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HomeMy WebLinkAbout1441A , � WORKERS'COMPENSATION DECLARA710N - I hereby oFfi.m �ha� 1 have a certifkore of consem �o�alf � ' insme,or o ter�ificafe of Workers'Coampenw�ion Irourance,or 7646l7D i� Polecy'N�Yg�' Y°��o5m��800,5 V61 )r(4u� - . CE8�9:REV.lr871 APPUCATION FOR PERMIT � : ❑Ce��ified copy Is hme6y furnished. - SEWER - SEWAGE DISPOSAL �� �Certified topy ia filed with�he munty building inspecuon COUNTY OF LOS ANGELES BUILDING AND SAFETY . depOrlmenl. ' , . Daie"8 26 86nvPlica�� T. F�eeID&II FOR APPLICANT TO Flll IN CONNECTION DATA CERTIFICATE OF El(EMPTION FROM WORKERS' eunwrac � � • �COMPENSATION INSURANCE nodt[ss Surior� °evrH . (Thia sec6on need not be completed if the wo.k involved by rhe ����n, wnnnpiE rte�teer+� i°PE R permit is Ia one h�ndred dollws(SI00)or less.) - I certify tho+.in Ihe performance o/Ihe work tor which this cRoussr. r TYff a�O�+E�T�Or.� ��,rH Fvp�� , permi�is issued,I shall nor employ ony perzon in any manne� Cuae v i. M i.To v.t. v c wo. w as io 6emme subject�o�be Wwkers'Compenwtion Laws. pwr,�R ' AISd@n G CO.IMP.NO. Jpp Pq, .O� - �� �`�� iRUNR P[RMIT NO. � POAD OfYMIi NO. Date ' ..., Applicom A�E� O NOTICE TO APPLICANT: li,pfier mnkin this Certificate of AFfIpAVlI wnrvtc EASEMENI ItFCORD.INSTR.NO. DAIE g� OTY TEL NO. � F-�mption, you should become subjec� m the Workers' IEWL � pensolion provisions of rhe labor code,you must forthwith pF$�RIP710N LOTNO. HWy,pq ST.wioEvinG ply with such p�ovisions or ihis permit sho�l 6e deemed C revoked. ' � � " � . eiocK TRACT p S1A/E ENCROACHMENT LICENSEO CONTRACTORS DECLARAitON � r''°p�gtWs- v[RMir r�o. SIZE Of l0T NOW p+lOT I here6y offirm thot I am licensed under provisione of Chap�er ��� 9(commenting�with Section 7000)of Division 3 af the Busi• Bvnon�GS Sin � �{eQ• o��eG[5 � nese ond Professions Code,and my license is in full Iorce ond lHOCt. ' CONTQACTOR CONNER�ON CHnR�E FEE l�tense Number 474es7 �IC.C�O55 �34 q�pE� REIMBURSEMfNT ifE � 4 �0�«OC�Of T� FTBLID8i1Da�e g ��/�O � _ D�SiRIRNO. GROUP MAF N20CESSEDBY Q �-�i! aTv �t8 OID�.� !v BR � a ❑I am acem t under Sec. of�he l.A.Co. stnrt uc . / P � LICENSf NO. RA55 PlumbingCodeond/wSet. ofthe �� DESCRIPfIONpFWORK r�e F�Hq� V NOUSE SEWER CONNEC1�NG TO DAfE Z VALIDATION W6 B.B P.Code for�he follow7ng reason vueiic s�w�a i o `z�z -Qb YTIC TANK,SEFPA(�(N7 0R N PIT$ANp/pR pR�INf1ElD fINAL Z Dote �5E 5[W[R COW+FCTiNG f0 BY . vRrvAi(DISR�Sn�SMiEM $ignOtUfB COr+NEQ nWiTiONAI&DG.qt , OWNER•BUIIDER DECLARATION 'NORKT01101J5E SEWER CJfRiIOW SEEPRGE Yli.DRAINiIEID I hereby offirm that I am exempt from the Contractor's license E%iN,�E$$POOI,DRYW41t,MANNOIE law for the following reason(Secfon 7031.5,8uisness and Pro- arta,cer�ia pa�wr�ooN rqu5� i--•ions Codej:. s�v+FR at oisrosu srshM .. . - ����.�;.�..�.�t rtie prcper!y,cr my cmpioyccs wi:h wagas as � �i�i u I H thev sole compensotion,will do the work ond the svuc�ure is noi intended or offered for wie(Sec�ion 70d�,8usiness �• ' a • � Q and Professions Code). OWNER�S Permit S 10 � ❑�,as ownar of the property,am exclust�ely conrracting with AUTHORIZATION TOTAI fEE � • •C 7'5� Ilcensed controc�orz to tonstruc��he projed(Sec�ion 7044, , I HAVE Af 7Hi5 DAfE A CONLFpCI WITH THE HE4E�N NAM(D CONT A OR IO • s s � _ BUSiOBSS OOCI PIOFESS1005 COdE�. CONNEC7 THE ABO�F IXSCiIBEO E%ISTINp OVIEItING TO THE%161IC SEVlFR. 2 7. O� CONSTRUCTION LENDING AGENGY , I hereby affirm ihot Ihere is o conslrVtl�on lending ogency S�GNEDTHIS � DAVOF IC �8 29`8 6 for the perfo.mance of ihe work for which fhis pBrmil is ��R� issved(Sac.3097�CIV.C.�. OWNERSI1GENl ADORE55 S Lender's Name Leader i Address � . I certify�hat I hava reod this opplicotion and stote�hat 1he � ' � above iniormalion is correct.I agree to comply wirh all Counry ordinances ond State laws regalating Piumbing and Sewers, ond hereby outhorize representotives of�his Co�n1y to enter upon t e obove-memioned property fo�inspedion purpoaes. ��7,`�r�1�<<���fG/�� $�g�aNre of Perminx Dote SFElEVERSE FO�EXRANATOM LANGUAGE _ - �n �. r'�" c� '- . . 9c "� N ���� o r , 7 � ` � . � � , � '�}• 6�`,N ry f� � �i' G��' � , .. ' . v Y ZC,�: �m'P � C�n j,� 1v; ,�v. • , , ' , ' . 4 r c��, n�9 O T'�, l�r O � ' ;� z�; ��;; z� ocl L . � , �\ `, .. �,.. �.;; x, y, ' � J�c�.c ,r.� `� �^,� � , ' � .�.'r� q N<A :% i � . . . .i . . , � :l•�f �[�(> �Cns f ..\ ' . '� ' . , . . .'" ���P�,. y . . ' , " • /. . ' , '1 ' \ , s O . ' . , , . . ,,'\ 1 ' � _. ^ �` . � 1.� • ' . , .1 . .' <. � . ' ,'�. � � �. � . � .� i . . � . ' , . . .'' . . . ", � ,11, 11, _ �`` ` ,; ' ` .� _ .. ,�` v 1 ` ` ,�,,\- '�' ���` . . � � . ' '` � � ' `�� ` . 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