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HomeMy WebLinkAbout1439A � WORKERS'COMPENSATION DEQARATION � 1 hereby o/Rrm rho� I have o cer��ficote of coosenr ta aelf _ , {� �insure,or a cerlificnte of Workeri Compenwtion Immonce,or ]6Ada7D �I� PolcyNo�� 'h°o�om���°°s�:`��una �EBOB�REV.IIB]I APPLICATION FOR PERMIT " ❑Cer�ified copy is breby furnished. ` ' . . SEWER - SEWAGE DISP05AL . � �Cenified copy ia f�led w�th the county build�ng inspect�on COUNTY OF LOS ANGELES BUILDING AND SAFETY de meni ' po„ ��26 S6qPP���o�j T. Freema.n FOR APPLICANT TO FIIL IN CONNELTION DATA � -. . CERTIFICATE OF EXEMPTION FROM WORKERS'. ��ip�nK, � ' COMPENSATION INSURANCE " nooaFu sTnna+ o[+�N (This sec�ion need not be campleted if�he work involved by the . MyNMpt��tat� uw[R permil is fw one hundred dollors(f10D�or lets.) �OUuiv _ i Q I certiiy that in the perlormonce of�he work for which�his �vosssr. irvtOr[onnKrwN �/J6THFROM Pprmii is issued,I zholl not employ any Plrao��n any manner �• CURB P.L M l.i0 P.l._ r� so os to become sub�ect ta the Workers;Compenmiion Laws. a�R � °��'NO' d�!" Anden G �.�M�.�. ,��. Da�e ' .�. APPlimnt � ADDRESS PO BOS-� iRUNK P[RMIT NO. POAD CE4MIT NO. NOTICE TO APPLICANT: If, of�er making �his Certificore o( �iiy AFfIDAVII WfIYFR EPSFMEN/ RECOCD.INSiR.Np OAIE � �p�ion,.,you should become subjecf lo rhe Workers' COP�IIB T����� � ansotion rov�s�ona of�he Lobor mde, ou must forthwifi or5caicrioni _ toTno. P Y Nwv.oa sr.wio¢wr+c ,_6ply wirh such provisiona or this permit sholl be deemed ' lGVOIIGd. � � BLOCR ' if1ACT SiRiEENCROACMMENI � ��� ���LICENSED CONTRACTORS DECLARATION "� '+o.a�o�s. °�p'"'T"�� ' S12E OF lOT NOW ON lOT I hereby affirm Ihof I om licensed under provisions o(Chopler 9(commencing with Seciion 7000j of Division 3 of�he Busi- g�iip�y $lII R68• au�s ness ond Professions Code,ond my litense is in(ull force and � ef/ect. ca�tcattoe �'S8@IDAu COIIB't� CONNECTIONCHARGEFFF . LicenseN�mber.� 4'I�LES�I tic,C�ass C�,.�,{�, ,��u BBCC WOQQ nS. ff�Mauuscn�NT�cE � d T. Freeman Do�e 8/e�c,86 ' A,4 T ois.a�a ra. cnauv n+nv vuocFsuo er O CoMractor [l{2( CiiY Ay Ya y��Q�.�. � BK Ka V K ❑I om axempt under Sec. of the L.A.Co. iiC[N5�r+o. 8S- ci�ss C� � P�umbi�g Codeand/or Sec. of fhe �. DFSCRiPfIpJ OF WORK �E FNAI V wusc sewev ca+.hcri�ro 1 OO onre VALIDATI N u+ 8.8 P.Code for the following reason �°°c S�w�R °� FT ANK,SEEYAGF P17 OR N � Yrt5 ANU�Oc OQMrJ�iFID fxa�t Z ' DOIB NOUSf SfN'ER CONNECTING TO !Y %lIYA �I M Siqnotura cor.�r�tt nnoirwwu eioc.oc � � OWNER•BUIIDER DECLARATION M'�K TO MIXISf SEWER . ONFRiIOW EYAGF VI7,DRAINFlEID I hereby offirm that I om exempt from the CommUor's license E%TN.,C,E$$GOpI,DYTV�IL M�NIIO{E Law for the following reoson(Sec7on 7031.5,Buisness and Pro• unp,�v�iR pt!b.�.�voaa nOuSE ' r1ons CodeJ: . s�wcrt oa asros�i svsrtM � � 1,os ownwr nf eh.p...�ny,er my amp!oyeea wi!h wages cs . �i �'� '°��' - �heir sole compeneotion,will do ihe work ond the strvUure • �� � � � � O is nof inlended or offered for wle(Section 7041,Businass ond Profeisions CodeJ. OWNER'S Permit f ],� r ❑I,as owner of the property,am ezdvsively controcting with AUTHORIZATION TOTAL FEE `Z I�� •2 7.5� � licensed con�rocrors to tonstruct rhe project(Section 7014, i wavE Ai TMI$DATE l�CONTRA�1 WIIM TME HEQEIN NMMED Ca'110/.�LOR iO o B-0��,j O U BUSihC55 O�d PfOIlSS�OIIS COdl�. CONNEC7 TME ABOVE DESCNIBEO E%ISTING DWFIIING TO TMF iU&�C YN4R. CONSTRUCTION LENDING AGENCY �'f ► O H.Z 9�B b I he�e6y aHirm Ihaf there �s a canslruClion lending agenty , SIGNFDTHIS "' DAYOF_____��19_ for Ihe performonce of Ihe work (or which Ihis permit is Ow�EROR G pWNFQS AGENf _�2_ issued(Sec.3097,Civ.C.). A�ys 8225 Baechtvoed 7h`_� Al 1:�1 T, g lender's Nome ' � lender's Address 1 cerii/y thW I hova read this applicmion ond s�o�e thot�he obove informolion is corrxt.I egree fo comply wifh oll County ordinontea ond State lows regulating Pium6irrg end Sewers, and hereby aulhorize represenlatives of this Counfy fo enter upon Ihe above•menlionad property for Inspection purpotes. .�>�,�,�.�/a./�G Siqno�ureofPermilee Oole , —, — Sf[REVERSEFOIIE%/LANATORYLANGUAGE . � ro ;�z� ,^� zr o � , . " a n v n �'� �`' c= �'I k . • . � � � Zp �� %j p� T�A Cl . � � . I 4� �'Z t) }'� �` �; r � • . ` � � . , - � c Z� h�" i n On � � ' ^}r n' �i� k� ,�, . �, '� �;�i , � I ; �, °� �� � T�� c�; , O � .. . ; • ; t __. 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