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HomeMy WebLinkAbout1445A •WORKERS'COMPENSATION DECLARATION � 1 hereby off�rm thor I hove o cen�ficme of co�sent to self � �� (� insure,or a cerlificote o(Workers'Compensation Im�ronce,or �e.+eazo ��I a cerrfed,��e���(Sec.38oD,$c�b C.y�d CE6081REV.1/WI APPLICATION fOR PERMIT " Polity No. Compony ❑Cenified copy is hereby furnished." � SEWER - SEWAGE DISPOSAL � �Cerrlied copy i:flled with rhe couny build�ng�nspection COUNTY OF LOS ANGELES BUILDING AND SAfETY de�°r ment. ' � oo�e v 26 8�Applicon�T. Fr88IDSII FOR APPLICANT TO FILL IN � CONNECTION DATA ,CERTIFICAOMVENSATONNSURqNCE RKERS'. ' ��Ess 802 Featherwood Dr STATION OEVfN This section need not be com le�ed i(the wwk involved 6 Ihe Di8 B�2• ��� ( P Y LOGllir /IwNHOIE REfEar{F pe�mit is for one hundred dollars�=100)or less.) I certify ihal in ihe performonce of Ihe work for which fhis �yp�55T Y TYVEa�OMIE�T10fi IENGiNiRONI CURB v.(. M L TO V.L. permit is issucd,I shall nol employ any parson in any manner � so as�o become sobject to t6e Workers'Compenmlion Laws. o„�,�y �de � �_„�.,,�. �;�� d 2-F I Dale- � ApplicaM . . �DDRE35 PO BOE. Z iRUNK PERMIT NO. ROAD PERMIT NO. NOTICE TO APPL�CANT: If, afte. making �his Cerrificore of �iTY � AFFIDAy17 w�rvte ENSFMENT eEcoQo.u+sm.ra owTe F-�p�ion, you should berome wbject �o the Workers' ���i penw�ion provisions of the labor code,you must(orthwith o[xa�vTiorr ioi ra_ Nwv.qtsi.wioeNn+e .. ply with such provisions or fhis permit shell be deemed revoked.' � • . eiocK TRACT 35761 S7AlE ENCRO�CHMFNT LICENSED CONTRACTORS DECLARATION nq a e�ocs RRMIT NO. 52E OF LOT NOW pN IOT I hereby aifirm Ihal I om licensed under provisions of Chppfer �� 9(commencing with SeUion 7000)of Division 3 of Ihe Busi• � aunon�GS Sin . Res� Oaac.[s neas a�d Professions Code,and my license is in full fwce and effec�. d�] �] �1 �prate�ooc �Q8IDQI1 (i0218t• ��«���HARGEFEE Li[e�se Number *`��• LI[.Cbss - v�� �ppqEu W'L'G BeeC1iW��d �+• frtuNeURSEMEr+ilfE p�, �Of11fOC�Ofy• �Qiem� pple 8/26/86 CITY .�. _ DISiq1�TN0. GNUV eK MP.G � iROCESSEDlV V . ❑I am eaempl onder Sec.� of�he L.A.Co. ��Ny'q, anss a � � Pl�mbinp Code and/or Sec. of the �� DFSCRIPfION OF WORK rtc pNq� ' � / �a,s�s�wea ea.�a�r+�To D�iE VALIDATION a 8.8 P.Code for the following reasan 1 vU&K SEwER 17 � f , . SEVTIC fANK.SfEPAGE%i O4 y v1T5 AND/04 DRAINFIEtD NNAt Z Dole �DUSE SFwEe CO'Mtti�+G TO . er ,. iRiyATF D1 5�'S�EM Siqnaru�e cmu�ccr�oo�r�owu xoc.oc �1 Ll Q 5 A OWNFR-BUIIDER DECLARATION W�T����`�'F° R l EiAGf R7,DRAINfIEID I hereby offirm 1ha1 I om e.empt from the Controtlor's license [xm.,cessrpp,oxrweu..n�w�ac ;;s e e . � Q law for tha following reason(Sedon 7031.5,Bu�sness ond Pro- ur[a,a[o.iQ oa�y�Npq•�rqus� � ��OnS COdl�: 3E'AF4 OR 013P03�t SY51EM � e •2 7.5 0 ;�I,ae owner of fhe property,or my employees wi�h wages as their sole compenwlion,will do the work and Ihe st�utlure . e n e 2'],J�� is not iNended or ofiered for wle(Set�ion 70<d,B�siness and Profess�ons Code). OWNER'S Permit S l� �j� 0 8 2 9-8 6 ❑I,as owner of�he property,am eMclusively contraUing with AUTHORIZATION TOTAL FEE 27 Q litensed tororactas ro tonstrutt the project(Section 7W�� I HAVE AT THIS DATE A CO/JiR/CT w1iH ill[H(i(IN NFMED CONID�CTOR TO 8usineu and Professions Code). cOWr.�Eci rHE nBovE Of5Cki9Eo exisnlaG owEtuN(',io rHE Neuc sEw[k. - . CONSTRUCTION LENDING AGENCY , I hereby oNirm that lhere is o tonafruUion lending ngenty ��EDTHIS �AYDF_� I for the performance of ihe work for which this permit is �a� � OWNFRS AGE iiSUEd(SBC.3097,Civ.C.�. � aooacss Lendei s Nome � , Lender's Address ' I certify that I V�ove reod this opplicarion ond slole�hat the a6ova Infwmation is torrect.I ogree to comply wi�h ail Coonly ordinonces and Stole laws reg�la�ing Pl�mbing ond Sewers, and hereby owhorize represen+otives oI eh�s CouMy to enrer • upon the above•mentioned property fw incpection purposes. � . ���,�iz� > �/�Gf�� $ignalure of ermittee Oo�e . 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