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HomeMy WebLinkAbout1444A • WORKERS'COMPENSATION DECLARATION � I hereby affirm Ihar I have a cenifico�e of consenr selF , }1 .insure,or o ce�tifica�e of Workers'Compenwtion Insura e,or - �6"^'zo U a�cerlifiedc,o.f�,r,h�er�eo�f(Sec.3800,1abC.) �EBOB�RE�.,,�„ � �APPLICATION FOR PERMIT Policy No.�(�om��Y . SEWER - SEWAGE DISPOSAL ❑Cr�ified copy is hereby furnished.. • _ �- ' � �Certified copy is filed wirh the counry building in�p ction COUNTY OF LOS ANGELES BUIL�ING AND SAPETY pa�e C�T�IB���;�a„� T. I�eBID3ri FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' ewianc siniiori oevn� � COMPENSATION INSURANCE. �ooaEss 8 Th�s sec�ion need not be com leted if the work in�ol�ed the urr[a ( P Y �p�AUTY a NANNOLERFfERENCE� R permft ia for one h�ndred doilon(SI00)or less.) � r.�na�si� rrn�or coa�aaN �.1ctH v¢oM 1 cerfify�hat in the performance oi the work for whc�h ihis [¢p5,55T. Y. CUR6 V.L. MI.TOP.I. permit is iseued,I aholl not employ any person in any rqanner f � so as fo become subject to the Workers'Compenwtion LAws. • °�'"'�� O y � ��R Anden G CO.IMP.Np. J69�1p. � M411 iRVNK PFRMIT NO. ROAO IERMIT NO. Do�s A�IiCOM ADDRE$$ ARiDAV1I WAIVFR EASEMEN7 iFCORD.INSTR.NO. OAIE NOTICE TO APVLICANT: If, ofler�makinq �his CerlilirQle of . �iTy Covina tei.t+o.8�.8 6 � � p�ion, you should become subject,to the Wprkers' �penwrion rovisions o(the Lebor code, ou mvst folthwiih ���� _ � P Y oesca�vrroN ioTroo. ,..,.nply with s�ch p.ovisions or this pe�mit shall be deemad ~��ST.��µ� flvOklCl. ' BIOCK TFACT STALE ENCF04C11NFNT � . UCENSE�CONTRACTORS DEGLARATION Np pF&OGS- VERMIT Np. S�ZE O�IOl ' NOW ON LOT I hereby oFfirm ihat I om licensed under provisions of Chapter 9(commencing wi�h Settion 7000�of Division 3 of the Busi- 9�nDn+cS S� Re owac[5 ness ond Professlons Code,and my license it in fu�l force ond eI{aCt. , 7 r/ �pp�Tp�Rpq e ID CONNECTION CNARGE FEE L�CMSO NUmbN �1 48�! �i[.CIO55 ' �'� �RF� 8 p[IMBURSEMENT fEE � Connacro. T- �'PPi71A11 Do�e R/7�/A� ' 1 80— o�sm�cTr+o. c,ua�v r+.�v vvocFssEoer p ��TY aita Lom�E�. l J BK � � � ❑I om eMempt under Sec. of the LA.Co. ile[Ng nq «A55 � �+0. pESCRI ION WORK RE Plumbing Code and/or Sec. of the pNai O �����R coru�nn�c io wTe /p VALIDATION V B.&P.Code for rhe following reason 2�` r'�� u� $EPTIC TANN.SEEOAGE%T Oq y ' YITS AND/OR OR�INFIELO iINRI � Dpl! 110USE SEWEY CpJMC11NG TO �Y Z' YlIYRI[DIS YST(M "'� Si9l101u!! CO'NER AODITIONAI&OC.OR � OWNER-BUIIDER DECIARATION �MOkK f0 MOIJ$E SEWER qFi Y Vil,OR�iNfiR� 1 hereby aHirm ihat I am eyempt From the Conhactor's Litense . exrru.,cc55ooa,oavxr[tt,iwr+ua¢ `1 4���� Low for the following reason(Sectan 7031.5,Buisness ond Pro- wtrFa,rsEvua pc nBnNppra�qvSE ' `�ons Code�: scwEc a+wsaosnt 5r5hM �e • • i � O i i,a9 owne�oF ine properiy,or my empioyees wiin woges as . their sole tompensofion,will do thework ond the strutl�re " � • "C 7,Jr O is not iMended or offerad for sole(Section 70a1,Business ond ProFessions Code). OWNER'S Pefm�� _ � • � r x ❑I,as owner of the property,am e:clusively contrac�ing with AUTHORI2ATION TOTAL FEE 2 7�J O U licensed connaUon to conerruU rhe project(Section 7014, i H��aT tNis o�r¢n caarar�cr wnH iX[�a[iN rwmeo ca+ia,uiox io � 0 Q 2 9—�6 Busineas and Profeuions Code�. cowr.�cT n�c neovc otx4�e[o¢xisnr�c ow[wwc ro T�nixK s�w[R. CONSTRUCTION LENDING AGENCY , ' I hereby offirm ihat Ihere is a conslruclion lending agenry SIGNED iH15 � DAV OF 1� � ' for �he performance of �he work for which this permit is �'�R°R , OWNERS ACEN ISSUcd($et.9OV7�Civ.C.). . � FDDRESS � lender's Name lender's Address . � I cer�ify Ihot I hove reod ihis opplication and zMte thnl the obove iniormalion is torrect.I ograe�o comply with oll Counry ordinances ond S�ote lows reqoloting Plumbing and Sewers, and hereby authaize represallotives of this County�o enter upon the�fionp�j propeny for inspaction pvrposes. �i�o��r-�. �/��� Signotvre of Permitlee Do�e SEF RFVERSE FOt EXtU1NATORY IANGUAGE . 7 . y�� �n. ,: . ' r q N^..',':: 'N �� �'�^ <? 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