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HomeMy WebLinkAbout0980A .WORKERS'COMPENSATION DECIARATION , � I hereby'offirm thol I have a cartilico�e of coesent to eelf � � � insure,o�a certificme of Workers'Compenw�ion Insuro�ce,or �sAseao a cenified copy Jhereof(Sec.3800,lob C,) CEB^B;REV.V83� APPLICATION F4R PERMIT � � PolicyNo. � �_ Comparny ���.=,�;:il!%-,�ii � _�f �''� " •� - ' SEWER • SEWAGE DISPOSAL � Ce�tified copy ii hereby f�inished. ❑Cenified copv is Rled w�ih�he momy bo�id�ng��sPecnoo COUNTY OF LOS ANGELES BUILDING AN�SAFETY department. Do�e• Applicom FOR APPLICANT TO FILL IN CONNECTION DATA � CERiIFICATE OF EXEMVTION FROM WORKERS' eundNc ,-�i:•<'1. �s, $TATIpJ ocvrN COMPENSATION INSURANCE woow[ss ,�i;i ��✓'% G=;'� - (This section need not be completed if�he work involved by the i�iiTY ./, „ r:r..•,,, « µwHaE rs[pEa�r�c� ow[° permi�is for one hundred doltars(f100)or less.) �`"' `'��` � �-�"` ���a �"����� � p � f1A4E5T l � (YY[pF CONNECIIpN �/J(TH FRQN I cerr'rfy tha�in the performance of�he work for wh�ch�h�e , �youST. ,?�`/c,�,,^.,a- t r f,:! =!;-r,/.;���1`r r. cwe P,l M.4TOF.L. . permit is issued,I sholl not employ ony person in ony monner � � so as to become subject to the Workers'Compensolion lows. l 'J'`--� � °���P1�� 01MNFR ij.!: . 1'0`J t:"f�_ CO.IMP.N0. JO!NO. ��� � iRUN1(PEQMIT NO. ROM i4RMIT NO. Date Applicant . �004[55 l r-� - - ,�%f.=�-:�'"7"` �(� NOTICE TO APPUCANT: li, after mokin Ihis Certificate of d!• ''+ Y AFFID/Yli wnivEa EASEMENT RECORD.wSTR.NO. WTE Eaem �ion. 9 cvr �. ..,�::%:,�"' �:.,..�%.�a. %!U-'�::aJ.ji.^ p you should become subject �o the Workers' LfGAL CompensatiOn provisi0ns of the Lobor code,you must(or�hwith o[scaicriow tOiwo. �.� Hwv.ox 57.wioer��rle � comply wi�h s�ch provisions or this permit shall be deemed � revoked. eiocK TRACT f �_�f,'� STAiE EN�RO�CMMENt IICENSED CONTRACTORS DECIARATION r.p pr ptpc�,i a�rtMii rq. I heraby affirm tho�I om licensed under provisions of Chapter siztovior r�qwOwiot 9 commentin wi�h SeUion 7000 of Division 3 of the Busi- �Of ( g I BUiIDiNGS .:''�/f�:,</.:r_-^ a.uc,�s ness and Professions Code,and my license is in full forte and ,�/` / lffQC�. �7 COMTRAROa \/J� ,/ r�/��:..1�=^ ! '.rJ%//�J� . CONNEC110NCHARGEFEE � 6 , LicenseNumber `�a�i�7rt�;�.eia,5 t�'1 „ � App�u ���? i/ /_!� :/.'� � QEIMBVRSEMENT FEE � Con�ronor���1�✓%`�..?/'.eJ.'i i Dote ��"sf•�.:.1.� ' 1 J•f- +"�',�� /;, wsrR�ci r+o. ccoua r.wa u `� wocesseo er . crtv i'_h,�.J �� !.'../rfi.wo. J f' � � BK oc � - ❑I am eaempt under See. of tha L.A.Go. iiceNs�na-`=�'%� ci�ss' � . �' � - Plum6ingCodeand/orSec. � ofthe �� DFSCRIPTIONOFWpRK �t[ F�i � �' MOUSE$fWER(pNNFCTINCr TO o.Te VAUDATION ¢ B.B P.Code(or Ihe following reason oueuc sewea � SEOTI TM1K.$[Eo�GE vIT OR FNAI O PitS ANp/pR pqAINf�ELD Dote rause s�w[e ca+r+[cnr+G ro B� � 6 _�..` P41VAlF DI Y TEM � W Signolure cOr�r�E�t.NoiTqHnt e�DC,.qt � �,,, OWNER•Bl11LDER DECLARAiION '�'OFK 10 N0115E SFWER � ' GJERFLOW SE q %,ORAINiI�ID I hereby aKirrii thol I om e�empt from the Controctor's license ENTN,CESSiOOI,DkYWEII,MRNIIaE law for tha following reoson�Secton 7031.5,Buisness and 7ro- �urta,atvnia at ne��r�oau'qus� � feasions Code): ' s�wER ors oisoosu svsnrn . ❑�,as owner of Ihe property,or my employees with woges oa � ' r � �'�''�^�'� �::11.'��..I.a!5 their sole compenwtion,will do�he work and the strutfure � RI#': `"�-is not inrended or offered for sale(SeUion 7044,Business � ;;w� � c�„(;, and Professions Code). OWNER'S Permit s "' ' ❑I,ai owner of the propeny,am ezdusively controcting wi�h AUTHORIZATION TOTAL FEE /�,-(i , ���!.��.�1 I•��li � Iitl�SSCI CO���OC10f5�O CO�SIfUC��hB PlO�BCI(S2C110l1�O4E, �HAVE AT TH�S DATE A CONiRA�I WITH tHE NEREiN NAMED CONTRGCTDR'IO ���������i��'� � BU51nlSS Of1f�PfOf95510n5 COdE�. CONNFCT iNE ABOVE DF$CRilED FxISiiNG DWELLItJG TO TME�IIBUC SEWF4. �'���1�.�,f��!1�� CONSTRUCTION IENDING AGENCY ;J� r,���_- ` �ry, `�'��4.:�s'L� � I hereby affi�m thot there is o tonshodion lending agenty 51GNEDTHiS � � DAYOf ��`�-�.✓ 19� , .�!F.�+�,;��.+ for the erformance ot the work for which ihis °�`'`�^�R� 'j:/, �G_,j� �;,�s � P permil is OWNERSAGENT � ' f�,^.a :�,• � iswed(Sec.3097.Civ.C.). . . f' 4 -/,i.�'t/.,,��-:.��� lenders Nome A�� ,�� x ��Jl '�" � � Lender's Address 1 certify thot I have read this application and stote lhat 1he � obove informotion is correct.I agree�o comply with all County o�dinoncet and Stnro laws regvldtinq Plombing o�d Sewers, � . . � ' and hereby nWhorize�epresen�o�ives of�his County�o enle� � � Vpon!h�above-meniioned prOperly!or inspedion purposes. � / ! ^ '.' 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