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HomeMy WebLinkAbout0978A (5) WORKERS'COMPENSATION�ECLARATION . I hereby affirm that I hove a certificoie of co�sen� to self " , � i�aure,or a terlifitole of Workers'Compensation Ins�ronte,or �6�617D a certified copy�hereof(Sec.3800,Lob C.) �EB�e�RE�.,,e�� APPLICATION FOR PERMIT Policy No. Company -:f.�1' ��/ti:+i . ❑ce.�;Fed copy�i hereby furnlihed. SEWER - SEWAGE DISPOSAL � ❑Cer�ified copy is filed wiih+he coun+y buildtng inepecron COUNTY OF LOS ANGELES BUIL�ING AND SAFETY � department. oo+e%�'�/��%� Appliconf �� .�- %i?��'S�C.� FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE DIDRE55 -^' �r�J ;�/_�;/G! 1 7/� 7 st�noru otvrN (This section need not be completed i(iha work involved by�he / -,,.y�_ • �� r MANHIXE Rf�ER[N(y �P°ER � permit is for one hundred dollors(5100)or�ess.) �«''°TY 1_�'` `l�` ' "'r� _'�'"����"��r i ° rtnaeST ! � rvv[or ta+r.�cTia+ IENGTH fipA1 I certii fhot in the arformance of Ihe work for which this � �= �^'='��=^?''a ' v P cwoss sr. /%'/i�':�Elr ��,l? . ._.r/J1'.'-�l r. cuan e.i. M.i.ro o.i. permit is issued,I sholl not employ any person in any manne� P.C.HO. so os to become subject to the Workeri Compenw�ion laws. p�q t/, ,��_ ,��r,-�,,� CO.i�+v.ta0. ioe rd0. 'M°��� I•' " •""fr��" � �' T4VNKP[RMITNO. RN.O(4RMITNO.� Dofe ApplicoM a�u �ii��f _%1/- .i:=r+�/ NOTICE TO APPLICANT: 8, ofter makin this Cerliiicale of AFFIDAVIT WAIVER e�n�[r�i RECORD.INSTR.ND. DAIE 9 Crtv Ji'-=�r.�.:!��i/��dFR��io. �F��.`,-.'=, _%;f:?' Eaemption, yoo shoold become wbjeU to the Workers' LEG�I _ Compensotion provisions of 1he Labor code,you musl forthwilh p[$�RIRION lOTNO. Y-�l Hwy.oqsi.w�o[wr+G comply with such provisions or thie permit sholl be deemed - !lVOkBd. BLOCK TRA�T ��.J�I��^� SI�IE ENCROACNMENT 'IICENSED CONTRACTORS DECLARATION �.a&�5. / ������ I hereby affirm thot I om licensed undar provisions of Chopier 5¢eorioT wwa+ior 9(commenting wirh Section 7000)of Division 3 of the Busi- p Eipm�s �� /�=-'�t-:..'� ouqces nesa and Professions Code,and my license is in full force ond � effect. � , CONTN4CI04 i,.� �) !=�:>fi� rsi•."�.;)T'/.c.0 . C0�INFCTION CHARG[RE a License Nvmber "���.;%% lie.Class l t ADDRE55 1'";i /�.:`C�i,' i� '�� • REIMBURSEMENT FEE V ;�J;:li-'lif:5. l. `� -� . �„_ asrx�a�+o. cao�r �.av oaocFsseoer Comroctor�" Dote i1--�'-• 1 {J� ?7•�:M.� arr jI�iir f- � *��.�. J/ 7G � � ui � ❑I om exempt under Sec. of fhe L.A.Co. iICENSE rip. e,���/,1' ( °C" �� � / aAss � ��- Plumb�ng Code ond/or Sec. of the �� DESCRIV�ION OF WORK rce FHA� � � wus�s�wev coNr+Ernr+e ro o•re VALIDATION B.8 P.Code�ior ihe following raoson �� ������R e�C SFP IC 7AN[,SEEFAGf fli OR vrt5�wOiOQ o4wn.b�ELD Fmul � . O Dal! �qUSE SEV/ER CONnFCfING i0 BY Oc. PqIVAI 1 Y M i ' Signa�ure cOr+�cr�wort�a+u xo�.ox � W OWNER-BUILDER DECLARATION WORK TO HIX15E SfWER , � OJFRiIOW SHPIIGE iIT,D9AINFIEL� � I hereby offirm Ihot I om exempt from ihe CoMroctor's License EXTN,CESSoOIX.DQ'M4IL.MJNMpIF low for rhe following reoson(Sec�on 7031.5,Buisness ond Pro- uTex.c[vnia oe�nu�ow�ause , ,, , . fessiona Code): s�wEa at oisaosu srsreM ��:�� ti � � . ;_.� ':{.i.!..�C.�'� ❑I,os owner of the property,or my employees wifh woges as - '.�'i'I'f'"r,' ,; . � their so�e compenw�ion,will do the work and fhe s�rot�ure ��W��%��s�''r" is not intended or offered for mle(Section 70d4,Business '"�'",'S"' . ond Professions Code). OWNER'S Permit S ��:!���:-<l��C�i ❑1,oa owne�of tbe property,am exclusfvely conrrocting with AUTHORIZATION TOTAL FEE )1-1 !,:; ,��;�,1;'��,4��11-• licensed coniracrors�o cons�ruu rhe project(Sec�ion 70aa, i HAV[AT THIS DATF A CdJTRA�T WIiM THE MEREIN NAMEO CON7RAR0R f0 Business'ond Profeuions CodeJ. cOr+r+eR n+E neov[o[scaie[o[■isnr+a ow�ux.�io i�v�euc 5[wea. - "�� I . /.�,, '., j�r..�:..-;�:.a CONSiRUCTION LENDING AGENCY „!��+ J�,���: �' , I hereby aHirm fhar there is a conslruction lending agenty ' SIGNEOTNIS -� DAYOF - 19:_e for fhe performonce of the work for which thi� permit is Q ryERS�pGENT ����f��'�y!�� �"' �•�'y ���� �� issued(See.9097.Civ.C.). A�� %i'.} J %`.-1,f�;N' ��,!/j.,'y�,�'�. . Lander's Nome - tender i Address , � I certify Ihol 1 have read Ihis applica�ion and slate that�he . , obove informo�ion is correc�.I agree�o comply wi�h oll Coun�y . . ordirwntes and State lows regulating Plumbing a�d Sewars, � ond hereby outhoriza reprasentafives of this Counly�o en�er � upan tMe hbove-mentioned propeny tor inspection purposes. - l � � .. - ' I :'.:,-�':/ I�'q, .,.,r/;`• �.._,=/_.fjS'— . ' - ,. ... ! J �,4-" ,��.�,..�.�. . . Slgnnlu of Permklee Datd:�'' SEE[EVERSE FOREXKANATORY LANGUAGF .� `� � `��'� ' � �`a �( `I • . - i _ __ . . . . . . . .. .. . .: ..i;. . _.:-`. ._-`,. `.. -� - -i . 4� ;� y,,, � �, . � �, �; .� '� � 1 ; ► � � � � �; . ,--- ; : � ; � l � , � i ` �, ;; . - . • ., ' , , ',w + _ • , ;' , � � � ! �i � i ` ; ���i . . - .. .;; ; '`, '`, I .I � � '';_Y� s: � ,�.`' � '�- �I , _ � . , ;.. ; ��� , � ; i ti,, � � .:, I ��� . .. 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