HomeMy WebLinkAbout1003A (9) .�' N'ORKERS'COMPENSATION DF.CLARATION CE 808 z-ao, � A P P L I CAT I O N FO R PE R M I T �c,1�
�1 hereby af�rm that I have a cenificete of consent to self SEWER-SEWAGE DISPOSAL U
insure,or a certiYcate of Workers'Compenaallon Insurance,or
a ce i i y t e f( c soo, ab.c.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
���—�'�{�L�+� �� �,
I Poiicy Nq. Company��d/!3�
FOR APPLICANT TO FILL IN CONNECTION DATA
CertiFed ropy i.c hereby furnished. ,
BVILDIN6 O, lT11TION Dfi�TN •
� Certified co is(iled with th<count buiidin ♦oowess �.pGp
pY� y g inspection
department. �ocwurr ��D MwNNOLG N6iiNlHCC �awen
Dafe APPIiCent NE�wcar TYP6 OI'CDNNHCTIOH LENGTM INOM
CERT[FICATE OF EXEMPTION FROM WORKERS' cnose aT. � N SS1N6 Y. CURB �.�. r�.�.ro►.�.
COMPBNSATION[NSURANCE � t7. gQ u� r.e.no.
OMM611 �/�J O CO.IM►.NO, lOB NO. }
�•�115 bCC11011 fICCd IIO� bG COiII �l�� if the work involved ' wooaeee U /V L1W� TRYNK PHRMIT Np. RO�D►611MIT NO. �'
e �
by the permit is frn one hun red dotlara (Sl00)or less.) 6 �.,o.�� ,M......o.+�,...ao.o.��:.�.� o.+. U �
� ' ITY TEL.NO.
I certify that in[he performance of the work fot which tMs � �ec�� �
permit is issued,[shall not employ any Derson in any manner oescwi�r�on � �or wo. hwv,ow er.w�oewina p
so as to become subJect to[he Workers'Compensation Laws. V
BLOCN TRACT D� STATC GNCR011CMMgNT W
Date ADVlicant NO.DF BLD6S. �6RMIT NO. a
NOTICE 70 APPLICANT:If,after makin¢[his Certificate of SIZ6 OG LOT now on�or j
F,xemptlon, you shoulJ become subject to the Wn�kers' �es or ���^,�S , ewwweas — '
Compensatlon provisions of the Labor Code,you must forth• eu��o�Nes �.r<J ,
with comply with such provisions or this permit shall be �or�rwweTow r� CONNCCTION CHAR66 F'E6 �
deemed revnked.
� LiCF.NSE�CONTRACTORS DECLARATION I�DD1�668 S Q .s� RBIMDYRl6M6NT P66
� f hereby affirm that 1 am licensed under provisions of Chapter s,.�e awo� w.r P .we<u+ae s.
9(commencing with Section 7000)ot Divixion�3 of the Busi- ��Tr Q� T£�.No. L' *� � �
ness and Pmfeuions Code,and my license is in tull force and L CBNSE NO. � G1�166 � �n �� � �� '
!SflC�. np, O!$CRIPTION OF WORK F[c
�y��Q G4'2— •�•�,���*� FINAL 3/ � VALIDATION
License Number a//IL�L Lic.Ciass owr � e�
�'2�DH�1r�'2.� z 8 '�o:��`,:.�..�.. o0
Contrector ate • �oe oww�nFi��o� v�nw . ,
❑ .oi.�a�s*c�i� Bv
1 am ezemD�from the licensing requirements as 1 am a eem.io«w�s�ec,o.
lieensed arehitect or a registered professionel engineer .io�ooae..w.e .
acting in my professional capacity(Section 7051, Bus•
iness and Professions Code). o��� �
Lic.or Reg.Na. Date
IiOME OWNER-BUILDER DECLARATION �
I hereby affirm that [ am ezemDt from the Contrector's �1NNER�$ Permit f ,S'T/ i
License Law for the following reason(Section 7031.5,Husi- AUTHORIZATION 70TAL FEE �� c,� �� �a 3�
ness and Rofessions Cnde): ..ew.�n.. e cer.- #.• •���1 O
� �Hc.a.ue s�w.w. e w.ov�oa.c..�.se ixnt�..a o
I, as nwner of the property,will do tfie work and ihe
stmcture is not intended or offered for sale (Sedion SIGNEO TMI$ DAV DF ' 19 - I • •2 Z 5 Q
7044,Business and Professions Code).
CONSTRUCTfON LIiNDING AGIiNCY ��R���� .�.� �2 2',5 O� '
1 hereby affirm that there is e construcllon lending agency ��2� 4�8�� ,
for the pertormance of the work for u•hich this Oermit is � - .
issued(Sec.3097,Civ.C.).
Lender's Name �
Lender's Address �
I terti(y Ihat 1 hsve read�his applica�ion and state thot ihe
aAove intormatiun is correct.t agree to compiy with ull Cour.ty •
ordinances and State law5 re�ulating Piumbing and Sewers,
and hereby authori�e represenlatives Of this County�o enter . .
upon the above-mentioned perty for inspection purpous.
/J ��� SEE REVgRSE FOR EXPLANATORY LANGUACE .
.�4 � a//����
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