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HomeMy WebLinkAbout1476A � WORKERS'COMPENSATION DECL4RATION ' , I I hereby offirm thot I hove o can�ficme oF consen� to selt �� . . � q inwre,or o'certificate of Workeri Compenso�ion Inwrance,or ��s�a�to �II i PolicyfNo °g�1��°o�;sm;��800'st• '�d ' �EBCB:REV.1/831 APPLICATION FOR PERMIT " ; ❑Cerlified copy ia hereby furniehed. - . � � SEWER - SEWAGE DISPOSAL � �Certified topy is filed wirh rhe county bu�lding inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY �deparlmen�. � ��e–H�SGnPV����^� T. Freeman FOR APPLiCANT TO Flll IN CONNECTION DATA � CERTIFICATE OF EXEMPiION FROM WORKERS' punpr� COM7FNSATION INSURANCE �ooaF55 � 5*anpr� DEVTH �This section�need no�be comple�ed if the work involved by the Dia BB.I /MNHOIE RfFEPENCf UpPE R . permi�is for one hund�ed dollors(f100)or less.) �«��TM , ''ENNREST S 1v8I1 Gl@A iraac«+.xai«+ ar+c,Nrao.v� I ceHify IFwt in fhe performance of'Ihe work ior which fhis � �ppuST. � v. CuitE P.L MLTOP.L - , permie is issued,I sholl nol employ any person in any manner P�� ��_ ^ so'os ro become�s�bject�o the Workers'Compenwtion Laws. pwr�Ea Anden G CO.uv.r+0. �oe r+o. s� . . hNll TR�M(p(RM17 NO. ROAD iERMIT NO. Dote � . � ,APPlicant �DDRE55 NOTICE TO AVPIICANT: If, af�er making thic Cerlificn�e of ��n, TF`� AFFtDAVIT wnrvea EASEMENt a[toeo.naSrR.w. o�� F•emplion, you should bacome subjxt 10 ihe Workers' iEG�t �oe�wtion provisions oI the labor code,you mus�Forthwi�h ��i�ip.i IOTNO. NWY,QRST.WIDFNING .jply wi�h wch provisions or this permif shail be deemed . �l�Okld. ' � � � BLOCK TRAR STAfE ENCROACHMfNT � LICENSED CONTRACTORS DECLARATION . °�5_ v�aMiT r�q. � SI2EOF l0T NOW ON lOT I bereby offirm Ihot I am licensed under provisions of Chopter �� 9(commencing wilh Section 7000)of Division 3 oI the BuSi- BViWMGS n R Uu��RGFS - ' ness and Professions Code,and my license is in full force and y effect. � �����7� �- ��� � � cOr+tanttOa �BQm82] C.�]'18 y� � CONNECTION MARGE FEE License Numbei 41 4887 u�.na,�� C34 QfiMBURSFMEM iEE � 'n / ���u y 822 Beechwood Drp 0. • � (� / � dTV i►y.4g LO�A� TFI.NO. 1 po� 2 OISfRI�I Np. G40UV MAV P40CESSED BY O ConlrIXtof T RAI71}171D0�0- , � �i �n /� BK � V ❑I am e:empt under Sec. of the L.A.Co. ii�ry�r,p �Rn35 La � O � P�umbing Code ond/or Sec. of the �- DFSCRIPfION OF WORK r[e Hryp� V IqIJ$fSFWERCOn1NECi1NGi0 f DO oan V VALIDATION � B.&P.Code for the following reason °U��c��R �_�'�` N SF IC iANR.SENR RI OR FITS AND/OR DRAINFifLD FNAL Z Dote �q115E SFWFp CO�WERiNG ro 6Y ' - . V41VAT 1 i M Signoture eor+r+eCr.wo�riaui xoc.oa � � � OWNFR-BUILDER DECLARATION ' �K ia�qu5c SEwER pVENF�pW yEV�(�F%1,DRAINFIEID I hereby offirm�hol 1 am exempl from Ihe Conlrocror's License E%TN..CESSR'101.OW1"Mll.M4NHplE Low for the following reason(Secton 7031.5,Buisness and Pro- � utev.rtEvnia oa ne.wooN�+ous� '1.�/ /� f"•IOIIS COd@�: SE`MER OR DISOOSAI 5Y5TEM �� 4 l.b l, 1 _,JI,aa owner of the property,or my employees wifh woges ob �Y• • • ° � p � rheir sole tompenm�ion,w'�II do the work and the shutlure . is nm in�anded or offarad for wle�Setfion 70ee,Business . a and Professions Code). OWNER'S Pttmit f Q Jr 1 2�'5� ❑I,os owner of the property,am eMclusively con�racting with A�HORIZATION TOTAL FEE .,� e e o 2 7,5�� Iicensed conhacrors to cons�ruc�the projact(Sectian�OAA, I NAVE AT THIS DAiF A CONTRA��WITX TNE NEQEIN NAMED CONTRACTOR TO Business a�d v�ofassto�s Code). eaa�a r�.eove ocxR�e�o cx�sr�ue owEwNc ro rwc vueue sEweR. 0 8 2 9—8 6 � CONSTRUCTION LENDING AGENCY , I hereby aff�rm rhat there �s o conahucrton lend�ng agency 9Gn+EPiHiS `�� oAVOF � �v_ for fhe performonte o( fhe wo�k for which this permif iz �NFROR pWlJENS AGENT ISSUed(SBC.3097.CIV.C.). � . ADDYE55 Lender s Name • lender's Addross _ . . t ceriify tha�I ho�e reod th�s application and slale�hot�he above information is correct.I oqree�o comply with oll Co�nry ordinances ond Stole laws reg�la�ing Plumbing ond Sewe�s, ond hereby outhorize representorives o(�his County ro enier ��upo ihe obove•maniionad property for inspection purposas. �i����e� �/<9.�./d� . 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