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HomeMy WebLinkAbout1470A (8) � WORKERS'COMPENSATION DECLARATION � � � I hereby affirm �ha� I hore o cer�ifico�e of consent to self _ _ {� insure,or a cenificote of Worke�s'Compensatio�Insuronce,or �a�a.zo �II Pol cyfNo.`��io�asm;��'�°°s�:`��a �� Ce°e'R`".'"B" � APPLICATION FOR PERMIT . " ❑Cevlified copy is hxeby furniihed. . SEWER - SEWAGE OISPOSAL �Certified copy is f�led wirh the county 6uildinq insp«tion - COUNTY OF LOS ANGELES BUILDING AN�SAFETY de �me�� � ' � pa�e �r`�6 8C)qPP�i�a�j T. Freeman POR APPLICANT TO FILL IN CONNEGTION DATA . . CERTIFICATE OF E%EMPTION FROM WORKERS',. - eunwn�c � COMPENSATION INSURANCE poorsE55 w 5*wnOr� UFvrN (This settion need not be compkied if the work involved by the i�i�T, MANIKKE RFFEYENCE °�R permit is for one hundred dollars(SI00)or less.) hEACEST iYPEOFCONNECfION IENfiTNFRdA I cerlify Iho1 in the performance o(the work for which this Crto555T. ZOi�TI 8Yl v. C�k! PL. M.L.TOPI. permit ia issuad,I aholl nof employ any person in any monner p �_ �L� so os to become subject�o Ihe Workers'Compenwlion Laws. pwNEa � Anden Grp �o.��.No. ,��. � A�ODRF55 PO Box..3329 TRUNKPEQMITNO. ROADPERMITNO. Dale ` Applicont � IIFFIDAVIT WAIVER EASEMENT RFCORD.tNSTR.NO. WTE NOTICE TO APVIICANT: If, ofter moking Ihis Certifico�e of �Tr Covina �,��.�. 818 967-9541 � lpl7on, you should betome subjecl io the Workers' �ensnlion provisions of the Lobor code,you must forthwith pE$CRIMION - lOTNO. MWY.ORST.WIDENiNG _(iply with s�ch provisions or this permil sholl be deemed 35761 IlVOkld. � . BLOCR 7FACT STAiE ENCYOACHMENT ' � UCENSED CON7RACTORS DECIARATION rq.oF�o�s. rrRMit wo. ' SRE Of l07 NOW ON(OT I hereby afflrm tho�1 om licansed under provisions of Chapler �� 9(commencing wi�h Section 7000�of Division 3 of the Busi- evitoir�s Sin • R@S• a�rtc,�s 1 ness ond Prof.ssions Code,and my licensa is in full force ond y�.. , effe[t. CO�+TRACTOR pyQeTQan Ci0n0t� CONNER�ONCMwR�[FEE '� Li[MSlNUmbBI 474887 �If.��055 C34 AWRE$$ �ZZ geechwood 17r• � RE�MiWRSEMENTGEE y � co,,,.o�,o, T. Freemanoo„ 8/26/86 ' Alta Loma�.�714 980-4429 °'ST1TNO `""'° ""'° p�E55EDBY � I �„� � � ❑I am eaeM t under Sec. of the l.A.Co. STare uc �a 'GL : P I�CENSE NO. c1�55 No. DESCRtVTION OF WORK FEE O � �-PlumbingCodeond/wSec. - - ofthe FiNA� IAUSE SEWFR CONNFCTING 70 OO DATE �� p VALI ATION W� B.d P.Code for the following�eason °U�����R s �� H , SEPTIC TM1K.SEEMGf%T OR PITS AND/OR ORAINFIEID B�A� � Z �OIC WUSE SEwE4 CONNFRING�p � VRNq Y lFM ' Signolure . . . COnr+eR'�oo�now.l&oG.Ort � . OWNER•BUILDER DECIARATION �K������R � OVERiIOW SEEY�GE Rl,pRAINf1FLD I hereby oifirm tho�I om erempt from�he Conhoctor's License exw..c[ssaoa.a+rw[u.iww+ae -r 1 4 7.0 A I�w for the following reason(SBC�Op JO3�.S,BUISIIBSS 011d Pl0- ' A7FF.CfPA1R OQ ABANDON IqUSE ' . � , �OfIS COdB�: SFN4N OR D�S�OSAL SY57EM� �� h• • F • � � �1,a�owner of fhe property,or my employees with wages os � �heir sole compensation,will do�he wo�k ond the strutture � o °2�,5 Q I is no�inrended or offered for sale(Section 70M,Business � a�d Profeisions CodeJ. OWNER'S PB�mit f S'� • o •2'],5�� ❑�,as owner oF the property,am eztlusively tontrocling wi�h AtJTMORIZATION TOTAI FEE a. �iClRSlf�[OR�1OCIO�3 10 COIISilUCt IF!PfO�BCi�SBC110fl JOA4, 1 HAVE AT TNIS DATE A CONiRA�i WItH TNE MEYFiN NAMEO CONTRAC70R 10 0�,2 9-8 6 Business and Professions Code). ta+r�cr rwE naovc o¢scaieeo exisnrae ovrtw'+e To rr�ru�ic s�wta. CONSTRUCTION LENDING AGENCY� S�GNEDTH�S �� DAYOF i9� ► I hereby affirm thor�here is a construUion lending ogency p�yryFROR (or the performonce of�lhe work for which Ihis permit is OWNFfiSAGENT � �-�-�+,+�'�'�� issued(Sec.3097,Civ.G.�. / /� J �/ ADDRE55 X�r� /7'�.(a�,r�e..6 bL"_� �//A_. . lender's Name tender i Addreu I terfiiy�hat I ho�e reod�h�s applicorion ond staie rhat tha � . obova informa�ion is correct.I ogree to comply with oll County ordinoncas ond Sfofe laws rag�laring Plumbi�g ond Sewers, and hereby authorize representotives ot�h�s County ro enter �upo the o6ove•mentioned prcperty for inspection pu�poses. � �a�� i��ee pple /�� SEE REVERSE FOR EXrLANAiORV UNGUAGF - , � , , .. � . .. . �� Dc�+ u iN D" Tn T, � ' C C� . � i � n ?� p� y� Ln �: $ m� ^, • . . . � . e - � ' v l a� zfl n � .. � � 'i . , � J �i.� T' l',�7 G�-1 (- � ' Z y� � i i � . . . . :f . ' �I . '�ln c� �" � z<n <<_' 'Li � . ' ' -' ' ' � � ---I ',^ y `^';Ci ,ny �c. 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