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HomeMy WebLinkAbout1469A (15) ' VYORKERS'COMPENSATION DFCIARATION � � I hereby affi�m fhal 1 hove o certifim�e o( coasent lo self � � �nsure,or a cer�ifimro of Workerc'Compensotion Insuranca,or 16�6i7D a«,,,f;� o��, ��f(Sea 3�,t,b�,�d �E�9,aEv.,,e�, APPLICATION FOR PERMIT Policy No. Compony . ❑Cer�ified copy is hereby furnisl�ed. ��. SEWER - SEWAGE OISPOSAL � . � �I Ceriified copy is filed wiih�he coon+y baild�ng inepeu�on COUNTY OF LOS ANGELES BUILDING AND SAfETY deportmenl. ' � � �o����Applicant �+��.eg�� FOR APPLICANT TO Flll IN CONNECTION DATA. - CERTIFICAiE OF EXEMMION fROM WORKERS' q,�qpnK, ' COM�ENSATION'INSURANCE � wox[u sTprio� u[rtM (This section need no�be tomple�ed ii the work involved by�he i�i�T� M1aNMpIE REFERENCE �y permit is for one hundred dollars(5100)or less.) � n[aaEsr rvvE a conna[cTwr+ �ErvGtH rkor� Lcertify that in rhe performance of the wo.k for which�his crtosssr. $ ].QBII Glen r. cuce P.L ML.TOP.I. permit is ifsued,1�holl nol employ ony person in any manner � P�� so as�o become svbject ro�he Workeri Compe�so�ion taws. p�R Mden G w.irov.Ho. �oe r+o. �Z�� Doie� � APPlitont ' � �ooc[ss PO BOX" Z TRIINKRRMRND. 40ADRRMIINO. NOiICE TO APVUCANT: If, aNer moki�g th15 �Cl11{iCOfG Of ��n, AffIDAVIT WAIVER E Nf RECOWD.INSTR.NO. DAIE plion, you should become subjetl to the Wo�keri Covina - TE�.�. 8 8 6 - panwtion provisions o(the lobor code,you m�st fonhwith oFscelvflON LOTNO. HWV,pRST.`MDENING .. ply wirh euch p.ovistons or th�s parmi�shall be deemed C revo4ed. � ' aiocK TFACf pl S7AlE ENCROACMMENT �- IICENSED CONTRACTORS DECLARATION ' r�o.or�u�s PERMIT NO. s¢e a ioT Now ora ioT I hereby offirm thot I om licensed under provisions of Chop�er �� 9(commancing wi�h Section 7000)01 Divisioe 3 of the Busi- awioirics 1I1 n+�uc�s � ness ond Profess�ons Code,ond my license is in full fwce ond effect. d cp,i*Q�crac Tp ca�wetnoracr��ac[r�[ �ICMSl�`IU�IbN � ��T��� �i�a�5 � C34 ADDRE55 VZZ Beechwood I�� RFIMMIRSFMENiRE p } COnlraClo�• r�eem$� �olt - V/G6/86 Ciry �ta �j�tQB.' iEL.NO�l 9p0� 2 O�STRKlNO. G40Uv nv�v PROCESSEDBY O °K °G V ❑I am exempr�nder Sec. of�he L.A.Co. uCiNSE o-ip, 4�Il�8S7 ciau c3 � �a p� �+o. oescRlvrlori oF vroRK �E VALIDATION ri � Plumbing Code and/or Sec. of the FiNAL � HOl15E SFWER CONNECTING TO � QO OAiE 6.6 P.Code for the follawing reoson vueuCsew[w ��-S�g W 5[ViIC TANC.SFFPA(a[%T OR 6. Pli$AND/Cq DRAINfiELD iINAI y� � DO�B IpUSE 5[W[R CONNECTING TO By Z . YWVI11[D�SOOS�I Y M Signawro carontcr nooirw�nt xoc.oa OWNER•BUILDER DECLARATION WbRK TO 110UY SEWER OVERiIOW SEFPI1Gf Ri,DIIMNfIfID i hereby offirm 1ho1 1 om eMempt from Ihe CoMractor's licansa E_.�,�ss�«.�,�«,��«E �1 4 6 9 A Law for the following reason(SGC�00 7O31.S,BU1511E55 drld Pf0- NTFi.REYq1q pR AlI1NppN/qp$[ �,Ot11 COd[�: SEN4N OR d5PO5AL SYSIEM ' {f• •A • , O _�1,as owner of ihe property,or my employees with wages as � s +2 7.5 O their sole tompenw�ion,will do Ihe work ond Ihe structure is nol inlended or offered ior sole(Section 7044,Businass = ond Proiasc�ons Code). OWNER'S Permit T /Q ✓f + �s 2 7.J�c�, ❑1,as owner of the proper�y,am e.cl�si�ely conhocring with AUTHORIZATION TOTAL FEE � ,S' Q�2 q—�6 �ICBnSld[O�hOC�O�f�O CO�SINC�f�1B PIO�BCi($eC1i011 7a/, I HAV[AT THIS DATE A CONiflACI WITH iHE HERFIN N�MED CONTi�ROR 10 , B�siness ond Professions Code�. coNr.�n Tr�aeo�c ocsca�e[o[xisnr�+c ow[wn+c ro r�vuauc sFwFR. CONSTRUCTION LENDING AGENCY ' 1 hereby affirm fhat therc is a constrodion lending egency ��EDTHiS DAYOF 19_ - ' (or �he performance of tMe wwk for whith this permit Ia �'�R� pN��1ERS AGf {88UlC�($BC.�7�CIV.C.�. A004E55 le�er's Name �. Lender's Addresa I certify Ihat I have read ihis applitation and slale thal 1he above Infwmation is rorrect.I ogree to comply with all CouMy ordinances and S�a�e laws regula�ing Plumbirtg ond Sewers, � . and hereby aulhorize represeniotires of�his County lo eNer upon the ebove-menlioned properly for inspectton purposes. . . �����-�-�- �f.�,��G Signalure of Permitlee Dole fEE REVERSE FOR E%KANATORY IANGUAGE ' r ' . . _ ,';' T, T^• c� T . .. . . ' . ��. T 9 ,�., V` 7 o L � , ' j p r T(� DA }�� Vfl �;- S ' • , ' ' j � '1 � ' � Z 1 '"� Cr i�.T' C,, c r ,. r v; o. A+n Z7 " � , ' T�.: � t� �❑ r' r'ci �' v . . • ' � . ''1'. L., �j" }�; t-". < '�O' . . � � ' � ��' �:f y. �, U��� , . . • ' ! '� - T r � Nr� I.ni V' "P < ` • , ' ' 1 V �' � ' ,1: ��``� �;u .� - 1N . . ��iJ y - i� j 'i, . ' .. . �^ ' � � �' . ,. � � . �. . . ... . ',1 _ � ^'�'� v . � '� . '1` . :I �' . ?��1. � C � � , ., � ' � '� ,. , ,. 1� - U 1 ^ . � .. . � � __ . :1 • .. . - ; � �i` �i' '' i ,��- _ . � O . '' � � !� . 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