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HomeMy WebLinkAbout1443A (8) I � WORKERS'COMPENSATION DECtARATION ' ��' I hereby offirm tho� I hove a certifico�e of consent to self . � � � insure,or e cereificaia of Worke�s'Compansotion Insurance,or �6^6°�0 �� • P��YN�����eO�osmpo��s��;`.,�d "�e`"`".183. APPLICATION FOR PERMIT �c,.rr��a�oPY is hereby/umiehed. SEWER - SEWAGE DISPOSAL � Cer�ified copy i.f�i�d with the counry bvilding�„:��ro� COUN7Y OF LOS ANGELES BUILDING ANO SAFETY � deporlment: ' Daie R/9Fi Applicont T,� �e��� FOR APPLICANt TO FILL IN CONNECTION DATA � CERTIFICATE OF E%EMPTION fQOM WORKERS' eundnc � � COMPENSATION INSURANCE . Aoort�ss BZ Q$ ��T�� �� (This section need not be comple�ed if the work Involved by�he �a M4NNp�E HiE11EN� ��p permir is fw one hundred dollars(f100)w leu.) IOCALIiY i cerr�fy rha��n�he performance of rhe work for whtch this c�ao�ssr. � �.VBII Glen iYPfOfC��T'�"� u�+cT"fa�or� Y. CUR6 V L M.�.TO P.l. permir is isaued,I sholl nor employ any person in any man�er v.t.r+o. OZ so os�o become s�bjecl lo fhe Workers'Compensotion Lows. o�vr�R Anden Co.u�c.�q. �oe ao, � � � " hNil T4UNK PEQMIT NO. ROAO iERMIT NO. Do�e ' Applimm ��u -PFFipAVrt WMVFR EASEh1ENT RFCORD.INSTR.NO. DATE N^�CE�TO'APPLICANT: If, after making this Certifim�e of �iTy �i.r.p_ p��on, you should become subject lo �he Workars' i��i nwiion prov�c�ons of rhe Labor code,you musf(orthwith , p¢5caivnOrJ _ �OirdO. Hwy.pq St.WnOEr+iuG _„{ply wi�h suth provisions or Ihis permit shall be deemed . revoked. . &o�K TRA�T STATEENCROACMM[Ni LI�ENSED GONiRACiORS DECLARAiION r"o°F&°�s. ceRM't r�o. � I hereby offirm thor I om licansed undar p�ovis7ons of Chopler sizFOrioT raowor.�tot 9(tommencing wi�h Section 7000)of Divisio�3 of Ihe Busi• euii i°Fr�cs S'� B owa�[s ness and Professions Code,and my litense is in iull force and effect. � coNTa+�ttat eem CONNECTIpNCNA4G(RE LitenseNumber 47488.7 �;�.c,,,, -C34 ,,��u 8225 Beeehrood ffI�U��NTFFE ' ' d ConMacto�� Fl"AP.711'dn poro R/7r./pL tiTr fiita LOm t.�+0 oisrxKtrq. cwouv. r,wc wocpsseoer V n�,� ���. — f a �; � ❑I om axempt undar Sec. of ihe LA.Co. ii�N��.p. n,� . � Plumbing Code ond/or Sac. of the �''�� oE.�C` RiatiOra OF wqiK �[ FNA� U�F MWSE SEWER COMNECTING 70 WTE VAUDA ON {Y ������R /z-:z- c 0. B.8 P.Code for the following reason 1 TANK,5[EpA nr ort FlNA� � V�iS AND/OY DRMINFIELD ��B �qUSf SEN4R CONMCTIN�TO �T � , . WlIVATE DI M Signo�ure coruaccT.euomouni e�oc.oa OWNER-BUItDER DECL4RATION Wo�ro�ous�s�`''tR /' ONERiLOW SEEP/�((PIT.DY4�Nc�EID �i �y,J� I heroby affirm thot 1 om exempt from the Contmcror i license E%7N.,CESSPWL.DRVWELL,hUNMOIF I for�he lollowing reoson(Secron 703I.5,Buisnesa ond Pro• att4.a[veia ae neu�oaa r+o�s� t� � �il1ECOdl�: SfMffWORD�5W5hLSY5TEM n • • •1 O .�I oa awner of Ihe property,or my employeea with woges as � e •�'(,�j� _ ineir sole compenwlion,will do the work and the sirvcture ie not iNended or oNered for sale(Section 7044,Businms b e e C��J Q c=i ond Profeuions Code). OWNER'S Permit s 0 ❑I,as owner of the propeny,am eaclusively contracting with AUTHORIZATION TOTAL FEE 27 � d�2 9�8 6 __. licensed con�roc�ors fo tonshuU�he projact�Section 7a4, �HAVE AT TNIS DATE A CONi4ACi WIfM i11E MERFIN rvAMED CONTRrK10R f0 BVSIlIB45 Ottd FfO�E55iOf15�pd[�. CONNFCT THE ABpVE pFSCRIBFD Fl(iSiING DWEIIING TO TNE PU&IC SEWER. � CONSTRUCTION LENDING AGENCY I hereby offirm rhaf�hera is o consnuction lending ogency SiGNFDTHiS � DAYOF�iv_ , ' for Ihe per/ormante of the work for which this permil is a''�'"'ER°° pWNERS AGENT is��ed(See.3097,Civ.C.). noaetss lendar's Nome lender's Address 1 certify�hal I have read this applicmion and ua�e that rbe � � obove informmioa is correcr.I agroe�o comply wi�h oll Goumy � . . ordinances ond Sbte laws regaloting Plumbirg and Sewers, ' � � and hereby au�horize representatives of this Coun�y lo eNer �upon he obove-mentioned property for inspettlon purposes. � - ���� �/�1�� �Signaturo of PermiMee Do�e SEE REVtRSE FOR E%KANATORY IANGUAGF , � � - . . . � r� TT m r� �n ^ . ' � , . • ! . � a� nn `<� ��}{ 0�1 �i � ' . , . . . � Z� ��� CS �r� c�� S ' i � � � �'m �" _ D �� � r . • ` ��, ,-� �n o; .�, . =�� y ❑ ,;. � , . . i ' , . rl :;c "� i,;^ $o 'J�'1 . . . . , 1, : , . . 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