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HomeMy WebLinkAbout1474A ' ,WORKERS'COMFENSATION DECLARATION , I hereby offirm thot I have a cenificate of co��eni to self � � insLre,or ate��ifico�e of Workers'Compensatlon Insurance,or 16�64D . i� a�s.�;f���op iheraof(Set.3800,Lob C.) CE608�R[V.11q71 qpp�ICATION F4R PERMIT PoIlcyNo.76�51OCompany_ S'C. F11rid ❑cs�,;r��copy is hereby furnished. - � SEWER - SEWAGE DISPOSAL � �Cer�'rfied copy�s fi�ed w�rh rhe coonty boi�ding��sPKro� COUNTY OF LOS ANGELES BUILDING AND SAFETY depnrrme�t. � ooi� E S n�l��om—T. Freeman FOR APPLICANT TO FILL IN CONNEC710N DATA CERTIFICATE OF EXEMPTION FROM WORKERS' eunou.� . COMVENSATION INSURANCE �owt[ss STATIpN cerrH (Thii sectton need no�be compleied�f�he work involved by rhe MANMqE REF(RENQ U°PE° permit is for one hundred dollors(=100)or less.) , ����TM I cen�f iha�in rhe rformooce o(rhe wwk fo�which this �ARFST rrv[orcorn�t[raH ��tH�� Y PC CRO55 ST. $n en Y. Nqy P.L M.L.10 P.L. permit is issued,I,shall not emplay ony person in any ma�ner � p�� so as lo become subject lo ihe Workers'Compenaotion Laws. �,�Q Anden � c0.iMo.do. �oe ra. D L�r Do�e � � Applitant . . • � �ooxess PO Box..3329 TRUNKP[RMITND. 4phDPEPMITND. NOTI[E TO APPLICANT: If, ofier moking Ihie Cer�i(ico�e of - 818 C � � AFf101.V17 WAIV[R f.�SFMENT cpcaao.insm,rq. owrE ` �ption, you should became subje<t �o the Workers' ��Tr Covina TE��� O ensation rovis�ons of the Labor tode, o�m�st forthwiih �f�� P P Y DES[RIPfION lOfNp. HWY.pqST.WIDENING .. ply wirh such provisions or this parmil sholl be deemed 35761 revoked. � - � eiocK TqA�f $iATEENCRO�CNNFNT � ' � � � UCENSED�CONTRACTORS DECLARATION. � rq,oc eiocs. �aMrt rio. 512E OF LOT NOW ON LOT I Fie�eby affirm Ihot I cm litensed under provisions of Chopler 9(commancing with Secrion 7000)of Division 3 of�he Busi- e�viip�s Sin . Res.� a�„�5 ness ond Professions Code,and my license is in full fwce ond . effect. coNTqAcrpQ �e@mBSi COnet• . CONMECfiONCHA4GEfEE UtenseNumber 474887 ���.cia:. C34 qppqEg 8225 Beechwood Il�� QE�M&1RSEMENTRE d ComroUor T Paman pote fR 2Ei RFi oisreicr n+o. cr�ouc m,�v ]40CESSED BY O . F* / / �,,; Alta Loma• ,F�.�. 7i4 9$a4429 eK � � ❑I am eRempt under Sec.� of the L.A.Co. iiCiNs[*q. - cx�ss LV � NO. pE$CRIPfIONpFWpRK ifE � Plum6ingCodaond/orSec. oHhe FiNAi VqLIDA ION uVi - NOlISE SEv/EN CONNfCilr�(',TO O DATE B.8 P.Code(or�he(ollowing reason vueuc sewE4 -,�p' "'f ' y SE IC T�NK.SEE1qC�[MT pR iINAI Z . YliS ANp/OQ ORAINFIfLD Oafe � NOUSE SEWER CONNFC�Ir+G TO !Y . - PRIVATE�ISPOSl1l SYSIEM Signatvre mMNFCt,.ODitip�Id elp4.pa � ' OWNER-BUILDER DECLARATION W�Ta�qu5c 5[u'ER 1 hereby affirm that I om exempr from the CoMroUor's License ExTN���Cf55NOl.DP�YWE�iL�MAN�i10tE law for rhe following reason(SeUon 7031.5�BViSfIB55 Ol1fI Pf0- AL7FR,REPAIR OR ABANDp�1qU5E `� ��.J, n ��ons Code): stwEa oc oisroswi svsrtM . .a r� ,.��,as owner af tho property,or my empicyees wi!h wages as � N• . • . 1 !1 �heir sole compenwtion,will do�he work ond the shvcture '� is not inlended or offered fo�wle(Sacrian 7011,Business � e �2�.Jr O and Profesaions�ode). OWNER'S Permit s (`J fj" ❑I,as owner of the property,om eatl�sivel'y tontrocling with AUTHORIZATION TOTAL FEE o'Z `j • • �[7,:i Q u Ilcansed connac�ors to construct the projec�(Section�O/A, , �NqyE p7 THI$pATE A CONTYA�I W11M T11E NEFEIN N�MEO CONTRR�ipR f0 BUS�r1Cf5 Ond PfO1GSSiOf15 COdlJ. CONNER TNE ABOYE DESCRIBED f%ISiING pV.fIUNG W TME VUBUC SFM'ER. , 0&2 9-8 6 CONSTRUCT�ON IENDING AGENCY �/ ► I he�eby offirm Ihat ihere is a mnsnuUion lending ogency SGNEDiH�S � DAYOF I9• for the performonce of Ihe work for whith lhis permit is �"�R� Issued(Sec.J097,C�v.C.). OWNEaSa T A�DRESS lender's Name lender's Address � I certify�hat I have reod this applica�ion ond sta�e that�he above inFormolion is corretf.I agree to comply with oll County ordinonces ond Slote lows regula�ing Plumbing ond$ewers, ' and hereby a�lhorize represento�ives of this County to enter ' �upon he obove•mentioned property for inspet�ion purposes. - � .��r,�:�,� �/��/�'G $7gnoWreofPermittee Dote , SEEREVERSEFO�E7f►UNATOR�IIANGUA6E a� m r m i�,; �+� � ` I -.. . - y m_ , z� `<; ` , ' ! � n Dii '`� i_^ V.. v: $ . � � : . ' ; 70 Aa� �� _ . . � - ' . � I ' � - �j�. �:.n :� �D �i� b . ' � i -. . ' V z`� `-'•r �^ Fr o�' � ' • " � �y C�� C�R' '� n '�() Z . � . i i �. �^- � 7�•^• $a .,. . . 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