Loading...
HomeMy WebLinkAbout1586A (9) IWORKfRS'COMPENSATION DECLARATION . .. .. . . . �� �- � • � . . .. .. . . . , � 1• ., � . � � I hereby atfirm thai I have a cenifkco�e o!conaent lo self . � ' inwro,o�a cen�fko�e o/Wake.i Compensation Inaurance,or ��^'� - - °`"';"°�` Y.��;��'°°°.`°�` _ ��°'"`"•,"' APPLICATtON FOR PERMIT I PoGty No. , .. ' 5EWER - SEWAGE DISPOSAL ' ❑Certif�d copy is hereby f�rnished. . . _ � ��Cernf�ed copy�s f�led wi�b ihe[o�my building inspeUion COUNTY OF LpS ANOELES $UILDING AND fAFETY � � f� deporlmeN. � � ��e��Anci+�a���� FOR APPIICANT TO FILL IN CONNECTION DATA CERTIFICAiE OF EXEMiTIpN FROM WORKERS' euuo�r�c j ' COMPENSATION INSURANCf woowss � SUrwr+ D[crw � Qhis tec�'�on need no�be comple�ad ii ihe work lnvolved by Ihe i���, E NNNIIp(E OfiFR(NCf � �R permii ie for one h�ndred dollors(tI00�o�less.) �C I cenNy Ihal In fhe perlo.monce o(Ihe work lor w6ich Ihis ��rt�o�ssT r*c�os[or.mrtU�a. ��rxi� '� permit is issued,1 shall not employ any persan in any manner • cue9 v i M�.rov i. 7o as to becoma s�bl«�ro Ihe Workeri Compensotion Laws. � °�"iO OwNE4 f0✓M NO 10lNO- Daie Applicant ��oo�mss � - raur+cr[ar.�TNO. ap�ovteMrtr�q. IjOTICE TO APPLICANT: If, ofler mak�ng lhis Cenillcote of ��TM Ri� ���owvn WANER �.scn�[Nr YECOOD INSti.NO. DAIE �mp�ion, you �1+ovld become s�bjec� to �he Workeri ,.f�pensofon provis�ons of the Lobor code,yoo mosf fonhwiih �Fc�i com I with�uch �u'�'���' �o'�'O M'MY.04SL.W�DfNNKs . p y provieions o�this permii sholl be deemed revo4ed. . . �ocz T9��T � y:A�f[r+C�C�"FNI 1 LICENSED CONiRACTOR$DECIARATION w a e�oos. �vm�r r.o i � 1 hercby ofF;rm thae I om Iieensed vnde�p�ovisions o/Chap�er s�1[aior .vwp.io. � 9(commencing wi�h Secrion 7000)of Di.is�on�of the Busi• e�io�s � ness ond Protessions Code,and my I�<ense is in loll(orce ond �,�5 � effed. ��—y�{�,p`� � � ta+ra�ooa CONNEGtiWJ CMAxCF i(f �. License Num6er�t�tic.Clase a' �ppqfu 4E RSE1J,[NI ifF O �On1f0[IO/7�Dote � t�n Tf;NO � T� d5l4iC1 NO G40u> /MO V40CESStO!/ V � sr.rE ec rc � � ❑I om e.empt under Sec. of ihe LA.Co. ucr�:x ra � cuss p R p.y�� � AKJ QF$CRIPIIOFJ QF WORK ffF Plumb�n9Codeand/or5ec. o/�he "��` VALlDAT10N w , .�wu 5t wrn Ca+�+FC�n+e�o , o•[e �O'��_�� Vu&K SEWfe � 8.d P.Code for�he following reeson pp�GM,$FfOAG(pl pP �N^. ' G�I$AND�O➢pqAlN�l[l0 Doie apWiv��F O�RUI.�S[Fk�O B� � . Signowro [o�cr wo���a+.�x�c.pe ► .. . OWNER-BUIIDER OECURATION '"'QR"o"""�u�p � 1 hereby o�firm�hoi I om exempi from the Con�roctor i license ai[N`�Fss�ni na���ii4�AsuH�r � � . � �uy for the follow�ng reoson(Sec�on 70�1.5,Buisness and Pro• .arte,ae=ma ox�w�.�cx+�st . . ons Code). srwfv o0 o�sa s��srsi�M . . . . 3,� F��� U 1,os owner of Ihe propa�ry,o�my employees wiih wogas os lheir�ole compenwNon,will do the wo�k ond�he s�rucWro � �.,'� . •� � Q is na�imended or ofle�ed for sols(Section 70a�,Business and Professions Gode). 01NNER'S Perrtlif f �(..�` � ��G 7 Jr Q ❑I.os Owner of Ihe proparty,pm ezdusively eo�bocting w�ih AUTHORIZATION TOTAL FEE � - licensed comrac�ors to consrruct the projec�(Saction�O�a, i HAV[Ai TMiS OAtF A CONfGA�1�TH�N(h(R(iN l:AMFU C(NJTRlUiJ9 Ip � � �' 'C����� Business ond Profess�ons Code). . [p+r+[cr tH[�eovi asCe�e[o t.�sr�.x,o.n���.K:io mt r�eiic RMo CONSTRVCTION LENOING AGENCY �(. , � O Y O L�E b I he�eby o1f�n �har ihe�e �s o consnucron lend�ng agency SiGNE0TMi5 DAYOF iv r � for the �'"''�"°R � � performonce of �he work lor which �h�s pe�mi� if p�yry�pSAGENi tesuad(Sec.3097,Civ.C.). AOORCSS Lenda�s Nome � � � Lende��Addrosa � ' � � 1 ee.lify that I hove reod Ihis opplieoi�on end sraie ehot the above informorion is corroct 1 og�ee to tomply with oll County � � �- ordlnonces and Sta�e�aws rogula�ing Plumbing ond Sewe�s, � ond hereby ou�hori:e represenro�ives of�hia County Io en�er . � upon Ihe obore�meniioned prope•�y lo.inspeciion purposes. � � �re ot Vermillee DatO� � SEE�fV113t fOR EXHANAfO�V tANGUAGE . - ' ' � � INSPFROk'S NQTES OWNER-BUILDBR DfiCLARATION APPRO VALS o�n ►+svcaars sicwn�a[ � � I hereby at(irm thec 1�m eYempt Erom the Cootrettor� �,�,���4 - . . . . License I.aw tor the lollmving rcaion(Svction 7031.5. -�•�i �C�. . . Uwina.v anJ Pro/rrriowf Co�h A.y a�ry or munty CO'+''E�T',0D1f1O'i"� .ubicb n :ru. ennie M caufrvet,alt�r,�m ll1ND�NC OQ KOVK . .. . . 9� p ��� - smic T�na.s[[v.n�(sl �damo[isb,or w�pai.aw,y ttrrctrrr,f^or to La inrawtr, .. � �✓�oioa oa��wrrcio � - - . . . . also NQ4iY!! tb��liaert�or srtb�r.nit�o/ik n � � � ti,qnoJ tWta+n�wt lbat b�4 liewu!frrirant to Ib� assroa p nnrwcu p - - .. provisionr oJ tb�Cowlractori Lkv�+�Lav�(Cbaptar 9 Krtc.ttr�ic.sew[aat � (rommonci�g wtilb S�cfiow 7000J oJ Divuiow 3 of 1be sew�cc oisros�c srs�cu - Bwi�eu anJ Profe�aiau Cod�l or Ibae bs 4 e:anpt . �"��y��a � Iberefrv,n e�d tbs buu/or tL+a!lrg�A trer�peio�.A�y e�ariu sco�K iu�rs d . , , , , . uiaJatiow oJSxtim�70313 by ssy ypJicawt/or�yar/nit s[v.rn ❑ c[ssroas O subjectt�b�nppficu�t to�duil A�woi�Y n/wot w/on tba� • . J�us brednJ dolbrs(1560A: I � ' . - � ❑I,u thc ownerott6e pcoperty sill do the work,�nd .. . . . . . • . , . � - the cwcture b aot inteod�d a ofkred for tale. � rs.�. �oaa,eW;,.0 a.s r�re,.�c�:n �. . .. . � Irxtor'f I.Jtent�Caw doo woJ a►p!y fo�n ow��r c/ " properry wbo brJldr or irw�row�tbsno�,a�d wbo dosr . . _ sucb worM birru.y prooldaJ tbar arcb bnprowm�wa � an wot intsndrd or of/�nd/or rJr.,(/,bowecvr,tb� , - � bwikling or impro�.w��wt Is toll witbin on�yror o/ ' �- - - -- - - - - - - -- — — - tompJetin�� tbi oun��rbwW►w+Jl bow 1ba brnfrn . o/pro�,ing tbat b d:d wot bwilJ w irnyr�ow jo�eb. ' pwryw.ojwl�./ , . , ' ' - . ' ' . I am ezempt noder Sec. , ,� �� B&P.C.for thic reasot� � Date IQa�ner �, IHSPEtTOR'S lIOTEi � � , � � � �