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HomeMy WebLinkAbout1433A (15) � WORKERS'COMPENSATION DECIARATION � I hereby affirm �ho� I ho�e a certificote of tonaent to self ' •insure,or O cer�ificaie oi Workeri Compenw�ion Insuronce,or �6n6e7D � Pol cy Noa co2 "�Q�aSm��y°�st.`�'�a �E8091REV.1/931 APPLICATION FOR PERMIT . ❑Certified copy is hereby furniahod. - � � SEWER - SEWAGE DISPOSAL I �Cerrified copy is filed wirh rhe counry buildi�g insp«tlon COUNTY OF LOS ANGELES BUILOING AND SAFETY deparemenl. � � � pa�e 8 2E 8E)q�I;�a�r T. I'�CeIDBA ' • FOR APPLICANT TO FILL IN CONNECTION DATA . . CERi1FICATE OP EXEMPTION FROM WORKERS' COMPENSATION INSURANCE �ss $ $ g sunoer ocvr« ! (Thi�eection�need not be completed if the work involved by the i�i�T� a �N���F�� i�R permir is for one I+undred dollars(f100)or less.) �AREST irreorco�crbr+ I cerlify thof in �he periormonce of the work for which this ��usr, ��T�� S lvan Glen Y. ��� P.�. M,.To,�. permi�ii issued,I sholl not emp�oy any person i�any mnnner p�� so os to 6etome subjeU to�he Wohers'Compenw�ion Lows. pve�q pnden T ta.�Mv.hq. �oe rp, Oj- ��� IiUNK PfRM1T Np. ROAD iEQMIT NO.- Do�e Applitont � ��u O ' ♦FFIDAV17 WIIIVER E�SFMFNT RFCORD.IHSTR.NO. DATE NOTICE TO AVMICANT: If, ofter mokiog this Cerlifico�e of Otv riOV�A2. i�t.r+o. 818 6 � F��-mp�ion, you should become subject,to Ihe Workers' iEcpi �pensa�ion provisions of the Labor code,you mus�forthwith oEscainiou _ iotno 11WY,pRST.W�DENiNG �„�nDIY wirh s�ch provisions or this permit shall be deemed L revo4ed. � BiOCK TRACT p� 51�IE ENCYO�CMMENT ' �LICENSED CONTRACTORS DECLARATION � rq.a xocs PERMIT NO. SRE O�LOT NpW ON l0� I hereby offirm fhat I am licensed under pravisions of Chap�er �� 9(tommencing wi�h Sxiion 7000)of Oivision 3 oi the Bosi• auimir+�5 � �wavc.�s nesa and Professions Gode,ond my licanse is in(ull fwce ond , effecr. ca+�v�aoc FrB@IDSTI OIISt cowua�«+c�ncccr� titense Number t�d.887 Lic.Class �.34, �oprsEu 8 Q R[IM9VRSEMfNT i[F p�, Con�rottor T�� �j','APi11Ar1 Do',e �7FiI AFi �Rv Alta Lom�.�� 8O� `Z DISrR�CE NO. WOUF MAv vROCE55ED Br v lx BK PG ❑I am exempt undar Sec. of the L.A.Co. ucENst r�o. � ..cinss � � PlumbingCodeand/or5ec. ofthe �� DFSCRiVfIONOFWORK cfE ryNA� � 'avs�s�wea cowNccriNc ro oare �L� VALIDAt10N w 8.&P.Code for the following reoson °U&����R Z�"�.�i o. - SEiTIC TANR.$[fP�C�E PIT OR fINPL ? VrtS AND/OR DRAiNF�ELD �Ole �p�5(gyyER CONiFCTING TO BY PRiVATF DIS V3TEM $ign0lUf! � CONNEC7 ADdT10Nl1t llW.OR � OWNER-BUIIDER DECLARATION ++'ORK To nous[s[wte I hereby affirm thal 1 am eKempt from�he ConVactor's li[ense f�NFI ES YF��R'i,�DRAI�NI�E Law for the following reoson(Sec�on 7031.5,Buis�ess ond Pro- xrea,rsevn�c ow�poro Hous� • •(On3 COdC�: SE'MER OR D�SPOSAI SYS�EM - .. - , ._ti'I,o�owner of the propeny,or my emp�oyees with woges as �,� ��3 p their sola mmpenaation,will do the work and rhe st�vcWre - is no��n�ended or offered for sale(Section 7044,B�s�neas permit f l� �� • • ' � � and Professtons Code). OWNER'S 5� ❑I,as owner of the properry,am exclusively controcting wirh AUTHORIZATION TOTAL FEE 'Z Q I • •2'].5 0 licensed conlroclors to tonstrutt the projecf($ection JOGG, �µqy[AT THIS DATE A C0�1TRA�T WI1H TM HERE�N W.A1fD CONTiACTOR f0 BUSInCSS OOd PIO1BSSi0A3 COdl�. CONNER THE ABOVE DESCRIBFD E%ISTING DWEIIING iD TME PUMI�SEWER, e a e��,$Q� CONSTRUCTION IENDING AGENCY 1 hereb affirm that there is a cons�rucfion le�din o ent SIGNE�THIS DAYOF L 19� . Y 9 g r q,,,�R� ► 0�.2 9--8 6 for the per(ormonce of the work for which this permil is p�y�qSAGfNT 1 ��(a��„�a,;,i_ � issoed(Sec.3W7,Civ.C.�. aooucu 8225 Beechwood Dr�� Al$A T.n � lendei s Nome Lander's Address ' I cenify rhar I have reod+his oppl�corion and s�eta�hot�ha above info�malion is correct.I ogree to comply with oll County ordinances and Slate laws regulating Plumbinq ond Sewers, and heroby o�thorize reprnenlotives of rhis County to en�er upon fh obove-mentioned properfy for inapection porpozes. - � �����/.��/�� �Signafure of PermiHee Dale ��T fEE tFYERSE FO�EXRANATORY LANGUAGE r ' - , •"" . ' '.. ' . . T� y�, m D m j f., '�,C T � � � . i i • . i i ' � o� �� yp (� �i�'.� F� O. T�' z,. 7 i i' � ' . = Z=F; `�> � ;Z 6�2. a '' ❑ n" . ' . i � ' .. 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