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HomeMy WebLinkAbout1432A � WORKERS'COMPENSATION DECLARATION � I hereby aff�rm +hot I have a eer�ifiea�e of co�sent to sel( . ' �l .im�re,or o cerlifito�e ot Workera'Compenwtion Inwronce,or 16A6fZD . 11 PolcyNo.'�����f(Sec.3800,S�Lq.C.�� CE809�REY.1/8JI APPLICATION FOR PERMIT ° �OTPOnY G ❑Cer�ified copy is hereby(urnbhed. - � � � � SEWER - SEWAGE DISPOSAL ' , � �]certiried copy i:filed wi�h the munry 6uilding inspection COUNTY OF LOS ANGELES BUIIDING AND SAFETY ' deEor 261 86 � Dale �� Applicanl T. Fr2@rt1a11• FOR APPIICANT TO FILL IN CONNECTION DATA � �.•CERTIFICATE OF E%EMPTION FROM WORKERS' g�iip,nK, .COMPENSATION INSURANCE �oo�ss � 862 Featherwo Stniia� otvrN � (Thia secrion need not be completed if the work involved by the ���iT� hNNHOtE REFERENCE i°OEQy 'permil is for one hund�ed dollars(SI00)or less.) , ' I certif that in the rformance of the work for which�his �A�St Tr°Eo��q+"'E�ia� IEMGTHFROM Y Pe caou sT. e�mi�is issued,I sholl not em lo on Y� tuae a.i. M.i.To o�. P P Y Y Person in ony monner � P c.�. �Q�I so os to become subjett to ihe Worketi Compe�so�ion lows. owr�a CO.IMP.NO. JOB NO � ' ��� T'f 7RUNK PE4MIT W. ROAD iERMIT Np. pote � Applitont ' �ooa[ss t NOTICE TO APPUCANT: If, ofter mokia thie Cerlificote of . nrFionvir wnrv[x EASFWIENT RECORD.INSiR.NO. Dn1E 9 Crtv tE�.rao. ' �ption, you should become subjet� to the Workers' pensa�ion pov�sions of fhe lobor code,yov mosr for�hwiih o[scR ttiow lOTNO. HWV,qt ST.4ADfMNG 'i,,. ply with such provisions or this permit shall 6e deemed revoked. . - . azxK iRA[i S�ATE ENCROACHMEN� ' LICENSED CONTRACTORS DECURATION "'°.a�ocs. v�RMrt N° 1 herehy offirm that�om licensed under provislons of Chaplar SREOF�O� t�owOniipi ,, 9(commanci� wi�h Sec�ion 700p of Division 3 of the Busi- �°f g. 1 ew�o�r+cs a+�acts ness ond Profen�ons Code,and my licenae is in full force-ond effec�. - �/A 7 cor�rc��tpa CONNECTION�NARGF F[E License Number� 4 f'T88 1 �tC,Class - '�3� ADDRF55 �,1L 2 B e KIMBUQSEMEM RE � Conrracrol�`]7rAman Da�e R/7G/a� arr� 1�t8 OIR&e�.� � o�srQ�aw. ceouv ..no veoccsseoer O G� eK o� V 57A1F 474887 "� I am eaempt�nder Sec. of�he l.A.Co. i���.�y r.p nAu . � �. DESCRIPfION OF WORK fEE 0 PlumbcngCodeand/orSec. ofrhe F�Na` VALIDA ION MOVSESEM/ERCONNECTINGTO D0.TE �+ ,��/�� Rl&�C SFhFR B.B P.Code for the follow�ng reoson ori ANK,$[FiAGE PIT�R � �� W GIi5AN0/OROR�INFlELD iiNnL � ta/' �OIE 1qu5E$EWFN CONNfCTING 70 BY ? PRrY�TE 01 $YSTEM Signature Ca1rxCT ADortipwl xoG.ou � OWNER-BUILDER DECIARATION �R1 r�"W��"�° pVFRftOW E7?Gf OII,OYFiNFi(�D I hereby affirm that I am erempt from the Conlraclor's license EKTN,CESSPOOL,OYYWEII,MiNMOIE �1 4 3 2 A I�w for rhe following reason(Sacton 7031.5�BUISnB55 OI1d PIO- Al7ER,RE7AIR pR AMNpON IqU$( _ i0�5 COdl�: SE�MER OR DIypSAI WSTfM _fl,os owner of the properly,or my employees wilh woges as #• • • • 1 O their sole compenwtion,will do the work and the sh�cture �w •2 7.5� is not in�endad or oHared for sale(Section 7044,Business and Professions Code). OWNER'S P9�miT S e o e�'],rj Q� ❑I,os owner of the properly,om extlusively contracting with AUTHORIZATION jOTAL FEE licensed controcrors ro conatruct the pro�e�t(Section 70dl� , .,_ �HI1V[AT THI$011iE A CONiYAQ WITH lllE IEQEIN NAMED CONTNACTOR IO 0�2 9—8 b � Business and Profassions Code). couNctt i�neo�oes[R�eeo exiSnNc owewnc To irrt r�eut 5[weq. CONSTRUCTION tEN01NG AGENCY oZ J�DAYOF lv� , � � 1 bereby affirm that fhere is a constrodion leoding ogency ��DTHIS � for fhe perfo�mance of the work for which this permit is °'"��4OR �f���� � ISSUld,S�t.3OG�.CIV.C.�. OWNERSAGENT� �,! . � . ADDRESS m.a. lender's Name � lendeis Addreu 1 terlify�hot I have reod this opplication and slate thol the ' above Info�mation is correct.I ogree to comply wi�h o�l County � ordinances and Sto�e lows raguloiing Plumbing ond Sewen, and hereby outhorize representolives of fhis CouMy fo ente� upon fhe above-mentioned property for in�pection p rposes. �� �u��. ��G�G Sipnolvre of Permiltee Date � SEE REVERSE FO�EXMANATOM LANGUAGE � . • ' _. . �. � ' �. Do �D ^ y� mn • � , � I � , . i �� °yn T� r Vn c� ' ' I � ' . � o:- Ci r m^ � �y-. 7(i C1 � � � �. ; s� =m ��' �7 "� � r �� D � ;• �, v . , i �i . '.� . ,�� ��� �,� ❑ �• �, ti ' j � : ,r c� ��„ 7!. �� � • � I ' �� I� ' � I -. T f ..^•i� �� 'p o� "7 � 0 . _ . � ' ' } U �'J N� IK . . � . . 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