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HomeMy WebLinkAbout0977A WORKERS'COMPENSATION DECLARATION' � . "-"• I hxaby affi�m tha� I have a eertificote of consent ro self - � _ insuro,or a cerlificale of Workers'Compensotion Insurance,or �6^6°l0 a certified copy�hereof($ec.3800,lob C,) . CEBOB;RCV.1/B]� � ' _ Volicy No�. Compony ;��� �,.��r i APPUCATION FOR PERMIT CQ ce:��fied copy i"syhereby furnished. SEWER - SEWAGE DISPOSAL ❑c�n�fc�d copy�:r�ied wi�h�he counry build�ng��sPec�ion - COUNTY OF LOS ANGELES BUILOING AND SAFETY I deparlmen�: ooie Appliconf FOR APPLIGANT TO FILL IN CONNECTION DATA - CERTIFICATE OF EXEMPTION FROM WORKERS' �iipi� �/ COMPENSATION INSURANCE noon[55 � T �` ?� j Y "° 7,1, �%�,� ST�ripr� OcrrN (TV�is section need not be completed if the work involved by the � `•�., ux'cR permii ic for one hundred dollors(f100)or lass.) ����Tv , r���!- � ,. 'a7itj .r I.���� ���E RFFERETVCE i R I ceriify thot in the performonce o(the work for which this ^E^rs�si S �' Tvr[OCConNFCiwq �rx-,iMpqpq, � RE CrtOSSSi. ��.1'f��' �/.. 1 ..)�iFl.it. Y. [�Rp PL MITOPI. permil is issued,I sholl not employ any person in any monner . .�No so os to become subjeU lo the Warkers'Campenwtion Laws. pwr�Ea ' ��, p�r�E� ca uva.roo. ,oe no. . Mqrt �� � TRVNC PFRMIT NO. ROAO PERMIT NO. Dote Applicanr ��ss I! u '� !,'T • 1 ! 16 NOTICE TO APPLICANT: If, ofler mokin this Certifimle of ) � .(j . !'?� � AFFIDAVII WAIVER [nsex�H� RfCORO.INSiR.NO. , pI�TE 9 aTr�llt,�li.l::��r�rEi.r�o. 7��Y ' 1�� Exemprion, you�should 6ecome subject to Ihe Workers' i��i Compenso�ion provrsions of the Lobor code,you must forthwith o�xxiPrioni ioT rao. +- 7 1 HWV,pq ST.VA�ENING comply wiih such provisions or this permi�sholl be deemed } - revoked. - eiaK L4ACT � L i/ � ' Si�TE ENCRp��HN,ENT LICENSED CONTRACTOR$DECtARATION r.q_o�g�p�s_ , ff�"�T rvo' SIZE OF lOT NOW ON lOT I hereby aifirm�ho�I om I�censad under provisions of Chapter ��� . V(commencinq wiih Seclion 7000)of Division 3 oi the Busi- eui�oiwcs 1's' 1:)C" �e' w�ccEs ness and Professions Code,ond my license is in full force ond effect. A,�, CONiRACIOR i.:�,� j F,v.J�;r i r. . I ;;�� CONNECTION CHARGE FEE a License Num6er��� �Z �� LiC,Closs � i / 1 ✓� � � / / AD�CE55 I �/ :J . J( ; +:� ' �_;,,1 J � ��V4YMENT FEE COlIhOCtOI_Ui�J 7�Y�CI DO�Q � ' ��•'�S� � ' , I �J,.� [..1`TEL.NO. //!� �f �L /J DiSiRiCT NO. GRW P MAP PROCESSF�Ev W CI7Y ��.. �.� ' )i J &C PG �''�..� ..1 ❑I am exem �under Sec. of tha L.A.Co. s'°rE t{ � 7'�r uc. / i ' u, -. P I�CFNSE NO. 1 y� J� � C1A55 I + �. ,� Plumbing Code and/or Sec. of the � �� ��RiPTiON O�WORK ffE NN4L ' � � 1qU5E SEWER CONNFRING TO D�TE VALIDATION ¢ - ' B.6 P.Code for the(ollowing reason <- aueuc sEwea � $[VfIC TANK.SEEVAGE GIT OR FINAI ' O P175 AND/OR DQ�MF�(�D - �Cte ry�SE gW(R CONNKTING Tp °Y c PRIVATE�I Y t . � Signature ��io���i R�.q� � � ._ OWNER-BUIIDER DECLARATION tr,,ERFi w ev,. V17,D4�!NFlEID I hereby aff'�rm that I am exempl from Ihe CoNrotlot's Litense E%lN.,CESSPOCI,DpYN1ll,AUNNIXE ' Law for�he following reason�Secton 7031.5�BUISl1lSS Glld P!O• MTFR,REPAIR OR AMNOOry 11Q�5[ 4' feuions Code): 5[wee ce o�saosu srshM :':�:{.��!.��i ❑�,aYowr.er of the property,cr my emplayees wilfi woqes cs , 1 r- �• '..�;,`;�,�•,F;(d, fheir sole compenso�ion,will do�he work and the siructure .�.�,�T.t.•.... � is not inronded or offerad for wle�Secrion 7044,Buslnesa Permil t 't�,�,'1•R.•�C�� ond Profess�or+s Code). OWNER'S ..,i.,.r�,...,,,,, ❑I,as owne�of the property,am exdusively tontracung wi�h AUTHORIZATION TOTAL FEE i.�% �'''�i""4•�`��'"' licensed tontracrors fo consfrucl the projec�(Section 7044, i MI1Y[q7 iH15 UFTE A CONTQ�CT WIiM TME HEREIN NAMfD CONTR/iC70R i0 l � ' Business and Prolessions Coda�. [Or�r�[ct ru[neov[o[scaie[o[xiSTrt+�rnrtwNG 70 ir�E vu&iC SEwEa. ��.F a G:t';�L.H CONSTRUCTION LENDING AGENCY , �� ► I hereby offirm ihol Iherg is a construction lending agency SIGNEDTHIS �•r DAYOF 'f%���` 19L- . fw rhe performance of the work (or which this permil is �EQ� ',�1,f..,y�•�,.f.r �`j�����,;,I . OWNERSAGfNT— ',_v / fasoed(Sec.3097.Gv.C.). ' , ' - Lender'sName . nooness •'ry/ ; I�•�s /(`:�'.'=li..,...:�.�' � ILender's Address ' ' , I �1 cmlify ihaf I Fwve reod this appl(calion ond sfale Ihot the ' � � obove informa�ion is coriect I ogroe to comply with all County � � . . �� ordinances and Stale laws regularing Plumbi�p ond Sewers, - ' o�d Mereby aathorize represen�atives of thie Coonry to enter upon fhe above-menfloned properry for.inspetlion purpo:es. � � � ' ' / ��., /� �/ tl.--- i�,.alt/j'�/ %!!.f/,�:.�/�?'.L 7�� (L�'C/1 , � _' . Signo� e of Perminee ;/ Opli SE[REVERSE FO�EXKANATORY IANGUAGE �.. ..�,,'" Y';) ....�`� :'�� :;i-�.- .-� !^. ti-.� i� � . . � . . . i _ .. . . . 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