HomeMy WebLinkAbout0975A (7) �
WORKERS'COMPENSATION OECLARATION
I hereby affirm rhat I have a certifica�e of coesent to self
insure,or o certiFicote of Workers'Compensaiion Inaurance,or ' �eAeeso �
- - a certified copy thereof(Set.3800,.�ob C) CE878�REV.11631 APPLICATION FOR PERMIT
Polity No..�_Compo�� ��C�n IJ�r��r
I�c�,,;�Ia��o$,,�,4,e,e`�.F,M,�h;� ' SEWER • SEWAGE DISPOSAL �
.. ❑Cer�ified copy is(iled w��h the counry building inspactlon COUNTY OF LOS ANGELES BUIL�ING AND SAfETY
depanmeM. ,
oote npp��conr FOR APPLICANT TO FILL IN CONNECTION DATA
� CFRTIFICATE OF EXEMPTION FROM WORKERS' �iipr.q
I . �COMPENSATION INSURANCE nooa[ss L� � L .� � � ' ��� STATIpN o[rtH
(This seciion need not be compie�ed if fhe work involved by iha ��R
I permit is for one hundred dollors(5100)or lest.) lov.�itr ��f ' "'•'Y ='.r r :'il.�l�=ji)`�f �HIXE REFERENCF i R
r[aaesi rrve or ca+rxaro� �r.�TH p¢pM
� �te�tify thot in the performance of the work for which�his ��sr. � ' �")^' /l ' s� /..+�a y. CUR! P.l, M.�.TOP.L.
I permit is issued,I shall not employ any person in any manner , P��
so oa to betome subjact to the Workers'Compenwtion laws. py,��R •I, �- ( CO.IMP.Np. JOB NO.
� hN�l ' .. 1 T4UNK ffRMIT NO. ROAO PERMIT NO.
-Do�e Applicant AWRE55 / � G� S/.{. .r %'7O
NOTICE TO AGPLICANT: If, a(ter TOkIl1 ff1i5 CRfifiCp�e Of � G (' AFFID/.VIT WAIVER fASEMENT 4fCOR0.IN5TR.NO. D/IE
( Exempfion, you shoold become subject lo the Workeri aTY'� � �� "`'x� Et.'+o. ��/M i�� I 3 S�
Com nsotion ovisions of�he Lobor code, ou must forihwith �EGAL
PB P� Y DFSCPiof�pld LO7N0. MWY.ORST.WIDFWNG
I tomply wi�h such provisions or this permil shall be deemed �
.evoked. e�«K TRRR �G STMTE ENCROOCMMEM
LICENSED CONTRACTORS DECLARATION ^'��r&°�s. �c°MiT nq.
S�2F OF�OT NpW ON LOi
1 hereby offirm thol I am licensed under provisions of Chopter �� -
. 9(commencing with Seuion 7000)of Division 3 of the Bus�- BURDi�+GS '('`/ /- ��� annc.�s
ness nnd Profassions Code,and my license is in full forca and
. . eHecL 'r ` CpNTRA�TpR i i�:� i� r:V I� ' T �i',,f, •;Ll� COMNECTION CHakGE fEE ' 6
lice�se Nvmbar��l 2�1 Lic Class � aooaess " (,: — r 1 ME�MSURSEMENT f(( �
I r � V
Contracto�..l+�iJ ��+13 Nt•;/ Dote 1+ ��L-�{+) orr �(!.A sl:irr. i Tei.r+o. %� y• �? i'iL 1:.� oin4icr rao. caouv rnnr roocesseo er
W
BR PC �
❑I am e�empt under Sec, of the L.A.Co. iI�N��.�p �}'ry '}� �u�ss .� � � �/`�^ "'
Plumbinq Code ond/or Sec. of the �� DFSCRiPiION OF WORK r�E Fi�i . �
1iOV5E SEM/ER CONNEGTItJG TO D�TE �
,�,,,��,�R VALID oN , a
B.B P.Code for tha followtng reoion 5[P�I TANK.SEEpAGE PIl pR fiNAl 6
� PItS nND/OR DRnMflELD
� Dote �ous�awca ca+r�cr��ro BY . �
NtiV4 v W
SignnWre cam.�c��oortqw.�gip�.pc � f„
OWNER-BUIIDER DECLARATION H'�K TO HOUSE$EWER '
OVERFIOW SE Y P17,p4pMfIEID
I here6y eRirm�hat I am axempt from the Conlroctor's License EKiN,CESSOODL,OaYN(��,M�N�qIF •
law for�he foliowing reawn(Sec�on 7031.5,Buisness ond Pro- xreR,e�vn�oa.neu.np.,wousc
- fasslonaCode): s�'�Rd+asaos�isrsnM . . .
❑I,as owner of the prope�ty,or my employees wi�h wages m �?r t i 1 '�`f ' • � . '�;};f�'''r.�F'
���a,'���a.iie
�heir sole compenw�ion,will do the work and the srructure � � ,,i�,,,�;,�
is not in�ended or offered for wle(Section 7044,Business �,�s:a r,��� �_
. and Professiom Code). QH/NER�S P@Ifflit - f ,„�� , ,
❑I,as owner of the properry,am exdusively conrrocfing with AUTHORIZATION TOTAL FEE l •� c"0 •�+`.,��n:��;��u
IIClf15�COI11lOCfOIS�a COlISIlUC1 1M!Pf01e��(SBCtiOfl�Odd, I HAVE AT TNIS DAiF A�pNiRqC7 W17N IME MEREiN NPMED CONTRACTO4 Tp '��i����•�," /�-'
BUSinl55 011d PtO�eiSi0�3 COdB�. CONNECT iNE�BO�E DFSC4iEE0 EXISTING DN4LL�NG TO TNF%1Bl�C SEWER. ��y�1.M��j G}.1 I%.
CONSTRUCTION LENDING AGENCY Z�^ U/�r �`� pC ► �I � '�
1 here6y oifirm rhot there is o constr�c�ion lending agency SIGNEDTHIS � DAYOF J • 1J9'_ �5.�6.�i,���ii
�or the parformanca of the.work for whith fhis permit is p�r.�RS�aGEHT �<=}/��„�rY+(^ �.;r.,/�g.;'=` /'`-. .
�- i:sued(Set.3097,Civ.C.). %r;G //J • l y C/, Cc:�r h�'".�-�lrJ. �
MD4E55
Lender's Name
Lendar's Address , �
I cerlify thot I hove read�his app�icotion and sta�e thot the
obove informolion is correct,I agree to comply with oll Co�nry .
wdinances and Srote laws raqulaiing Plumbing o�d Sewers, - �
and hereby authorize represeMofives o1�h�s County to eMer �
upon�he obova•memioned popferty fa inspaction purposes.
'�1 , f ;�rn r �`?�, l'��": J� , . + _ .
. ir 7lv�i.�.,t .
Signotur f Perminee tef � SEE REVERSE FOR EXHIINATOM LANGUAGE ��. �(�� � � -'�r ��t '���`°'"^� � ''' `�
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