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HomeMy WebLinkAbout0976A � , '� < WORKERS'COMPENSATION DECLARATION � � F I Mereby a(Ii�m tbat I have a certificate of coosenf to self -, [� j insure,or a certifitote of Workers'Compensation Insorance,or 16A6�iD � � a certifiedcopy rhereof(Sec.3800,LabC.) I CE9C8(RFV I/831 APPLICATION FOR PERMIT Policy No. Compony ; '^"�rJ%��/!� . d CerliFied copy�is he.eby�lurriished. . SEWER - SEWAGE DISPOSAL � ❑Cer��f�ed copy�s filed wiih the coonry building�napecr�on COUNTY OF LOS ANGELES BUIIDING AND SAFETY departmen�. Date r':%-'-�S Applicant �"� '� "�''�t'S�%L- FOR APPLICANT TO Flll IN CONNECTION DATA CERTIFICATE OF EXEMVTION FROM WORKERS' � eunow� „_y f�" � - STATION DFFfM COMPENSATION INSURANCE � AooaFu - - --�� �:� (This section need not be completed�f the work ir,�o��ed by the � _,';r,. � r ,� MANNOIE HFERFNCf • u�� permi�is for one hond�ed dollors(5100)or less.) ��trtr = /;�':. � _. _. � , !1 .l �`� :� � R I�EA4ESi TYPEOFCONNEC710N IFNGTMFAOM� I ceriify thot in rhe pe�formonce of�he work for which�his crtosssr. -f�.c1 .� " :.t'-:�Y v. Cuae r.� M.LTOG.L. permit is issued,I sholl not employ ony person in ony manner p�.�. so oa ro become subjeU�o rhe Wa�keri Compensalion Lowz. �Ea �' ,•'r co.uv�r,r.q. ioe r�o. �1! Applicanl �ES$ �/.i j �..�`.t".""r :�!`/%; TPUNKPERMITNO. ROR�VERMITNO. NOTKE TO APPL�CANT: If, aAer mokin �his Certificate of ' _ M . �ionvrt WA�YER E�SE�nENi RECOiD.INSTG.NO. DATE 9 aTv "��.�. 1�J- E.emp�ion, you should betome wbject to the Workerrs ��i� � � � � Compenwlion provisions ol lhe lobo�code,you must for�hwi�h DESCRiViION G''��: lOTr10. %.I_ HWY.OR ST.W�DENING tomply wi�h such provisions or this permii sholl be deemed .evoked. eiocc TYAR SfAfF ENCRO�CMMENT _ � LICENSED CONTRACTORS DECIARATION , �'�0,.�&DGS. 1 ���T�� I hereby affirm Ihot I om licensed under provisions of Chapler 5��iOr raowor�iOr -� 9(commencing wilh Setlion 7000)of Division 3 of the Busi- eunoir�s - d�x.�s ' . ness ond Profassions Code,and my license is in full force ond � � � effecL ` ) /� � cor+taattat �,�:.:e i.- " :"Y.. ..�A.'Yr - CONr�ECiqN CHARGE fEE !- � 4=•7�i:�I�I i.'`�J_. L� • ADDRE55 d� l� 4E�M6UGSEMENT iEF v Licenae Nomber Ua Closs � �OI1�fOC�OI t/!�/.� .�7/.�.:Jv�,:9ote %•�•'!�e�• ' • ~ '" ..•`...i..."':':.�i:7: DISiRiCiNO. GRWV MAv VGOCESSEDBY W � � . :':,' CttV '.; ��I F!/^';r;s TEI.N0. ' _ � pG J P ❑I am e�em t under Sec. of the L.A.Co. sure . uc ,� /J ! �„ p uceNst r+o. ' ; i`% nnss NO. �ESCRIPfIONOF�WORK IfE fiNAl � PII1T61lIgCOd1011d/OISBC. OI1FB , yqV5E5EWERCONNECTINGTO OAIE VALIDATION a ' ' � - PU&IC SfriEi � B.6 P.Code for Ihe following reason gmi�i�stEOAc[�T oa �i�� O � " ' i1T5At.R1/OQDR�iNF�EID BY � . ' Da�e wusc s�wta cor+r.�cru+c ro - ' PRIVATF 01 Y i M . 'Signafu�e ca+.+[cr�woir�ora•i�oc.at � . ' � � OWNER-BUILDER DECIARATION 'MORK i0 HOUSE$EWER dJERf�pW$[EP/•GE PI/,DIIAINfIFlO I hereby`offirm thot 1 am exempr irom ihe Commctor's licanse E%TN.,CESSOOOI.DRYWEIL AMNHIXF Low for the following reoson(SeUon 7031.5�BUISOESS 011d P!O• NTER.REPAIR O4 AN.NDOIJ HOUSE $EWER OR DISPOSAI SYS7EM ' Y''j"- feuions CodeJ: . �a�tj,,' �:� � � �I,ns owner of the property,or my employees with woqes as �'�`�"r-v 1-�'� �`� ,,-.��•i•,.,•T��J their sole mmpenso�ion,will do�he work and the strutturo :..:,^,��,�,J�S is not Inrended or offe�ed for sole(Setrion 7014,Business . �� ������1 ondProieis�onsCode). OWNER'S Permit f ;�,R;,��a..,,[%(,f - ❑I._as owner of the propery,arn eMclos��ely contrac�ing with AUTHORIZATION TOTAL FEE 'e�"�"e;f����j�;' licensed coneroc�o�e fo conarruct�he project(Section�OIA, �NI1VE Ai TN�S OAT[A�QNfRA�T WI1N THE NEREIN NRMED CONiRACICR i0 � �� Business and Professions Code). coran�[cr n+e�eove oescaie[p cxrsnnc owewnc To i�v�euc StweR. ' ' ^k' L,G:�;�a�•i��, CONSTRUCTION LENDING AGENCY . I hareby oHirm thot there is a constrvc�ion lending aqency S�GNE�THIS DAYOc � 19_: �or the perfamance of ihe work for which this permif is o�ERS�nGFNT ,%f��,!.;•.. - .� !�'•'- � � - issued(Sea 3097.Civ.C.). - / 'l, f i • ADDRE55 ��� - - . �Lender's Nome ' Lender's Address ' � _ i � F I cerri(y tha�I have read this opplicotion a�d s�a�e�hot fhe � /'� _ _�_� �J� . •� � obove infwmotion is correU.I agrae to comply wi�h all Counry t�_E ��'�� , . � , ordinontes ond Smte lows regulo�ing Plumbing and Sewers, � � -. �- � _ . and hereby avthorize representaHves of�his County to enter upon the obove•mentioned pruperty for inspec�ion purpo»s. , � !,. • . • ! �j ��:"f._i...� '.!%/ i,i,. � i`/i.-i. % J Signo re of PermitMe � ,Oaie SEE REVERSE FOR E%rIANATORY LANGIlAGL � . t , . . � � � � . : i� .-....,I: .� _ .I._i.- :i i..-i . : i i - ;, -; ..I. . ; , . f:_ �� `.I � � , - ( , I: I . � ' . , , I?- ;' �' ( .� I i--� � I I � ', . ;:._ ; "i , I �i t ; ; �l `; , �t I : . . . . . � �-. i`_.; i i, � ! ;; � i � ` ' ' I : i ;. i' ,i i. .�i i �� _ _ i: - �•` � C!�I _, . �� + :�, 1 ' , � ^! , !r :; i � � ,; � . � � ; :� ' I;!- ' ' �; � I i I i `-`�i . � - , ; r--: i ---i, L i I �' i� ,I � =; I I I ` �I := . 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