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HomeMy WebLinkAbout1446A (8) . WORKERS'COMPENSATION DKIARAiION , I hereby offirm tha� I have a certifica�e of crneenl lo eel( � S'� .insure,or'a certifico�e of Workeri Compensofion In:urance,or 76A6<ID � II CE8091aEV.1/83) qpp��CATION FOR PERMIT " a certif�ed co rheroaf(Sec.3800,La6 C.) - , Po�icy No. Company St_ Fund ❑fer��fied copy is hereby furn�shed. .. • . SEWER • SEWAGE DISPOSAL . � �Cerrfied copv is filed wuh ihe�000ry bund�r,9 ir,specron COUNtY OF LOS ANGELES BUILDING AND SAFETY �deporlmenl. � . � oore�$�pplicam T� j��mx�ri FOR APPLICANT TO FILL IN CONNECTION DATA , CERTIFICATE OF EKEMPTION FROM WORKERS' ��ia� . , COMPENSATION INSURANCE �ooccu ST^T1O''� �°�� (This secr�on need not be compleied if rhe work tmolved by�he �p�ALITY Mnw�oi¢ct�rten� uwta permil is for one hundred dollars(5100)or less.) i a I certify tl�ot in the performance�of the work for which this ��sr . rrvto�car+tCiWN �H(THFRpM permil is icsued,I sholl nof em lo an ���ST �� CURB PL M.L.TO Pt. P Y Y Person in ony mannx v[.t+D. O so as�o becoma subjact to�ha Workers'Compenwtion Laws, o�R � m.inv.no. �oe rq, � �' ' ��� iRUNK PE4NJT NO. IIOAD ifRMIT Np. Dote �APPliconl � • ��u NOTICE,TO AV�LICANT: If, aher moking �hPs Cerfifico�e of � nfrioevir wniv[R EASEMEN7 PKOQO.iNSTR.NO. W.7E `-'ynp�ion,.yoo shoold become subject �o the Workers' ��TY Cov�.na re�.�+o.$ $ }�pensation provisions of the la6or wde,you must fonhwi�h oescKv'wµiipr,i LOi NO. MWY.OR ST.W1�ENING _6ply with such provisions or this permif shall ba deemed lQVOAQd. 9IOCK fRAR 510.iE ENCYOACHMENT . • � iEflMl1 NO- �LICENSED CONiRACTORS DECLARATION sae or i01 raow pa ipr. I hereby offirm thnt I om licensed under provisions of Chap�er �� 9(commencing wi�h Setlion 7000)of Division 3 of�he Busi- eui�ort�s $in Q8 a,.,�g ness and ProFesstons Code,ond my�itense is in full face and y effecr. co,nencraa P'T@@A18II OII 4 CQNI�[CTIp11 CHARGE/{E LicenseNumber 47�87 LicCloss� ��14 �ppqE55 822 Beechwood ��+'�bWSFMFNTiEE ContractorT. FT9@m� po�e 8/26/86 - A1ta Loma��.� 1 80� 'Z oiSiRicrr+o. Gaouv M�o rco[EssEpgr O OTV ❑I om eaempl undar Sec. of�he L.A.Co. ST�re _ iK. /1J � "� V iKcruE w tt�ss l m Plumbi�Code and/or Sec. of fhe "q- DFKRIPfION OF WpRK �E FNAL � 9 wusc scwxR coNrxcnnc To oarc t r 7 & VALIDATION �'j B.6 P.Code for fhe followin reaso� ������R SEVTIC 7.WK.$[EPAG[%T OR PoT$AN�/pR DR�INFrtID HNA� d � Date �q�/5p 5EW[R CONNECTING TO bY 2 VRNAIE p15VO5M YS $i9nOfuIQ CONMC7 ADDITIOHILL!{DG-OR � OWNER-BUILDER DECLARATION M'ORK TO MpISE SEWER OYERFLOW SEEiAGE%.ORMNFIFI� 1 hereby affirm that I am eMempl from fhe CO�tra[for's License Exini.CE55ppq,perwEu,iwNwp�E 'I /I Low for the following reoson(SeUon 7031.5�BUi611C55 011d Pf0- AIfER,R[VAIY pt a9�NppN 1pp$( �� 4 4,b A or+s Code): s�wea oa wsros��srshM - ._,I,os o�.vner of 7he property,or my employees with woges os � tt. •. . 1 fl their sole compensolion,will do the work and the str�cture Is no�imended or offe�ed for sole(Saction 7044,Business � • •2��5� and ProFessions Code). OWNER'S Permit f ❑I,os owner of the property,am extlusively con�rocting wi�h AUTHORIZATION TOTAL FEE • ° °�7.5�� licensed ton�racion fo tonshutt the project(Sec�ion)a1, I WV[AT iH15 D�TE A CONiRACI WIIH iNE MEQFIN NRMED CON1R4CiOF TO Q��9�8 6 BUSInBii On(�PrO�lSSiOfIS COdE�. CO�WECT TH[nBpv(pp$�RIBED E%ISTiNG DVIELLWG TO T14 PIMLIC SFWFR. CONSTRUCTION LENDING AGENCY , I hereby oNirm �hal �here is a construUlon lendinp agenty ��'1EDTHIS � DAYOF 1 _ � for the performance of �he work for whith this permif ia �11fR OR � issued(Sec.3097�Civ.C.�. ��RSAGfNT , ADORFSS Lender's Name lender'�Address 1 cerlify Ihof I have reod fhis appiication ond s�ate thot the � � a6ove info�mo�ion is correct.I ogree to comply with o�l Co�nty ' ordinances ond S�ure laws regulaeing Plumbing ond Sewers, and hxeby ou�horize represe��otives of�his County to enter upon th above-mentioned properfy fo�inspection purpoaes. �(�Cl ��/O�esJ ycl � Signature of Perm�tee Do/e ����� SEF REYERSE FOt f%KANATORY LANGUAGE I • . -- . , ��, r�, �y � y� �� , . � , � o n i;n ,-... 7 : � ' � ^ �n rn� � u� �,.� f , � . i . 1 . ' i ' - �'' ^�i > aC'. �ii (1 ' . . • ..I �' Z 7 0'� � n D GI. � _' �' �;,' �� �[7 i" ��; ' . • � '� ' ' • T�'D ��4 ?'i w.c �f) O ' . ' I " . i 1 . - '_ � l n'D NU � �C nD < . . I , • . I ' �CJ }^ �:l . _ � . : - . � 1 - {� s . 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