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HomeMy WebLinkAbout1430A (8) � �� � WORKERS'COMPENSATION DECIARATION I heraby oN�rm rho� I ho�e a cartiflca�e of co�senr io self . }1 •in+ure,or a cxtifitoie of Workerc'Compenwlio�Insuranee,o� 16A617D U PolcyNo.`�COSmPOn�SYb.CFL1ISd - �E809�REV.1/83� APPLICATION FOR.PERMIT � ❑Cen�fted copy is hereby Iurniehad. - SEWER • SEWAGE DISPOSAL - �Certified copy is iiled wirh�the co�nry buildinp inepxtion COUNTY OF LOS ANGELES BUILOING AND SAFETY deporlmenl. ' Da�e ZF) Al1Q_Applicanf T. FTB@ID2I1 FOR APPLICANT TO FILL IN CONNECTION DATA .,CERiIfICATE OF EXEMP710N FROM WORKERS', eunoaac COMPENSATION INSURANCE �oou�s5 H STAT�CN o[mN (Thfs secr�on need not be completed if the work involved by the t a M4NHOlE REfERFNCE �Q permit is�for one h�ndred dollars�j100)or less.) ����TY i nrne�sr rrP[or wr+r�cria+ ur+eTH rxom I certify thot in �he performonce o(the work for which this cQosSST. S ZYStl 1 11 r. [urte P.L. MI.TOPI. permil is issued,I sholl not employ ony person in any manner v c.No. so as ro 6ecome subject to�he Workers'Compe�sa�ion taws. owrxa Anden Grou ���'WP��� ���' /O� . µ41L � BOX-. � iRUNKPEPMITNO. ROADPfRMITNO. Da�e � �Appiicani ADDRE55 MOTICE TO APMICANT: If, ofter maki�g fhi5 �Qf�lEltO�! O� C7Y h�� AFFIDAVIT WAiVER fASEMEM RECORp.INSTR.Np. DAIE � mption, you should become a�bject �a the Workers' � • �enwtion rovisions of the Labor code, ou musr foriiiwi�h ���� �C P Y. �ESCRIPIION lOTNO- HWv.ORST.W�DENING ly with s�ch provisiona or this permi�aholl be deemed re�oked. � ' � �occ TRACT STAiE ENCYO�CHMFNT � . IICENSED CONTRACiORS DECLARRTION � �'1O�pP B1D�� ��M�T�� srze a ior Now or+ior I hereby offirm thot I am litensed�nder provisions of Chaprer �� 9(commencing with Seciion 7000)of Division 3 of the Bvsi- eu�toirres a�eces ness ond Professions Code,ond my license is in full fwce and � 91fBC1. CONiRAROR greeman n �°""E�T'°"�""°�� license Numbe.• d7488T uc.Gaas C�id ,�Eu 82 x�Meuas�n+ENr r�e • y, ConMoaorT. Freeman Do�e 8 26 86 ' � DiSTiiCI NO. G40UP rnnv iFOCE55E0 BY- �' ! / nT� Alta om��.� la BK � � ❑I om dxemp�under Set. �of�he LA.Co. ucE�is�na 88� anSs p,. PlumbingCode ond/or Sec. of the ^�- DFSCRIPfION OF WORK �e FiNa� . p wus�s�wER co�.�n�a��ro DAtE q VALID TION Z'i B.B P.Code for the(ollowing reoson � °�°�'��1NER 17 � 1L'Z�—p�p W $EPTIC T�NN,SffVAGE VIT qi p. vii5 AND�Oa D911MF�ELD FiNnt y� . Dote � �5(5EW[R CONr�KnNf�i0 B� ' Z ' VRIV/�T IS Y M . Siflnofure CO�K7 AOO�Trora�t&DG.oR � OWNER-BUILDER DECLARATION WORK To r+ous[sewea OVE%lOW A Ti.pqAlHiiEl� I he�e6y aFf�rm tha�I am e:empi from rhe Conrrocior i license E%iN..CESSR7CA.DRYNrEtI.MANMIXF /I n Law for the fotlowing reason(Set�on 70J1.5�BUiSf1B53 Ond PIO• Al1ER,RE4AiR OR ABANDda 1qU5[ �-'� µ�O n `�{OnSCOdl�: 3EWERORU�SPOSMSvSRM N . - 1 . }'� �� � �1,as own.r of rV�?p.oper!Y,cr my emp!oyees•.vi!h wcycs as� their sole compenwlion,will do the work and Ihe structure - � ° •2 7.5 0 is not intended or oHerad for wle(Secrion 7014,Businass a�d P.ofauro�:cod��. OWNER'S Permit s 1,Q 0 e. .2 Z 5 0 c=i ❑I,os owner of the propa�ty,om e.clusively tontrac�inq with AUTHORIZATION TOTAL FEE p(� - licensed coMraclors to tonskutl fhe projacl(Secfion 70dd� I H4V[RT THI$pAiE A CpJiIiACT WIiH 1Y1E H[i[IN NHMFD CONTRAC70R 70 o R 2 9�V V 8usineas ond Professions Code). co�x.�a r�neOvc oESCc�eeo rx�snr+e ov.cwwe to T�[weuc SEwea. CONSTRUCTION LENDING AGENCY � ► I hereby offirm IFwt fhere is a conshucfion landing agency SiGNEDTHIS �� DAYOF�19_ for rhe perfamance ol rhe work for wh�ch +h�a permi� is °'""�R� �� �+�, isaued(Sec.3097.Civ.C.). ��RS�N���T��r'� p'�"'� �nort[is lender's Nome lender's Address , � I cerlify that I hove reod this applico�ion and sta�e Ihot the obove information is correct.1 agree�o comply with oll County _ ordinonces ond Srate lows regula�ing Plumbing and Sewers, ond hereby outhorize represemorives of�his County�o enter upon Ihe obove-mentioned property for inspecuon purposes. - L�r�g. � cY/�G/�_ . ignoture of Permittee Dote SEE REVERSE FO�EX/UNATOM IANGUAGE . r . i . . . _ ,.._. . . . �4, Sv �;y M D� cc�i ? i I ' � � � I s n �n 5 , '^ u� r � 1 C r x; �i n o;: ; � ' � � � • . . � Ci7 �.^ �j £y £'iti O � �� ��i �n ' S:n p� � •p ' _ ' ' . � . � ' �7'-" �n - ❑ r� o 'v � , . . . � �� i ' n c:.c n^ � 7`: F� TJ .. . . i T D �.� . ;., a O O • i , .. ; � ' . • �, 'n j uD Nu �o C�v _ . G . . 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