HomeMy WebLinkAbout0999A • R'ORKBRS'COMPENSATIOND[CLARATION 7BA642D APPLiCATION FOR PERMIT �
CE 808 12-80)
�I hereby at'rrm thet [ have a ce.titicate oe consent to selt SEWER-SEWAGE DISPOSAL
insure,or a certifcate ol Workers'Compensation[nsurance,or �
�ic}F.��,��vLd cnpy,therr,ofGfSec.3so�j,La�6.C.)� � /� � COUNTY OF LOS ANGEIES BUIL�ING AND SAFETY
Pbl�c"y�. /`+'LL4'ComDanY_Sa/�x�e./ A7Kc�' .
� FOR APPLICANT TO FILL IN CONNECTION DATA
�j CertiFled copy Is hereby furnished. -
lUILOING ETIITION D6PTM
� Certified copy is filed with the county building inspection •oowsss p u'P6R
department. ��p MANNOLE XEFERENCE
�oewurv �owew
n8}¢ Applicent NCIIRCST
TYlC OF COXN6CTION L6NGTNfROM
CF.RTiFICATE OF EXEMPTION FROM WORKF:RS' cwoss aT. v, euRe ►,�. M.�.ro n�.
COMPFNSATION INSURANCE OWNER � CO.IMV.NO. 100 r�io.
MAIL
(This section need not be Completed if the Wotk invUlved woowess rnutiK r6RMIT HO. ROAO�6RMIT NO. a
by the permit is for one hundred dollus (S100)or less.) •� �„o.�� ...w�. �...,......�ce�o.�..:.....e. o�.� p
c�r � ret.no. V
1 certity that in the pertormance of the work for which this L6GNL
permit is itsued,1 shall not empioy any person in any manner oescw�rr�or� �or r�o. .
= MWY.OR 9T.WID6NING �
so as to become subject to the Workerc'Compensation Laws. . Q3�� O
OLOCK TRACT STAT6 6NCROACMMCNT F
rERMIT XO. V
Date Applitant NO.Oi'BLOG0.�• W
NOTICE'f0 APPLICANT:lf,after making this CerHficate of ��ss or�or now or��or a
Exemption, you should becnme subject to the Workers' us¢or O ewwwaee Z
Compensation provisionx of the Labor Code,you must forth- eu��o�xas _
with comply with such provisions or this permit shall be GONNBCTION CNARGE F6E
Jeemed revoked. eonrwwerow
LICENSED CONTRACTORS�ECLARATION wuoncss � RHIMBUR6HM6Mf PH6
I hereby atfitm that]am licensed under provisions of Chapter I� _ _ / L s�e�er.o, c.00. �.. c..eo..
9 (commencing with Section 7000)of Division 3 of ihe Busi- ��rr TI'� T6L,ND, 0 7'� •s /�
ness and Professions Code,and my license ix in tull force and erwre / ue. q �Q �/ � `ij'�J _![___���'
ePfect. uceNSE No. cuss �,. / ,vG
No. DESCRIPTION OF WOR1( F¢¢ VAL�DATION
�{ /��- FINAL
License Number�2�L2L� L(c.Clau �"`� �i eiE:E:`o.�«r�..o.o / DATE � �� �
e•ric r iow'ow.`».iio�
COI1If3ClOt���91G � ep FINA
� 1 am eaempt from the licensing requ'vements aa i am a c ow ev '
liunud architect or a registered D�ofeasional engineer
acting in my professional ca0acity (Section 7051, Bus- �..•
. iness and F'rofessions Code). i.00��..w's��,
, .�...eo.»o�.�
Lic,or Neg.Nn. Dale
IiOME ON'NER-HUILDER DECLARATfON
i hereby affirm that I am exemD� Crom the Contractor's OWNER�S Permit f Q
License Law tor the following reason (Section 7031.5,Busi- AUTHORIZATION TOTAL FEE aa (f
ness and Rofessions Code): eweu.w uio e
r rwi ��eov.oe�cwiaeo sa�a.�wc e
� f,as nwner of the property,will do tfie work and the o r`.e'vusu`e�e:ca�'" «jww�j~ �� �0 9 9,9 A
structure is not intended or offered for sale (Section SIGN6D THIS owv oc �s �
70a4,BusinessandProfessionsCode). N`w�wc` #�,�,�,�1 O
CON57RUCTION LIiNDINC AGCNCY
I hereby vffirm that there is a construction lending agency � •��2 2 Jr�
fur ihe performance of the work fur which this permit is � _
issued(Sec.3097,Clv.C.). • • •2 2 S Q�
Lender's Name ' ' �
Lender's Address �2� 4'�$F� :
1 certify Ihal 1 have read ihis applicafion and state that�ha ' ' �
above in(ormation is correct.I agree to compiy with all Cuurty
ordinances and State lau•s regulating Ylumbing and $ewers,
and hereby authorize representatives of ihis County In enter
���upnn[he abov-mentioned erty for inspection purposes. �
�I�O �yI��ISI SEF.�REVERSE FOR EXPLANATORY LANGUAGE
.1¢. ��E/�17
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