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HomeMy WebLinkAbout1471A (8) � � WORKERS'COMPENSATION DECLARATION ' � � I hereby offirm Ihat 1 have a certifica�e of coasent to self • 5'� inSure,o�a crtifito�e ol Workers'Companwtio�Inauronee,or �a���o � ' U dcertifiedco thereo((Sec.3800,LabC.) �Eeo9�°Ey.,,e�� � qpp��CAT10N FOR PERMIT Policy No.�Company S''t. Ft2t1[i ❑Cer�ified copy is hereby(urniihed. - SEWER - SEWAGE DISPOSAL �]Cerrified copy is filed wnh the coumy bu��d+nq inspecron . COUNTY OF LOS ANGELES BUILDING AND SAFETY department. ' ' � o;�� 8 26 86 aPPi��a„r_ T. Fr@@N8II' FOR APPLICANT TO FILL IN CONNECTION DATA „ CERTIFICATE OF E%EMPTION FROM WORKERS' �'��'^� 81 Featherwood sunora oevrN COM�ENSATION INSURANCE ��ss (This seUion need nol be tompleted if the work involved by the Df 8 B� MqNHIXF REHRFNCf � U�ER permit is fo�one hundrod dollars(ZI00)or less.) � ����T� t e I certify Owt in the perfo�mance o/the work for which this �qp5�g55T iYPEOfCONNFCTqN ��tH�� 8 lvan Glen Y. �„�, ,�. M�.,a P.�. ppmif i6 issued,I sholl not employ any person in ony monner � so as to become subject to�he Workers'Compensa�ion Laws. P��'�� �Dy�� , . OWNFR G CO.IMF.NO. JOB NO. �'� PO Box_3329 TNlINK0ERM17Np, qp�.pP[RMITND. Dole Appl�tonf AooeFss AFFIDAVII WAIVER EASEMENI RKOQD.INSTR.Np. DAT( NOTICE'TO AVPLICANT: If, ofter mokiog this CertiFim�e of �irr r¢t.r+o. = �p�io�, you should bxomc subject �o Ihe Workers' ^ � pensa�ion provis�one of the Labor code,you must Iorthwifh �y�,^�ipr.i torr�o. 76 _ ply wifh suth provisions or ihis permil shall be deemed L Hwv.ORST.vnDENx�G revoked. - eiocK TRF�f p� SiAIE ENCWOACMMEM ' ' IICENSED CONTRACTORS DECLARATION - ^'o.o��ocs. �°Mii r+o. 512E OF lOT I�pW p.��pT I hereby offirm�hal I am licensed�nder provislons of Chap�er 9(commencing with Section 7000)of Division 3 of the Busi- �iiDv.�g Sin . Re8• O1�RGF5 ness and Professions Code,and my licanse is in full force ond ellett. pp�7 �TR4ROR m CONrXCTIDN CHAa(;[�E �i[@nSBNUmbG/_.����7v/� ��i[.��aSi C34 ��� . RFiM8UR5EMENTi[E CoarracrorT_ Rrwwa�an pore R/9F,/R(� aTr � o�sraictwo. wooa �,nr vcocessener O � A1 a m _ ,E�.� ' ❑I om exempt under Sec, of�he l.A.Co. surt uc, gK °� N . L�CENSE.NO. � �H CU55 l d � -�Plombing Code ond/or Sec, of 1he �� �ESCRIVfION OF WORK if[ �N�i O �+ouscs�wERcayNccrn+cro � onrE �,,Z� VAUDATION v B.8 P.Code for the(ollowing reason °���c�'^'ER g� W $EiTIC TANK,$EFP►GE PIT pt {INAt �^ , � PiTS r1N0/pR pRAINFiELO Date MDUSE SEWER CONNECT�NC TO Bv ,(.�'u.(�f�... Z ' pRNAiE�ISPOSAI SYSIFM S�g�atu�e caw�a�owrKK.u,��o�.oa � OWNER-BUILDER DECLARATION wowc To Nous�S�weR I here6y affirm that 1 am e�emp�from the Gonrrocfor's License E%�N���CESSPOOI,DiP�YW[LL.�IAAAN�HpIE ' law for�he lollowing reawn(Secron 7031.5,Buisness and Pro• xtex,rt[vn�a oa n�aHopri�quse �1 4 Z 1 A ons Code): sewea oa oisros�i SrsnM ,� a;owrer of ihe properiy,or my employees wifh wagesas �• ° � • .� O fheir sole compensorion,will do the wo.k ond Ihe struct�re . is nol in�ended or offered for sa�e(Sec�ion 7044,Business ond Profezstons Code). OWNER'S Pefm�� f /� ,'�J� I ' '2�.5 Q ❑I,os ownei of the property,am excl�sively contrac�ing wirh AUTHORIZATION TOTAL FEE � '"� � � •G'�.S�� �itenaed tonlroclon fo tonsh�tt the project(Sec�ivn 7014� I NAVE AT iH15 DAl[A CONTRA[7 WI1M THE NEHIN NAMEp CpJTRACIOR f0 Business ond P.olessions Coda). corar�[T rr�t naov¢oexaietp exisnr,�oweuiNc To r�rueu[s�wea. �8�p_$6 CONSTRUCTION LENDING AGENCY ' ► I�hereby affi�m that there is a conshuUlon lending aqency SIGNEDTHIS � DAYOF �� I9_ for �he rformance of the work for which this �'^'�R� pe permil is OWNERS AGEN issued�Sea 3097,C��.C.�. � ADORESS tendar's Nome - Lender'e Address � I certify Ibat I hove read�his opplica�lon and s�o�e�hot the - . above Inlwmolion is correct.1 agroe�o comply with oll County ordinantes ond S�ote laws�egulating Plumbing and Sewars, � and hereby ou�horize representalives of ehis County eo en�er , upo 1he above-�mejntioned properry for inspection purposes. r7L f�{! !�✓�..QO-YiXi],C/ �fGL.�o�Y Siqnature of Pe�mi�lee Dole � SEE REVERSE FOR E%tIANATORY tANGUAGE .. � T,y� c� � m y � �cy .. . .. _ .. . . - rL,L, a�� • Z .. k � . q i 70 rx� � 3�>��: [> � � . . 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