Loading...
HomeMy WebLinkAbout1434A � � WORKERS'COMPENSATION DECIARATION � � I hereby pffirm thal I have a tertificole of consem �o self �- � 5'� � .insu�e,or a te�lifica�e of Workeri Compenwtio�Insurance,or ldA6�7D ' II . a�ceri�f�ed co v�hereo((Sec.3800,Lob C.) CEBOBfREV.I/871 qpp��CATION FOR PERMIT `� Policy No.7�8510 Compony Rt_ Rllrid ❑Cer�ified copy is hereby fumished. _ , � � SEWER - SEWAGE DISPOSAL � �Ce2�roified copy is'(ilad wiih the counry bui�ding inspecrion COUNTY OF LOS ANGELES BUIL�ING AND SAFETY i Do�e e"���/86Applica�l T. Freeman FOR APPLICANT TO FILL IN CONNECTION DATA .CERTIFICATE Of EXEMPTION FROM WORKERS' g�iipn� COMPENSATION INSURANCE nooa�ss srnna+ o[vrH � (This tec+ion need nor be compleled if the work involved by rhe uwER � permit is fa one hundred dollors�SI00)or lesi.) LOL4LITY MANHOIE RfcfRENCE R . I cer�ify ihof in �he parformonce of the work for whicb this �A�ST rvveor[OwtC�wN ��TNi� caoss sr. y. ��� v�. M L.TD P.L. permil is issued,I thall nor emp�oy any person in any ma�ner . P�� so as to bemme subjec�to�he Workers'Compenwtion lows. oW�R �o i�� � �� O y ' hNll TRUNKpERhVTNp. RWpP[RMITNO. Da�e �. APPlicant � ' ��Eu � BOS.. AFFIDAYIT WAIVER EASEMEN7 RECO4D.INSTR.NO. OAiE NOTICE TO APPLICANT: If, afier making this Cerfificofe oI �irv Covina TE����8 ' ,` �ption, yo� should become subject ,to the Workeri ��qi ensotion prov�sions of the lobor code,you must forthwith pe5ceivnpN lOT NO. HWV.OR ST.WIDFMNG „ ply�with suth provis�ons o��hia pe�mit sholl be deamed revoked. �ocK TRAR 51AIEENCNOACMM�FNT. ' �� LICENSEO CONTRACTORS DKLARATION r.�p.pr gtpos PEFMIT NO. SREOF LOi NpW pN lOT 1 hereby offirm thot I am licensed under provisions of Chapfer ��� 9(commencing with Section 7000)of Divisien 3 0(the Busi- aunnn+cs .SlII • Re8• au�s ness and Professions Code,ond my litense is in full fwce and effect.... ��/ �} . . m�+ra�croc Freeman 021 � CO^�NECr10N CH4RGE FFf . . . � License Number �/�8�/ �iC,��055 ' ' C�� ADDRE55 p�2 w 4EIM9URSFMENT f[[ � Cono-auo.T. FrE3Pmt�n Dme ��7fi�RFi crtv �t8 �OUIc'L��.r,o 1 � Di57RKTN0. GROUP nwv vcocfssE�er O BK PG ❑I am exempt under Sec. of�he L.A.Co. iIt[Nsc�O 88. �Ii�ss �8 � ' PlumbingCodeand/orSec. � ofthe �� DESCRIPT�ONOFWORK rEE GINA� � � ���ca+�cnr+c�o 17 � onrE VALID ION �'j B.6 P.Code for the follow�ng reoson z` W � PTI 7ANK.SEEVA WT OR FINAI y PIIS A1J�/OR DRAINFI�O Z DOIB � 110u5E SEM�Ei CONNEC�ING TO BY Anvn w �. Siqno�ure eoHHetr nonrtipa.i gin�.pe � OWNER-BUILDER DECLARATION woxc ro wous[sew[Q RROW$[EPA�(G17,DFniNfqlD '1 � 1 hereby affirm thal I om exampt(rom the Con�rocroi s Litense E%iN.,QSSVOOI,DYYN4LL M4NMOIF �� �'7J.4 A Low for ihe following reason(Secton 7031.5�BWSnEE.S OOd Pf0- AITEY.REPA14 OR A6�.NDOIJ YqUSE �(On5 COfIQ�: 3FWfR OR p5PO5Al SYSIEM � `��' i • • ' O �,�I,as owner of the properly,or my employees wi�h woges as I their sole compenso�ion,will do rhe work ond the zhoc�ure � . •2'],F'j O , Is not iroended or offered for sole�Sec�ion 7W4,Business , and Professions Code). OWNER'S Permit f �.� 0 •.• •2 Z 5 0� ' � ❑I,a:owner of the property,om e�clusively contracting with AVTHORIZATION TOTAL FEE �IC0I1Sl�CO�h4C�Of5�O COI1S�lVC���12 pIO�CC1�5CC110�7a4� I HAVE AT TNIS DAiE A CONtl��T WIiM THE HFYEIN NLNIED CONTiAROR ip �A 2 9-8 6 � Businesz and Profeasiona Code). ca+�cr nrt�eove o[scQ�eto eKrsnr+c ow[u�nc ro rN[ru��c sEw[R. CONSTRUCT�ON IEN�ING AGENCY , 1 hereby effirm thot Ihere is a consl�uction lending agency S�GNFDTHiS � DAYOi 19� Ior the performonce of the work for which.this peimit is a�+Ee oa �" pWNERS AGFM issued($ec.3097,Civ.C.J. �E� 8r� , Lender's Nome lender's Address I certify Ihot I hove read this applicotion ond state�hal�ha above iefo�mo�ion is corrocf.I agree lo comply with all CouNy � ardino�ces ond Slole lows reg�loting Vlumbing and Sewers, and he.eby authori:e reqesantotives of Ihis Gounty to enter . upo�n�the obove-menfioned propeNy for inspection p�rposes. � t�T�R'd•G� �1P�r��a� cY/.7�,��� . SignoNro of Perminee � Da1e� � SEE REVEIISF f0�EXtIANATOtY IANGUAGE . _I_.. - '€ ac� Ny m� ry„ �'�+ 7 , � , a:�• N z� co , ! , : . I !' o�� (r;V �"� 8 un nf F ' ' . ' ' � . , I , I ' C I n... O .a�D 4��-� � �'' . c. . . . , � . . '^ Zn -a ,� ;T on , Z,. , _ . . . ; �i €^ �� r^ `:o 7�, i� ti : � - '. ! � .. . � �;� , . �.,., - w . � , . . . T :, ,.,�� 2:i a.o ;u 0 � . . � , ' _i t � , '_—� y�.j� ^�A Nir �V C'r ni � . �� 1 ' . • , .. 7 �' ,�.�O �A) < '�� r : ; � . �o � $ ' Y�, � � i I � N 2 ! I , ' . -� !� � �I • � i � I � i ' , � , ,. � ; -'--.j._ . �i , !' .. ; ' I � ; '' �� n , , • , O ! ` I -- -- � I � I � ' ' f 9 t � . - I �- " �' • ' __.... . • ' . �!' � � ' I . . � I h ' . • . �J` .._ _ _ ' ' � , I _ � __-. N . . � . , � '� , ' ' � . ' ., ' . � . . . . •- ' - ' . . . . � ` , . � 3• � . ' ' � , ' . .. . . . . . � - , � ' j ' . . -.-_. ' . . ' . _ .-� . .. . ' . . , � . � � . .. : . 1 � ` i � . � ' � . � . � , I`. /:� _�_ __� _�_ _�_ '__'' _ j`l; � ' _ ' ' .' • . . _ (.J • �' � i -_ '}� � Ti ' I ' , �.� � i_�' i I i I _ 'i , .'L: i ,. . ' ; -- --- • -'—'i- i' •i - - `f; '} . .t � ; ' � � � - . . • ii i ; � ��;: ( � ' ; -• ' ! ' I ! -II111 - '�J . �:. , .' — . '. � • ��-� �. � i . . � ! � 'I ! I . .�.� - . � R . _ '� ' : . •:� �,_.. •� 1 ��� , - � - 1 . � � � l_} I . _ � 0 . . . � ' � �•� '� , I .' ,• �� . � i.� . � 1_ i � ��� ^( • �!� � A -� II ' ! ; � . ., .I� � ' - ,i 'l.t` ,` .0 'C.. 14, ' } . ^J i^ ' : � , . I. ' I .1�I _ '" _ L� 1 , . �. . . . � I. � . ` . ' ' i . _ " "" ' ' � . , ' ' . I ! � ' • � �/• . . �' _ .. . � . . �� I ' . �. ' _ ' . '. . . - . ' . � _ • , � ' � .• .+" '• t C x p� o-�'y= �^��^ Cl��.� ^ � �r . � � . ._ . = .� � o.._.n� m ,� . n n'p t•o _ . .. -. . Q � ' w :� 0.' - � :� in❑ ��. � R � � � � r � ' .. • � i: i :i. ti � ` q � �t ^'�`�'.'.'' ' n n � � , � .. i _� _ ' . ' .`..' � �.. p?� �y. m.�.Om^1 � LyL4� o^ `. � 4pc � `�' r � O . . (. . ' : ' , ' . ' r - N' f' ��'� \ti� C L F � J ee 'e �'�U C 4`. C C ••v,. / . . � • �- , , . _ " . '� ; n �� a ? �_�'�a.z +� " ° ' �+`- � � � „ c..� 4 r ,. - � o. � �� •M „ n �a �L, � �., ti `' C'7 . ' . • - '< , . • , , ' , i i�. ? �'o�o ^-c c` '^ ` '�`^`'�o m ti c�n "' c �c � j. . �� �4 M 7 � �.�;'✓; .�". �., p � _C �� . . _ - . . � �. .. ' . - ,' �� � `� n � `-`� h .C. r�- l.r�� n O �� �� e�c p M.�^� ,�+ . . . . ' _ � . � . � ' �L � �' .`. CC7y ` .' C�.10 � r1 fpL:.• .� ._ �� . ' + `^' � � ^ � � �� F� �L� p ��^-,• ^. ' �-+ '. _ . . - �; c. +;�'c_ ^� �a_ -o 0 .^.4 �-� ''���,.M _•�� C, , ^ . � � � - ' ' . - . • - , ' � , ' c � ' „i 'n ,n c.� �"c:` c c n,o� �„,� , , ' , '_ • ` . . _. ' y'. ;� C�,t�°-A `�G.Z-i C�p 4` � =� ^.�_ , . ~ p tn ►� n` ` � y %� . -_ � u' :�; � ��� '�� = �° 'd C�' �� ' � = - . � _. � o ` a,�.eo''e � �`'•�tin �' � _ ^ z' -' .C ' - - �• ' . P`a3 � o � � � �q � �:, �°o-,��i'�n �O ..r ._ i • .. ' � _ . _. _. , : � =.� o _ ., o n�'� ��: .. �a: : z ° �`' � -,.. .r; - _ - �. c y � c _ c �° r � C� -�� c c- C" - - . _ ` , . - -. �-- _ ' '. . : ' . F' _� C C` = .`m �q- = `'`��. ��^ .a b v�o -- � � . . . ._ .. -- , , _ . . ��-..'^_.0 n ; c '�l� c y n�c tn�y ��� c ir,�.- �,"' ' � . . - . _ _ � . . - ' , ' . •Oo � n��a � �.G r_ sy2 m 'O d � ,y ry^., y ' ' - �.i �e 4. '� `° .�._^. `:° ' ^ ^� • - - . • .. , , " .: - � � - • a F s.� nm i: c��c .(;'� �n 4^; C:' „"J . . . . . . . . � . }� ,� ` G p , ti � C R ^< C 0=. �"'. - . . _ '_ . . ... . � ' .. . . . ' � `�E p �q = ^ ..R 1 ' M �. � =�. � .�. � O • . . , . � 1 �� n ^ � `v, ` ` V^ .L. .. �, , _ .. c' 4"�=V T• q"J � p a w n ti= C n _. . - � .._ � . i� . , �' ; ,ti�.6 �,:..�C. �.C �`y C n�� R�h ' 5...' - - , , • , . - . , � ... . . � . .. �,n n 4.C. .h, c �e � h`,h F,m i•�-c"v_ • ; .