HomeMy WebLinkAbout1001A (9) • tVORKIiRS'COMPENSATION DECLARATION 76n642o A P P L I C AT 10 N FO R PE R M IT '
CE 809(1-60I �
�1 hereby affrm that 1 have a certificate of consent to sett SEWER-SEWAGE DISP05AL
insur,or a certiflcate of W�rkers'Comyensailon Insurance,or
�ifjpt�fg y,Lhtre�Sygc.380q,yab.C.�� �� COUNTY OF LOS ANGELES BUI LDING AND SAF�TY
vMicy 140.— `f�' Company �
� FOR APPLICANT TO FILL IN CONNECTION�ATA
� Certified cnpy is hereby furnished. .
BUILOIN6 6TIITION �EVTM
� Certified copy is filed with the county building inspection �DDRE39��D f 1 uppE� .
department. �oca��rr �1� � M�NHOL6 R6FGRCNCG {,ONGR.
Date Applitant N6I1RE6T TYPE OF CONN6CTION LENGTM FROM
CERTIFICATE OI'fiXGMPTION FROM WORKC•.RS� CROSS 6T. s Y. CVRB �.L. M.L.TO Y.L.
COMPENSATION INSURANCL � ►.c.r�a.
OWN6R * � CO.IMV.NO. JOB NO.
(This SECt10P IIEPQ 110� bC compleled ii the WOf�C invoived ADORE9E �['�L� �� TRUHK V6RMIT NO. ROAO oGRNIT NO. }
6y the permit is fm one hundred dodars (SI00)or IeasJ .,,o.�� .mo+ a.K.,�...q.oe«o.��s....o. o..s �
CIT� TEL.NO. � U
I certity that in the performance of tfie work fnr which this L66AL
permit is issued,I shall no[employ any person in any manner o65CPIGTION LOT No.
NWY,OR ST.WIDENING a
so as to hecome subject m ihe Workers'Compensation Laws. O
- 6LOCK TRACT O pfiRMIT NO,�OACMMENT U
Date Applicant NO.01�BLDGS. �
SIZB OF LOT NOW Op LOT
NOTiCE TO ANPLICANT:If,aCter making Ihis Certiflcate of o-
Exemplion, you should beenmr <ubjett to !he �Nerkers' uee or �^�D�� enwweEs ��
Compensatlon provisions of the Labor Code,you must torth- euamHes Lyv _
wi�h com 1 with suth �p � coHHec�ion c��wce FEE
p y provisions or this permit shall be �pNTn�CTOw
dcemed revoked. �
LICENSED CONTNACTORS DECLARATION 1lODAE88 ,S',� jJj .i. , Ri1M�UR8EMENT C66 '
K.
I hereby affirm fhat f am licensed under provisions ot ChaDter = �74 ^�e... owoo. . Pc ..
� 9(commencing with Sectlon 7000)of Diviaion 3 of Ihe Busi- � � cirv ♦e�.r�o. / ,
ness anJ!'rofessions Code,and my license is In full fnrce and °T•Ts ��c. �Q /C/ ,p �7 �—[i
GTfOC�. LICEN56 NO. CLA93 Z � /
NO. �E3CRIPTION F WORi( s6f
,..R� „..«r,..�.o ��NAL � VALIDATION
License Number.��. Lic.Class o^ DU owr��' ��
Coniractor ate �����" F�NA�-
❑ c.oa Bv
I am exempt from the licensing requirements as I am a
licenud architect or a tepistered proPessional engineer
acting in my professional capacity (Section 7051, Hus-
ineasandRofes<ionsCode). FVWF��� ou•c
.rRwoo+.�
Lic.or Reg.Nn. Date
HObiB OWNER•BUILDBR DECLARA7ION � � �
I hereby effirm that 1 am exempt from +he (ontrartor's �WNER�$ Permit f �.� O a.� p ,
License Law for the tollnwing reason (Section 7031.5, Busi- AUTHORIZATION TOTAL FEE �
nessandPmfessionsCode): �'=s . #.• •��.�� p
� :o.wE:u:�c'scwca. .::o�:':.�.�o o y�::�«o�o <<
1, as owner of ihe proper[y,will do iNe work and�he T '��• •2 2 5 0
structure is not intendeJ or offered far sale (Sectinn SIGNED THIS o�v oF ig �
7044,Ausiness and Prnfexsions Code). w�qs wcs ��'� •2 2 5 0 c=i
CONSTRUCTfON LF.NDWG AGIiNCY �
I here6y affirm that there is:+construction Icnding a�ency 1 2� /1=S�
(nt Ihe performancr of the work for which this permit is �
issued(Sec.3097,Civ.C.).
Lender's Name .
Lender's Address
I certify that 1 have read ihis application and state[hat thr
above informatian iz correct.1 agree ro comply with ull Cour.ty
nrdinances snd State I3W5 regulating Plumhing and Sewers, �
and hereby authorize represe Sativrs of this County to enter '
upon Ihe abm•e�mentioned y�perty fnr inspection purposes. �
`��� ����/P/ SF.E RfiVGRSG POR IiXPLANATORY LANGUAGE
Signature nf Yermittee D e
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