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HomeMy WebLinkAbout1442A (8) • WORKERS'COMVENSATION DECIARATION � . I here6y affirm that I have a cenifitote of consent to self � }1 .Insure,or a certificote of Workeri Compenw�ion Insuronce,or )6A612D U a�e�;,;��o rhereof(Sec.3800,tab C.) CE BOB IRE�.7/877 APPLICATION FOR PERMIT PolicyNo.7��851oCompany St_ 7Tund - �Certified capy is hereby f�rnishad. SEWER - SEWAGE DISPOSAL Ceritfied copy is filed with�he coun�y building inspeclion COUNTY OF LOS ANGELES BUILDING AND SAFETY . deporlmenl.� ooro 8/9F/�tSApplicant T. �T@E'ID8ri . FOR APPLICANT TO FILL IN CONNECTION DATA . .CERTIFICATE OF E7(EMPTION FROM WORKER$' g�itprK, , COMPENSATION INSURANCE � ��nc[55 STPTION � �ERN (This seciion need no�be completcd ii the work involved by the ��i�ry py�NHIXE RF�ERENCE �P°ER permit is for one h�ndred dollars(5100)or less.) - � ° I.cenify riwi in�he performance of�he work for whith�his CRO555T. iYPEOf�ONNf�i10N ��TH«py, permit is iss�ed,I shall not employ any person in any manner Y� cuRe P L. M l.TO V.L. o C.NO. f �` so as�o become subject�o the Wo�kers'Compe�wtion Laws. pNrn�a Al1fIQA G CO.IMP,Wp, �p9 Np, /D4�(,) Dote Applicont ADD'RESS PO BOg-� � TNUNKRRMITND ROADPERMITNO. AFilOAVIT WMVER EASEMfNT RECOIID.INSTR.ND. DA7F NOTICE TO APMICANT: If, aher moking �his Cenifica�e of �irv Covina ����� F-amp�ion, you sbould become subiec� �o the Workers' LEGnL _.�penwtion provisions o(fhe Labor mde,you must forthwi�h - �xuimroN ioT r�o. Hwr.pt sr.v.�oeNn�c ply with s�ch provisions or this parmit shall be deemed � !lVOItCd. ' BLOCK iRACT S7AlE ENCROACHMENI � � LICENSED CONTRACTORS DECLARATION "q.p��p�s. v�RMiT r�o, , I hereby�oHirm that I am licenxd under provisions of Chap�er s¢eovtot r.qwora ior 9(commencing wi�h Sedion 7000)of Division 3 of the 8usi- p�unon+GS Sln • Re8• cr�xcEs neas ond Professions Code,ond my license is in full f«ce ond sftaa. �«rT=�� Freeman on CONNECTION CHARGE FEE L�cense Nomber d7d887 Lic.Closs '(,�d ADDRE55 tE�MBUNSEMENT fEF � Comrocror T_ '(Yrpaman Dare R/9�/A� nrr �� DISTRICiNO. G4WP Mwv rxocesseoer 0 — �� eK w V STAiE LIC. ' I am e.empf under$ec. of�he L.A.Ca. i�Ng r.p �i,� � . �7lumbinq Code and/or Sec. of the �� � R ION WORK r[F NNAi � Ha,s�s�wcc coN�c.�r+�,o DAfE VAUDATION auxK s�wea B.8 P.Code for the following reason yrri 7ANK.SEEPAGf%T OR L � y � PIiS AND/OR d1�iNFIELD FINPl N �OfL� NOUSE gwEY CdVNECTIMG TO BY Z RtIVAIE p15705.41 Y M ^ Signarure COWNEC7 Aoo�r�Onul e�oG-oe � OWNER-BUILDER DECLARATION 'NOYK TO 110USE$EW4R I hereby offirm thot I am exemp�from the Confrettor's License �VfNF CESYOOL.OR9MrF�lRIpMAN�ibIF Law for�he following�eason(SeUon 7031.5,Buisnass and Pro- �utea.aev�ia pt�euJoora�quse -4� (1[l,2� � �Z ns COde): SE�'FR O�a3PO51�1 Sr57EM /i,aa owner of Ihe properfy,or my empioyees wiih woges os ft'" ' ` i U Iheir so�e tompensotion,will do the work ond the sfrocfure � is not inlended or offered for sole(Sec�ion 70M,Business � e �2'],5� and Professions Coda). OWNER'S Permit f 10 Q ❑I,as owner of the prope�ry,am ezclusively contracting with AUTHORIZATION TOTAL FEE °" •2 7.J�� liceneed contractors to construct�he PlO�eC�($BCIIOII�OII, '�Hpy[p}THIS DATE A CONIRA�i WIIN TNE HEIEIN Nl.MED COl�1TRACiOR TO Bvs�neu and rrofess�ons Code). cowHea rHe neovc oexRie�o Exann�c�v.�u�e,e To r�vuauc sfwea. 0£i 2 9—8 6 CONSTRUCTION IENDING AGENCY ► I hereby affirm Ihat thare is a construclion lending agency ��fDTHiS � DAYOF 19 For fhe perfo�mance of the work for which this permit is a^�'^�R� pWNERS AGFNT iswed(Sec.3097,Civ.C.). - AOU4E55 Lender's Name , Lender's Address I tertify that I have read�his applicatton and s�o�e thal the obove informotion is correcl.I ogree to comply wilh oll Counly � Ordina�ces and State lows ragulating Plumbing and Sewan, - ond hereby outhori:e representativee of this Counry to enter upon the obove-mantioned property for inspeclian purpases. � � ' �.���'��r�,,_._,,.� �'�L.�� SignotureolPermilee Da1e � SEFREVERSEFORfX►LANATORYIANGUAGE . 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