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HomeMy WebLinkAbout1436A (8) • WORKERS'COM7ENSATION DECIARATION 1 he.eby offirm �hot I bove o certificore of confem to self }1 � .insure,or a tenifico�e o(Wor4ers'Compenwlion Incurante,Of I6A617D , ' II a certified c �jonr(Sec.3800 b C. Cf 809�REV.11871 � Policy No. ����+Com��Y ��• '��a APPUCATION FOR PERMIT - ; ❑ca++E,�a�o��=ti«eb�+�.���n,�. - SEWER - SEWAGE DISPOSAL � �Cert�fed copy�s filed witb the counry build7np�nepec+ton COUNTY OF LOS ANGELES BUILDING AND SAFETY deporrmem. - • ' � po�e 8 26 86aPP���o�� T. Freeman FOR APPLICAN?TO Fill IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' � g�,ip,� COMVENSATION INSURANCE noo¢tu $ a SrarroN otrtN (This secrion need not be completed if Ihe work involved by the Di ,w,�E��� i cu�Q permit is�fw one hundred doilars(SI00)or less.) �ocAurr 1 tenify�thot in �he performance of 1he work for whi<h this Cqpu55T iYffOiCOHNEC710N u�rNFcO�n pe�mit is issued,I=holl not employ ony person i�any monner Y. CUR! P l. M L TO P L. so os to become subjeU to�he Workers'Compenwtion�aws. Anden G � �a,,M,.�. ;o;�: o i� � � owrxa Da�e APPIicaM ' DOQES$ PO Box�.3329 TRU�M(PERMIT NO.' 4pM PFRMITlq. NOTICE TO AViIICANT: I(, otrer mok�n rhis Cerrificore'of nFFiaavit wnivea EASEMFry7 G{�pRp.INSTR.NO. WTE o �„Y Covina .��.� 818 96 - 1 �y+ption,:yov ahould become subjecl to the Workers' LEG�t �pensotion provisions of the lobor code,you must forlhwith oE5�4ivnpH iot r+o. H,M.,at ST.wio�tiinc c..�6ply wi�h such provisions or�hfs permit shati be deemed revoked. � �oCK TRACT StA�EfNCROACNMENT tKENSED CONTRACTORS DE�IARAT70N n�p.a�ocs f4RM1T NO. size a ior rqw p.ioT I hereby offirm thot I om litensed under provisions o1 Chapler 9�(tomme�cing wirh Section 7000)of Division 3 of the Busi- e�uimi�s S1 • R@8• ��g ness ond Prolessions Code,and my license is�n full force and effec�. . . 34 CONTRACtOR FT@@mSII COIIB't. ' cow+FttioNcr+r,�c[r�[ litense Number ������ �i[,��dis � � A�E� RE��/�BURSEMENT FEE Comroc+o�T. Fr@el�atl Doie 8/26/86 • o,57Ri«� �v � o+ocFsseo n. Q arr t i.No � � u Sf�1E �IC. ❑1 om erbmpt under Set, of the L.A.Co. ii�N�r,p 8 . nnss � OC PlumbingCodeond/or5ec. ' o{the �''�� DESCRiPTiONOFwORK n[ ��N�i O rousc u..�a cawfcnric To oare ���Z Z�g VALtDAT10N rj B.B P.Code For fhe following reason °�'��R y� SfPTIC IANK.$FFPAGE il7 04 RNAL �' VITS ANO/OR ORAINF�ELD y� �pIG MpUg gyoE4 CONMCTiNG t0 �� Z � ' ViWplE D� vSiFM Signolure ca+N[ct iwortrauu&oc.Ok � OWNER-BUILDER DfCIARATION �To"°�s�s�vrtR � UKRF�pW 3[EP�GF Rt,DRAiNF�ElO 1 hereby affirm thaf I om eeempt from ihe Contracror's License EXiN.Cf5$POOI.OQYN(LL IMNMIX( . Law for�he following reason(Sedon 7031.5,Buisness ond Pro- urce.►Ea�iR pt�e'.rep��qust l�ns Code): st�vEc oQ dsrosu svs+[M �J,os owner of ihe properly,or my amployees wiih woge5 os "1 4 a 6 A tbe�r sole compensation,will do the work and�he strotfore - ' � is not In�ended or oRared for sale(Sec�ion 7044,Business � ' �• ° • • � � � and Roieasions Code). OWNER'S Permit � = 10 ❑�,as owner of�he properly,am exdusively tonhacting with AUTHORIZATION TOTAL FEE � � • �2 7'`5� IiCl�lad tOflffOC1015�O[OOfilll[I IFIG P�OIe���Sl�NOO 7044, �{IAVF AT TN4 Q61E A CONiRACf WIIH iME NfRfIN N.�MEO CpJ RA oa ro • , •��,r�O� Business ond Professions Code). . coNr�a tHt aeovc oesc4ieeo tzi5nr+c ow[wraG ro rH[rueu[5[wta. CONSTRUC710N LENDING AGENGY , • I haraby offirm Ihat there is a�construction lending ogency SIGNE�THI$ DAY OF �q, ��.2 9`8 6 fw 1he performonte of tbe work for whith this permif is �`'�R� issued(Sac.3097,Civ.C.). own[Rsnc,�Ht Lender's Nome ADDRF55�ZZ e Lender i Addrea . ' 1 ce�lify Ihat I hove read this opplicotion and s�ate thot Ihe above in(ormotton is correct.I aq�ae to tomply wifb oll County ordinances and SMIe lows regula�ing Pl�mbing o�d Sewers, . ond hereby amhwi:e reprasenio�ives of this Coumy to enter � �pon ihe bove-menfioned property for inspeclion purposes. �d� ��.� �f�L . 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