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HomeMy WebLinkAbout1477A . i " WORKERS'COMPENSATION DECLARATION ' I here6y affirm �hot I have a ce�tifimte oi consen� �o self � � � � }'� insure,or d certificote of Wor4e�i Compensa�ion Inwronce,or �a�6i7o U � 'a certified c���i�osm�.�,��., �d �Ego9,RE�.,,e�� . APPLIGATION FOR PERMIT � Policy No. P�Y SEWER - SEWAGE DISPOSAL ' ❑Cenified mpy is he�eby furnished. � � � � . �Certified coypy is filed wi�h Ihe county bvilding inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY + oaroe���b�8�pplicanl T. Freeman FOR APPLICANT TO FILL IN CONNEC?ION DATA ' � -� CERTIFICATE Of EXEMPTION FROM WORKERS' �iipmK, � � COMPENSATION INSURANCE � nouxcss B STATION cevrN (ihis secr�on need not be compleied if fhe work Invalved by the . ia . rnnN�+aE e�FEeer�c� L�ov�•[Rw 1 permit is fd one hundred dollors(5100)or less.) . 1O�i0TY " i f�EAREST S 1V811 G Atl r. rrveacor+nxcraa IE�IGTMFYPM t certify,thal in �he perlormonce of the work for which Ihis �apss sr. cuae P L M�L TO P l. permil is issued,I sholl nol employ any person in any monner � w os to become su6jeU�o t6e Workers'Compe�wtion Laws. o,,�,�,�R "���"'�� `v 2.� i Anden G �o.�MP.�. ,��. � Dae � �Apphmnt .oREss PO BOZ_. Z TRUNK VERMIT IJO. ROAD PERMIT!!O. � AFfiDAVIT WAIVER f�SFMEN7 RfCORD.IHSTR.NO. D�TE NOTICE.,TO APPLICANT: If, ofler moking Ihis Cerliiicole of atr� COV�riB TE�.t+0.818 6 � F-�mp�ion, you should become subject to the Workers' �-^entotion ovisions of the La6or code, ou mus�forthwith �E�'�'� � - W Y oEscrt�vr�or+ _ iot r+o. Hwv.ow 5T.wioenrtae ��.�p�y with svch provisions or rhis permil shall be deemed � re'volied.' ' � � ' aiocK TY1,Cf S7A7EENCRO/CMMENT ' � UCENSED CONTRACTORS DECLARATION "'o.a�Ws. �caMiT r�o. I hereby affirm tha�I am litenaed unde�p�ovisions of Chapler s¢eovtor niow oni ioT 9 commencin with Sedion 7000 of Division 3 of the Busi- �°F .S'j.11 � R98• �,�,�g � 9 � BUIIDiNGS � ness ond Profesaions Code,a�d my license is in full force ond effect. . . . mr+rR�aae FT@AIDA21 COI19 t.. eor+r�tcnon a+naec�[e . �i[Gni!�lUmEiQi 4'14887 ���.c�o55 � C34 REIMgURSFMfNT f[E � ADOPE55 Comracror T. Rreema�o�e��9(+�fi6 ' L � o�s��crr+o. wwr MAG PROCFSSED6r d O7Y TFI. l BK PG � ❑I am eaempt under Set. of rhe L.A.Co. ST�NSE np. 88 aass �� � � � � Plumb�ng Code and/or5ec. of Ihe �� OESCRIPTION OF W�pRK RE �iNpi A ������eor+N�a�r+e ro � �� oer� p VALIDATI � B.8 P.Code for fhe following reason —�D�8 W - $fPTI�T�NK.$EEPI.GE RT O4 iINAI d PrtS ANDiOR ORMrS�FLO y� DO}@ IAuSE$EWER CONPIFCTING Tp By Z NtrvpT(Di5p0'S�t YSTEM $ignotura CpNJECI AOOi7iOMnL&W.OG � OWNER-BUILDER DECLARATION W��ro wus�s[v.fR OYEAfIOW SFEi�GE Rl.ORAINi1FlD � i hereby affirm that 1 am exempt from the Contraetor's License ExiN,R55q�p1,ORYuh��,Mu.nlplE , Law for�he following reason(Secton 7031.5,Buisness ond Pro- ut¢a,acv�iR pt aenNppN Nouse t '11OlIS COdQ�: SEWfR OR DiYVSµSYSTfM � ,Jl,os owner of�he p�operty,or my employees with woges as �� 4 7.7 A their sole tompensolion,will do the work ond the shuclu�e . $j s e . . � p is not imended or offered fw sole(Sedion 70e4,Bus�ness ond Professions CodeJ. OWNER'S Permit S /Q u`�"c`� � e e 2�Jr� ❑I,as owner of the property,am exclusively con�racting wiih AUTHORIZATION TOTAL FEE � � licansed tontroUors to construct�he projecl(Sec�ion�OdA. I HAVE AT THIS DqTf A CONTRA�T WITM iME MERFIN NAMED CONTRACTOR TO e e e 2 7�J Q U Business and Professions Code). cor+r�cr n�c neovc oesceie[o exisnnic owewne ro rr+�weuc s�wew. � CONSTRUCTION LENDING AGENCY � � , � o u 2 9—8 6 I hereby off'rtm lhat there is a construction lending ogency �W'1F�TH15 OAYOF I for �he parformonce of the work (or which �his permil is ��e� . pNTI[RS AGEN issued(Set.3097,Civ.C.). � AOOQE55 lender's Name le�der's Address I cerli(y that I have read�his oppiicoiion ond s�ote rho�rha � � above informotion is torrecl.I agree to comply with all Covmy � ordinonces and S�ate lows�egulating Plum6ing and Sewers, a�d here6y aulho�ize represento�ives of this Cou�ry to enter upon�he above-menfioned property for in�petlion purposes. � j �� �l�������� SignolureolVerminee Dale SEEREVERSEFOtEX►IANATORYLANGUAGE . • - ._ � .. , .. ^4� nc� ::p R 1•+� �5 7 - • I ' . � � • '" i•p Da ��x; c� c�: f . , � , . - �i i �^� 2S i' i - �- � ��� �^ �' � . � ' . � r�� D "` i;ii " � ' ' . 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