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HomeMy WebLinkAbout1475A (8) � ` WORKERS'COM7ENSATION DECLARATION I hereby offirm fhot I hove a ce�tifitole of co�senf to self � ' }� inYure,or�certificafe ol Worken'Compenwiian Insurance,or �a.c�zo ' - � Pol cr''Neod.C�Q�osm`���°"s`t:`��a ."B°9;R`°.,`8" APPLICATION FOR PERMIT Y � Y SEWER - SEWAGE DISPOSAL ❑Y C�ertified copy is'hereby fumtshed. - Li'Cer�ified copy Is f�led wirh rhe county building inspecrion � COUNTY OF LOS ANGELES BUILDING AND SAFETY 'deporlmenl. � ' � oo�e�26/86Applicon� T. FT2emRri FORAPPLICANTTOFILLIN CONNECTIONDATA CERTIFICATE Of EXEMPTION FROM WORKERS' g��ipi� COMPENSAiION INSURANCE noocess '� ST0.TIpV p¢piH (This section need not be�comple�ed if the work involved 6y the MANNOIF RfFERENCE uwta permit is fw one hundred doltars(SI00)or less.) ��'��T� � 1 cernfy�ho� �n ihe performonce of�he work for whtch fhis CRpsssT rrvcacoN.xcnom �ry(�THFROM permii is issued,I sholl no�em lo an _ � 1Y�I1 Glen Y. CURB P.t. M�.Tp V.�. , p y y person in any.manner so os to become'su6'ect�o tha Worka.i Com P����� � aensafion lows. owNCR AAderi G co.i�aw.F,o. ,oe r�,o. °� � �a�! . ' I�P�iCOr11 � �DRE55' EO BOX�� 2 TRUNKPERMITNO ROA�V[RMIiNO. - NOTICE�TO APPLICANT: I(, ofter moking.ihis Cerrificore of �,TM �Covina ,E,,,�, 818 967-9541 ^FF'o�wr warv[a EASEMENT RECORD.INSIR.NO. �ATE � - �puon, you sho��d bacome subject to the Workars' �EGq� ' � � ensoiion provisions oi the Lobor tode,you musl forthwith ' pExaivriow iotno. Nwr.pa 5T.wioewr,G { �nply with such provisions or this permit shall be daemed , , i revo4ed. &OCK TRACf STAfE ENCROACHh�ENT � LICENSED CONTRACTORS DECLARATION Np,pf g�p[:5. YERMIT NO. I hereby affirm tfiot I am licensed under provisions'af C6apter saeortor nqwpci�pr 9(commancing with Sec�ion 7000)ot Divis�on 3 of the Busi- e Eioiracs a�acts ' ness ond Professions Code,and my license ts in full force and affect. - coraraaaa+ FT@6IDSil COIlBt. eoNr�aer�aNCHnaeErEe - LitenseNumber 474887i��.ao5�� C34 p��55 � 8225 Beechwood Dr� 4E�M&1RSEMfNTIfE co�„o�,o,T. Freeman oo,� 8/26/86 �,,;, plta Zoma- TE�.�71 80- 2 DiFxICiNO. GRWv ,�,P VRpCE55EDBY 4 ❑I am e�6mp1 under See. of ihe L.A.Co. sT�TE uc. gK � V ������. 887 «..0 C Gg � ' Plumbing Code and/or Sec. of the �� DESCRIPiIqJ OF WORK �e r�rvu O wvsc s�weR ca+r+crnr�+e ro on,e. y VALIDATION �' B.8 P.Code for ihe fol�owing reoson °U�'«'"hR �� yZ'—Z��p_. W SEiTIC TANK.SEEYIIGE PIT OR fiN<l ^ 4 Da�e Pi75AN0i0aDRAiNFiEID � 1� J N 1AUSE 4wER CONNECfIIJG i0 BY �/ ' VqIVA1E DI Y fEM �H'�"�• ? $I I10�VlG � 9 CONNECT AO�tTIpNAI&DG.O4 � OWNER-BUILDER DECLARATION �K to iaus[5[wta � ' OJERFiOW SEEPA(�Fi,[MnMFiEID j I haraby offirm Ihot I am e.empt from fhe Controctar's litense F%TN,CESSPOOL,DQYWF�I,MANNOIE �aw(or tha following reason(Secton 7031.5,Buisneas and Pro- utee.rzea�iR ce nenNoor,�quse �-'� 4���� . I '�•!lons Code): scv.�a oa o�sros�i srsTErn �i e . • • 1 O , �:I,os awner o(the p�ope�ly,or my empioyees wifh woges as j their sole compenw�ion,w�ll do the work and rhe st.uU�re I • a 2�Jr O � is no�intended or offered for so�e($ection 704<,B�siness � ond Profetsions Code�. OWNER'S PC�mit f Q �j • � ^z•j,5 Q� � ❑I,as awner of ihe properry,om exclusively contracting wi�h ' AUTHORIZATION TOTAI FEE p`� "" �] p Ii[lnSGd COlIIroC�OfS f0 COIISffVC11I12 PfO�ECI(S2CIl0(1 JOAA, �Np,y(qT THI$OATE A�pNTRA[I WIfM iME MFQE�N NAMED CONiRAROR i0 ��.L�'�V 6 Businass and Professlons Code). ca+H¢cr Tr+�aeovt oes[4�e[o[xisnroc ow¢unae TO tH[weu[sewew. CONSTRUCTION IENDING AGENCY �j /,� � , � I hereby oifirm thol there is o construction lending agency SiGnffDTHiS v DAYOF �` 19 for the performance of the work for whith this permit is ��q� pWNERS A T issued(Sec.3097,Civ.C.). tandar's Name � A�+E55 . � Lander's Address � . � 1 ter�ify thot I hare reod�his opplication and state thaf�he � above Informotion is corrett.I ogree to comply with all County ordinances ond S�ote lows regoloHng Plumbing and Sewars, � - � and hereby au�horize reprasen�oiives of Ihie Counly�o en�er vpo the above•mentioned properfy for inspection p�rposes. � �� �.��� ����,�G Signature of Permillee Dole SEE REVERSE FO�EXMNATORY IANGUAG[ . ' ` i � t: Qo $T N zg <c 4 : • ' ' � �a'^ �'n r>, °n �'^ z. . . � � � ' _ - S�7 �ih �j i ti�� �� y . . . � . .;7 �"-. �. D �� . . r c�-. i'L nw b . i ' . ?^i u :❑ 3" ,.ii L' � .. �f• , ; ,. 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