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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//���� Signeture of Permittee �D � , n T,c� can m ;nca Dfl �'D S''ICO 1r"r m Zv Z < -- - ._ - mn Dn 1{� N �-1'roZ S �� �`;�.L1� p , �,�,� ZC��1 �' � . _ �t . .. � ar o2',`"v�� , o2;I�� m, 'n � ; 2m �m � OT' . . ' �r� n to�`❑ YT• 37d M� Q ' � i � .�� � n; Q-i -eD 1 cn;�D , �. ' ��� �-� ��lo� o ' ��,�oa �� � -� �,r ��- � ml y '.il . -: . 1! `. .. � ' � ' �• r�'�+(1 ���D` ��, r�.��z i�l� � • ' ti�-4 TN„ cf.: r� ' d'O D i� �D D {m �.' �� r -' �. ,� � . � p� m��,c�� r �y, �..�; • . . �I .�� .� .. ' . , r�� T �O�TJ . =. 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