HomeMy WebLinkAbout1000A � WORKERS'COMPENSATIONnrC4ARATION 76A642D qpPLICATION FOR PERMIT
� CE 808(Z-BO) � .
1 hereAy afCrm that I have a certificate of consent to self SEWER-SEWAGE DiSPOSAL
insure,or a certificate of Workers'Compensation Insurance,ot .
a�cer�1���p�tpt�rtp��o^yo�ab.C.) � �� COUNTYOFLOSANGELES BUILDINGANDSAFETY
aa�� � �""� ��-h�--�
� FOR APPLICANT TO FILL IN CONNECTION DATA
� Certifie�copy is hereby furnished.
lUIIDIMG ETATION � OE/TM
� Certified copy is filed with the county buildinY Inspection wooxcss � O r2 S UPn6R
department. �ocwt�rr p/J(� 8 MAMMOL6 R6Pl1�6NCC L�WlR
n8�! Applicant N@AHE9T 'r TVP6 OF COMNBCTION LCNGTM FROM
CERTIFICA7E OF E%tiMPT10N FROM WORKERS' crtoss sr. SUN S�� p G Y, CURB ►.�. r+.�.ro►.�.
COMYENSATION INSURANCE ■.c.Ho.
OWNCR U� CO.IM�.NO. lOB NO. }
��115 BCCtIOtI tICGd 110} �IC completed /��h! WOI�C IIIYO�V!'Q ADDPElS �� � �� T11UNK P6RMIT NO. RDAD P6RMITl10. �'
by the permit is for one hu�red dollara(SIOD)or less.) �N D�h1� S � by ,,,,,,,,• �,,,�„",�,,,�o.o.��.•.»..o. os.s U
CITY T6L.MO. � .
I certify that in the performance of the work for whith this �c�w�
permi�is issued,I ahall not empiny any per9�n in any menner DHECXIVTION I.OT NO. HMV,OR fT.WIO6NING �, �
so as to become subject�o the Worke�s'ComOensation Laws. 2 V
BLOCK TIIACT VJ STAT6 6MCR04CMMENT W
�6RMIT NO. a
Date Applicant NO.Oi BLOG6. N
NOTICE TO APPLICANT:If,after making Ihis Certificate of bae or�or �+ow ow�or � .
Exemption, you should become subject to the Workers' V°E oF S CwAA6FS �
Compensation pmvisions of the Labor Code,you muat forth• eu«o�x�s
with comply with such provisions or this permit shall be �'1 CONN6CTION tMAROQ e¢¢
deemeJ revoked. eonrwwerort e�--
LICENSEp CONTRACTORS DECLARATION wonwess � m ��� � RlIMOUR96MBf�T FEE
1 herehy aft"rcm Ihat 1 am ticensed under provisions of Chapter , ••+,e,» o.o�. .... � ..s�e.. . _.
- 9 (commencing wifh Seeliun 7000)of Division 3 of the Busi• � e�tr � �rs�.tio. (p27 Z� / �/J.� �
ness and l4ofes.vnns Code,end my license is in full force and iT�Ta 'I�J ���• � �oo ,�/ �I .� i"'f�l'��
efiea. icense wo., c��es �— ;
� �+�� No.. O[$CRIPTIOMOFWORI( FEE � .
i �N FINAL 3 VAlIOATtON
License Number Lic.Ctass D Q OATE
Contractorr�bll��ZDate oC woiow'ow�u�.v`e`io'�R F�NwL
O .w�ve.�o ��ire..c Tow Bv � . I
I am exempl from the iicensing requirementa as I am a
licensed erchitect or a registered professionel en6�neer �:.wc.��
acting in my professiooel capacity (Section 7051, Bus- .w�e n. ew.�nr�.�o i
iness and Professi0ns Code). . ao�Rowrwi«,M�wwwo«
AsI�MOON �1f
o�lnOiAL�r��lM �
Lic,or Reg.Na. Date �' O Q O p •
HOMEOWNFR•BUILDERDECLARAT(ON #� �• •.�O
OWNER'S Permit s �'
I hercby a�rm that I am exempt fmm the Contractor's �:� �2 2 5� .
License Law tor the following reason(Section 7031.5, Buai- AUTHORIZATION TOTAL FEE ,�,j ,S''jJ '
ness and Prnfessions Code): �'�'� �2 2 5�
U
� 1,as owner of the properiy.will do tlie w•otk and the *o�wi.usi ee:we�p i�e'w'seviToi�ew�se c'� -
strucfure is not intended or offered for sale (Section g�pHED THIS owv oF ewisL_ .�Z�4 i 8°�
7044,8usinees and Protessions Code). '
CONSTRUCTION LF.NDING AGBNCY �eas wcc
1 hereby affirm that there is a wnstructbn lending agency �
(or the performance of the work for which this permit is �
issued(Sec.3097,Civ.C.). �
Lender's Name '
Lender's Address �
1 certify�hat I have read ihis application and state that �he
above intormatton is correct.1 agree to comply wi[h all Courty
ordinances and State IaN•s regulating Ylumbing and Sew�ers,
anJ herehy authori�e representativ. nf this County to entef � �
upon the abo��mentioned prop y for inspection purposes.
�� '� 'r � __, SEE REVERSH POR EXYLANATORY LANGUAGE
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