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HomeMy WebLinkAbout1438A (8) • WORKERS'COM�ENSATION DECIARATION I hereby affirm that I have o ce�tifico�e of tonsent to self }1 .ineure,w a cenifica�e of Workeri Compenserton Insurance,or 16A6d70 . II PolcyfNo�.fi�� i`5°�oSm��800s�:`�'Funa "B°e`°`".,,8" -- � APPUCATION FOR PERMIT u ❑Certified copy is he�eby fu�nished. ' • SEWER - SEWAGE DISPOSAL �Ce�filied copy is filed wi�h�he counry build�ng inspec+ion COUNTY OF LOS ANGELES BUILDING AND SAFETY � deporlmenL ' � ' � Do�e Aoo���a�� fOR APPLICANT TO Fill IN CONNECTION OATA -CERTIFICATE Of EXEMPTION FROM WORKERS' eununx, � COMPENSATION INSURANCE noors�ss sution otrtH This sec�ion need not be com leted if�he work involved 6 �he �R ( P Y tOCnu7r � � hwNFlp�ErsE�fcENCE Q permil is(or one hvndred dollors(f100)or less.) " ¢NGiN faoM I cerlify Ihol.in the performance of�he work far which this Caos�.sssr. S ZVS11 Glen Trv�Of�Ow�E�TiOr.� Y. CVM P,L M_L TO P.L. permil is issued,I sholl not employ ony person in any manner p�� . so as�o become sub�ect�o the Workers'Compensolion Lows. a�4 Anden G to.n.w.rio. ios r+o. d2,� ' ��� TRIJNK PERMIT NO. � 40A0 PERMR NO.� Date Applicant � �o�u PO Boa-� 2 NOTICE TO AOPLICANT: If, aNer making this Certifica�e of �iT� AFfiD4Vli WABIE4 e�M[Ni FFCOCD.IN$TR.Np. �AIE � p�ion, you should betome s�bject to the Workers' COY1318 ,��.�. 818/967-9 41 �nw�ion rovisions of�he Lobor code, ou musl fo.rhwi�h �EW'� _ P Y oescaivriori tor tio. wwr.oa sr.vnur+u+c c...�tply with such provisions or'this permit shall 6e deemad 357 1 IGVOkCfI, , BLOCK iRACI STAiE ENCRO�CHMENT UCENSED CONTRACTORS DECIARATION no a aocs. �R""iT^p. I hereby offirm�ho�I am licensad under provisions of Chap�er S12EOFtOT r�owor�ioi 9(commencing wi�h Section 700p)of Division 3 of the B�si- g�iipu.�s .51IIg• R@B• ��y ness and Wofase�ons Code,and my I�cense is in full fwce ond effect. �p.�o�ttqr CONNECT1pN(l1AYGE FEE License Number 474887 lic.Closs C34 AODRF55 822 Beeehwood WE�MBURSEMENT FEE �„ COnlractori• �eeQl� Dale B�G�,Sv CITY L DiSTGiRr+O. GROUo hu.v c40CE55E�Bv O STI.tE L . � \ BK PC'i V ❑I om eyEmpt under Sec. of rhe L.A.Co. ii��r.q nAu �� K �. DESCRIVfIONOFWORK fFF Q Plumbing Code and/or Sec. of the FINAI VALIDATION V , '+ovst stwta ca+Ncctir+c ro 1., O DATE 1 Z�2 vuetK sew[o B.d P.Code for the followfng reason vrK rux. [r vir oa F�q` W PITS ANO/pt ORA1NfIElO N �OIB �y 5[y.hp CONNEC7ING TO �Y Z PRNA OISi051115Y57EM � Signaturo coryHE[i AODirqr�ul p�p�.ox � OWNER-BUILDER DECLARATION W�to�sc s�weR RF�pW SEFPAGF P�1,pYI�iNFiE�D 1 hereby offirm thot I om eiempt from the Contractor's licenae t�nu,cessroa,owrweu.ww�a¢ � low�or the(ollowing reoson(Satton 7031.5,Buisness and Pro- �1TFR.REvqiR OR�NDON�+OVSf �� 4�a� � �OfIS COdC�: `aFwER pR DI$PpSµSYSTEM �11,aa owner of 1he p/operfy,or my employees wilh woges as �e � � � j � their sole tompanw�ion,will do the work and ihe structure is not intanded or offered for wle(Section 7044,Business I Q s 2 7, .Jr O ond Professions Code). OWNER'S Permif f ❑I,as owner of�he property,um e.clusively controcting wirh A�HORIZATION TOTAL fEE '� Q s o a 2'],,rj�� licensed tontroctors to conslr�ct Ihe�lO�CCI(SQC�iOt1�WA, I MAVE AT TNIS DATF A CONTNACT WIM THE HEREiN NFMfO CONTRKTOR TO , B�a�ness o�d Profess�o�s Code). coNr.�cr THc aeovc oesc4roeo exisrn.�e owEwNe To r�vu��c sewEc. 0 8 2 9—8 6 CONSTRUCTION LENUING AGENCY ��J , � I hereby offi�m thol there is a constrodion lending ogency SIGNFDTHIS �+ OAYOf 19_ for the performance of �he work for which this parmit ia o"^'^'�ROR O'MiEYS AGEM �,s��a�s,�.�,c��.c.�. p�S5822 eeehro A1 om Lender's Nome ' lender i Addross - I cenify thot I hava reod ihis opplico�ion ond s�ate that the obove iniormotion is torrecl.I agree to tomply with all County ordinonees and S�ote lawe regolaiing Plumbing and Sewers, � � o�d hareby oulhorize represenlolives of Ihis County to e�fer upon rhe obove-meneioned properly for inspattion purposes. ��iJ�-�, ��,��/�� SlqnoWreofPermillee Dale �-T SFEREVERSEFO�!%►LANAiOMLANGUAGE i . . � � . � . � . . .. . . , � Dc Nr T yk: co � . . � . � � ! 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