Permillee Dole SEE YEVERSE FO�EXKANATORY IANGUAGE . ' � � ' � - >g N� n� r� ti�n 7� � 9'y � z c c� . , i � : . . . I ' ' � zp n� t�, �_, `, ti . i o � � � � i ' ' j _ - �7 m� ;� Or� 7ii (1 , -� " y �>.� �� r , . j,= �� �� �p �" i�; �^ z , I (� T �t) �C i, � ' � . . T �� D 7 � Ci�� O . � , � ; � � "_" '. 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