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HomeMy WebLinkAbout0976A (7) � WORKERS'COMVENSATION DE�LARATION � � I hereby offirm thot 1 have a certificote of cor+sen�to sel( : � . imure,or a cer�ificate of Workers'Compensotion Insuronee,or , �eaea�o . °�°��;';°d�°PY,h°�°°'�5°�.'�°,�e�., .y. "�e`"`",,B" APPLICATION FOR PERMIT " Policy No. Compony � N G/�R++ l ac����F�e oPY s1,�.�a,y,,;,,;i�s SEWER - SEWAGE DISPOSAL ❑CeniF�ed copy is filed with�he county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY deporiment. Date �4pp�icant FOR APPLICANT TO FILL IN CONNECTION DATA � CERTIfICATE OF EXEMPTION FROM WORKERS' evno�n+c � / .X ��rL, SUTipri pevrH ' COMPENSATION INSURANCE aoDaE55 , / ��� . (ihis section need not ba tompleted if ihe work involved by the - � j.r MANHIXE REfEREN� �°°ER permit is for one hundred doliars(E100)ar less.) LOC'���r ��• " 7'' ��%4� -� ^�! _ '�, � Q t�lAREST ' IYPE OF CONNfCTiON (ENGTH FROM I certify thm in the per(ormonce of rhe work for which rhis caoss st ��, �..,i - t/i,i `�.(.':.7r r, cuRa P.L M.l.TO P.l. permil is issued,I shell nol employ any person in any monner � ' ., p�� _ _ so os�o batome subiect ro fhe Workeri Compensation Laws. aw�R ��� �J:•��.f.' m.v.w.ao. �oe r+o. ��� " .�- r iRUNKPERMITNO. COADRiMITNO. � Dote AppliCont � aoortess /L., J i •r� �1 i� //9 � NOTICE TO APPLICANT; Il, ofter mokin this Certilicate of /� AFFIDNViT WAIYER fASEMFNT RFCORD.INSTR.NO. D�TE 9 an fK/;-,,.,i:r %.'rEC{a_ /!�4 '✓%S"%:3� � E.emp�ion, you should 6ecome su6jaU to the Workera' tecex � Compensa�ion provisions of Ihe Lobor code,you musl forlhwith p¢xaimroN �Oirq.� HWY.pR ST.WIDFNING . tomply wiih such provisions or this permit shall be daemed �p revo4ed. aiacK TRA�T •� �- �U� SLATE EN�Rp�CMMFNT LICENSED CONTRACTORS DECLARATION � r+o.a�ncs I °��"'T"'�� s¢e oF�oT raw ow�oT ---. _ 1 hereby affirm�hat I om�icensed undar provisions o(Chapter �� . 9(commencing wi�h Section 7000)of Division 3 of the BU51- gpIIDINGS � �>I 1�f�n.��G' . o��x�s nesf o�d Professions Coda,and my license is in full(orce ond �. .y.� / / CONNECTIpry CHnR(�(FEE � effecr. ca�na•aoe "�;t+� l d s�Ur��, r.c / l f.l� Ucense Nomber`I'%�� � lia Closs � AppRF53 ).' N. i� C I i� `� �:� 1 �[�vas��nrt ff � v eom�oc�or.�•1U :n�Nlit�me C. —LG-�� ' ' tli r,., �:i � rc�.r,o. ria - '-:C 70 ��sia�ano. caa,v �a,v MOCESSEDBY W atr!;:�, ec rc �-.f � sr�rE � uc. � u, ❑1 am e�empt under Sec. of the L.A.Co. i��N��.L�7 S%7 J aass '1 �`% NO. pESCRIVTIONOFWORK FFE / , � Plum6ingCodeand/or5ec. ofthe � F��� ;� NWSE SEWER CO'1NECfING TO D�TE VALIDATION � B.6 P.Code for the following reason �B1����R $EPTIC TANK,$EFPNGE PIT 04 fINAL D �1e GIiS AND/OR DRAMFiELD BY G. 1qU5E gN4R CONNECTING TO FRNAtE�I VST M W Si9n01ufe CbIJNfCf ADD1710NA1&W.OR � •. �.. OWNER-BUILDER DECLARATION W«+K io Nous�s[wec bhRFIOW SEEPAGE P17,ORAINFIELD � , �.I hareby offirm thol I am e.empt from�he CoMractor i license exrN,cEssaoa,d+vwtu.rnnr�Hott � taw for�he following reoson(SeUon 7031.5,Buisness and Pro- arzA.ctvaia oa nantiooni�aus� � � fessfons Code�: s[�aeR oR o�sros.i svsh+n - . � i ❑I,ai owner of the p�operty,or my employees with wages as / �`= "� _4��(i'J��f: � �heir sole rompenmlion,will do the work ond the structure , �' is not imended a oHered for sale(Section 7044,Bvsiness ���i,'��1'�[i'��� and Profesatons Code). OWNER'S Permit f t�••�:•,••,-•-: ❑I,as owner of the p/operty,om e:clusively controcting wirh AUTHORIZATION TOTAL FEE J t ;' _-1 ,�j';,];;;/.(�I� ' �iCl�S�conlrat�ors to tons�rutt ihe projecl(Setlion 7WI� I HAVF AT THIS DATE A CdVfRICI WI1H THE NEREIN N�MED COMTRA�TOR i0 BU510l55 OOd PfOf055fOn5 COdG�. CON�IEQ iME ABOVE Df5C41BE�E%ISTING DM/EILMG TO TME PVBUC SFWER. ��'��"���"�'/�`�°' b�„��Ii h�41�i � CONSTRUCTION LENDING AGENCY � �5�r �, — -� � •�� .� � • I hereb affi�m thof Ihere is a construction lendin o enc SIGNEDTHIS DAYpF ����r�-�-� • r9�! Y 9 9 Y pNndEa orz • .� , F1,1.1 4:�1,^,;:F f for the performonce of �he work for which �his parmit is •� ii�;.r':'�, . �`it' + ,.� pWNERS AGFNT ' issued(Sec.3097.Civ.C.). - �.,;. �^9 ' . . ADORESS �•'t" i-ii_�. . /r� �.,��.�--_.� tender's Name lender's Addrass 1 cartify rhai I have read this applicarion and s�ate�hat rhe above iniormo�ion is correct.I ogree lo tomply wi�h'oll County � � ordinances and Srate laws�eg�loting Plumbing ond Sewars, • � � and heraby authorize rapresanla�ives of this Covnty to en�er � . upon fhe ebove-menlioned properly for InsBec/fion purposes. t � ""� S / �.r �� �) ..- ��'1.rl.r.,'7.-l•, .�j-,,•_,,,+.t i,- � �� •% , , i.•.., t_.. 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