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HomeMy WebLinkAbout1473A � WORKERS'COMPENSATION DECLARATION - � I hereby affirm �hat I have o certificate of to�sent ta aelf �1 � infure,or o'cenifitate of Workari Compensalion Inwrance,o� 1dA612D ' U � ace�ti(i g���,8of(Sec.3800s�a,�.�a � �EBo9�RE�.��B�� APPLICATION FOR PERMIT . _ . ` Polity No. Compony Z ❑Certi(ied copy is hmeby furnished. - . , SEWER - SEWAGE DISPOSAL 'I �]Cer�ified copy is filed.��rh the co�nty buildinq inspe�tion COUNTY OF LOS ANGELES BUILDING AND SAFETY � depadmenf. f . . . Do�e,�pApplicant T. j7'rPaman ' FOR APPLICANTIO flll IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' eunwwc � � COMPENSATION INSURANCE ^��u 8 eatherwood IJ¢�. Srnriora ctvrw (This section need not be tompleted if the work involved by the ����TY MFNHp�E REifRENCE �y permit is fa one hvndred dollors(SI00)or less.) �Dia �3r hEAREST TTYE OF CONNEC710N IENGTH F4YA I cerlify fhat in the performance af ihe work for whith this ' Cap555i. .S ZQe`LA Glen r. CURs Pl. MI.TOPL. permit is iesued,I sholl not employ any person in ony monner v.c.r+o. �q �+ so os to become subjec��o the Workera'ComPenw�ion Lows. owuec Anden G CO.IMP.NO. JO!NO. v�" � ��� TRl1NK iEYMIT NO. IIO�D RRMIT NO. Doie Applfcant AD°�u AFFipAVll WAIVER E�SEMfNI RECOWD.INSTR.Np. DAIE N(ITICE TO APGIICANT: If, ofter moking this Carlifica�e of titv (�iOV�21& rE�.�b 8�.8 6 � 1. / �iion, you should 6ecome subjeU to �he Workers' iECAi nsalion provisions of the Lobor code,you must forthwirh oexaiariorr _ tor no. S �vn•,pqsT.y�pfqir+r, ._.�iply wirh such provis�ons or�his permit eholl ba deemed C revoked. � �occ iQACT Ol STAIEENCRO/CNMENT I.ICENSED CONTRACTOR$DECtARATION �'�&�'S' �pM'T� SRE Of l01 NpW ON LOT I hereby oHirm-thot 1 om licensed onder povisions of Chaprer � �a 9(commandag wHh Secfion 7000)of Drvis�on 3 of the Busi- eunoir+cs Sin • R@8• oarsc,�s nas and 7ro(essiona Code,ond my license is in f�ll force and � effec�. � � cana�aoc �FT@@ID&Il Ci0II6't'i• CO^1NEC110NCNARGEFEE licenseNumber 474887 u�.eias: C34 �ooaess 8'L'L�j B@eCY1WOOd DT• M[iMBURSEMENTiEE } Connac�or T. FrP2ID3B Do�e 8/26[86 oara�ci r+o. c,wouv M.+v vvocesseo e. 4 ��i� Alta I,oma- rE�.� 1 80— 2 / � ,� � ❑I am eaempt under Sec. of rhe LA.Co. �iceNse rrp. 8S anss Q (i� p{ ��Plumbinq Code ond/or Sec. � of�he �� OESCRIPTION Of WORK r�e F�N�� O wus�s�wec ta+r+ernr+c to / dO onr¢ t ''�..�'� VAUDATION �j B.B P.Code for+he following reason ��K u�R W 5(PfIC 7ANK.SEEV fll OR d P�iS AND/OR DR111Nf1ELD FINnI •� Dole �5(gwER CONNEC1n+G 70 BY , . qtIVAIE pISVOSAL YS�FM Signature CONI�LCT ADDIi1qJAl&DG.OR � OWNER-BUILDER DECLARATION watK To�+ous�scw[R ONERhOW SEEiAGE%T,DRAINfiEL� n� 4'7 Z� I hereby affirm�hm I am ezampt from the Comractor's ticanse . Exrv.,c[ssooa,oavw[u,r.�wwa[ �+ '�w for the following reason(Secton 7031.5,Buisness ond Pro- kteQ.acnr�ia at�e�Noorv Noust �•ions Code): stwea at asrosnt srsreµ � . r�• • . .� 0 ._.1�,oa owner of fhe property,or my employeea wirh woge:as � • a z 7•Jr O �he�r sole tompensotion,will do fhe work and the s�ructure , � is nol intended or oHered for wle(Saction 7W4,Business ond Professions Code). OWNER'S Permit. s � �i7J • � °�7,5�� ❑i,as owner of the properry,am e.clvsively cont.ocr7ng wirh AUTHORI2ATION TOTAL FEE o� � 0&2 9-8 6 litenscd con�mc�ors eo tonstr�tt the proiect(Section�O4d, 1 MAVE AT THIS DATE/1 CON7RACT WIiX iHf HFREIN N4MFD CONiCACiOR IO Businese ond Protessions Code). ca+r+[cT rr+e aeovc ocxxie[o exisnrrc o+xew�+e ro rw[ru�ic sEwra. CONSTRUCTION LENDING AGENCY /� ► I hereby aHirm thol there is a tonsfruction lend�ng ogen[y �NEDTHIS � DAYOF (✓u�� 1 ' for the performance ot �he work for which this permit is ��R� isa�ed(Sec.3097�CIV.C.�. OWNFWSAGEN7 ` ADORE55 Lender's Name � Lender's Address I cerlify thot I hove reod Ihis application and stale Ihat�he above informalion is correct.I ogree�o comply wi�h all County ' ordinances and State lows regoloting Plambing and Sewers, � � � - - ond hereby ourhorize.ep.esemotives of th�s Counry to eNer . �po rhe obove-meMioned property for inspection purposes. ,`���(>��. ��zG/�C : Signofureo4Permillee Dole SEEREVERSEFOtEI[riANATORYLANGUAGE i . i . � . . _ . _. . . . .. .- � � � o'o n r T y�; c( 7 .. . , • � V� D 1 �.ti N - . � . . i ' ' ; • n i::, r� �� v� x _ . . ' . . . , i ; � : �' _ �;� �� t5 °; �,�' � y ; . • �, . i, `� �.: y �z Q=' 'C _ . � i. .. ' ' . � Jri ��.. �u ❑ Dn ii '[; , I �.0 U�. 7� `�:� � . . , I I i . ' �� • "' ;: fl;.,�. :�z � ^ a() ,� O ' . . . � > �^ • n> Nr �u c,v �•� C . • , ` � � :. �; :� ..�, � - i: D � . .. . � - , � j �p �x: } N . v .. ' I : I � � � i � - � • m � � , � ; � . i ; : , � .. 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