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HomeMy WebLinkAbout1431A (8) ' - WORKERS'COMPENSATION DECIARATION . 'I hereby Qffirm Ihat I have o certifitore of consent lo eelf � . - � �iawre,ar a certificate of Workers'Compensa�ion Inwrance,or 16�d�2D . - i� PolecyiNaJ`°�°`��osm;��e00'si.`�'F,�a "a°B;R"."8". APPLItATION FOR PERMIT . ❑Certified copy�.h�.�b,.r�.��stiee. _ SEWER - SEWAGE DISPOSAL � �Geprfified copy�s filed wiih�he coun�y buildt�g inapection GOUNTY OP LOS ANGELES BUILDING AND SAFETY po�e��3/�O/86qPP���o�� T. Freeman FpR APPLICANT TO FILL IN CONNECTION DATA � CERTIfICAiE Of EXEAAFTION FROM WORKERS' �� eunninc � . ,COMVENSATIONINSURANCE " �oontss 868 Featherwood I?r 5i^TON °E°"' �1his eaUion need nol be completed i(�he work involved 6y the �pui�r Dia /+�°'NHOIE Rf�EREN� UPPE q permit is fd one h�ndred dollars(f100)or less.) I certify�hot in the performance of rhe wor4(or which�his c��ssr. iYPE����i� �t^wrM�eo� S lvan Glen .. �,,,� P�. M�..00.�. permi�is issued,I ahall no�employ ony person in ony monner so os lo become subject to�he Wo.keri Compense�ion lowe. °�'�� D+�'� , OWNfR CO.IMV,NO. Jp9 Np. . . � IMII TRUNK i[R/A1T NO. ' ROAD iEQMIT NO. Do�e � Applicom A��ss NOTICE TO AVPIICANT: If, ofler mokin this Cerfifico�e of nkionhT WAIV[R FASEMFNT RFCORD,IN57R.NO. DI.fE 9 CITY p�� TEL NO. �iption, you should become subject to �he Workerz' �E� � �pensalion provisions o(the Lobor code,you must fathwith p¢SCF�aTipa l01 NO. pwy.oq 57.w�oEM6�G c..�nply wilh such provisions or this permif sholl 6e deemed . .evoked. � � xax TFA�T SiRIE EfJ�YpACHMFNT � .�.UCENSED CONTRAC70RS DECLARATION r.q.pF�ocs v�aMrt r•p. � I heroby offirm that I om litensed undar provisions of Chapler siztoriot raowoa ioT 9(commencing wi�h Section 7000)of Division 3�of rhe Busi• e�uno�r�cs nesa and Professions Code,ond my license is in full force ond ���s Bf{![i. r� p � (� �pp�TpqRpq CONNECTION CHARG[fEE . �I[!n!e Numbel �/4�V7 �fC.��055_y(,� . ' qpp�Eu • 822 BeeC w RfIMBURSFMEM iff ' d �On11OC10R• 1'jeP.m�Y o�/36/86- ��,Y �y,�,Y'd L�m�l.NO. SO� D�SIRrCiNO. GRWP BK MAP � PROCESSFD6Y V — ❑I am baempt undar Sec. of fhe l.A.Co. LICeNS[rp, 4,'l 88 anss 1(� �� PlumbingCodeand/or5ac. o(�he �' �KRIPfIONOFWORK fEE FNA� O r i+ous�s�wEx conNernn�c To w*e / L VALIDATION 6 B.6 P.Code for Ihe foliowing raoson °U����R ( . . SFOTK TYJK.SFFAAGE%T OY FCJAL ' � VITS�ND/OR DRAINFELD 'Z Dofe `qus scwte ca+ra[a�rac ro er PQIVAf $Y $ignO�Vf! COMlECT AOpITIpNµ&DG.OR � OWNER-BUII�ER DECLARATION �ro�aus�s�wev OYE4FLOW SFFOAGE MT.DR��Nf�lO 1 he�e6y oNi�m that I om exemp�from the Contractor's Licenae EXiN.,CESSNOI.qiYNrElI.NWNWLE 1�• for the following reason(Sec�on 7031.5,Buisness and Pro• xnR,�+tP�iQaa.+enwoOr+rouSE ons Code�: sewea ov asrosu SvsrtM �, ' 14atA os owner of the properly,or my amployees wilh wages as ���• � � , O u their sole compenwtion,will do�he work aad the s�rocture . . is no1 intended or offerad for wle(Section 7044,8usiness and Professions Code). �wNER'$ Permit i �.� ''Z�].5� ❑I,as ownar of the properry,om ezclusively con+rocting with AUTHORIZATION TOTAI FEE _ Iicensad conrrocrors to construd rhe project(Section�OJd, . 1 HAYE AT THIS DATF A CONiRAR WITX TME MERF�N NAMED CON7 AC R ro ° • •2�'5�" BVSineSS OntJ ProfE53i0n1 Cotle). CONNFCT TME ABOVE DEXIi�BFD Ex15TiNG DWEtIiNG TO THf Fu&�C SFwfF. O n�n�S 6 CONSTRUCTION LENDING AGENCY • O. 7 1 hereby affirm thot fhere is a construc�ion lending ogency SIGNE�THIS � DAYOf�19_ , for the performonce ot the work for wh�ch rhis permit is °'^'�Q� �- �/j/ _ _,,,�, OWNERS GE�1h issued(Sec.3097,Civ.C.). po� 22�$eechr00(� �'.� lender's Nome � Lender's Address � I cxtify that I have read Ihis opplicafion and s�aie�haf Ihe • � above information is corratt.I agree to tomply with all County . ordinances and S�ote�ows�eguloting Plvmbing ond Sewers, � and hereby o�tho�ize represenlotives of�his County to enter upon Ihe above•mentioned properly for inapetlion p�rpous. ' �_�z/lp��.� �'�.����� . Signcture of Permi��ee Dote —� � SEf REVfRSE FOR EXRANATORY IANGUAGE . � . � .' ' . ..."" . ' , TC r,,, m� z�: C n .7 ( . , . I � Y ° � ``"' ., , , + i '� � ,� fm �� ; � . ' -- � ! � : • . I i a r Cz�.o �� Qn 9j. � � • • :n t (.I „�.�. .� �F D G,�� � �° I.. . i ' 1 ' . 'i . �IM1 �In, ND ^ yn �Y � • i j , ' � � �i � p.v lJ #!. F�. 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