HomeMy WebLinkAbout0998A • N'ORKERS'COMPENSATIONDECi.ARATION 76A642D �
�EBo8,2.eo, APPL,ICATION FOR PERMIT
�I hereby affirm that i have a certificele"nf consent to�e�r � SEWER-SEWAGE DISPOSAL
Insure,ur a certificote of Workers'Compensation Insurance,or
a�,,e� �p�,coo' qrgo�' c.3soo, a6.c.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
vfsi�&y�do;'��""Co�'empany �.L_�-.�� �i�o'
I �Certitied co FOfl APPLICANT TO FILL IN CONNECTION DATA
py is hereby furnisheJ.
eu��u�r+c �t� � r� BTAT�ON ocarx .
� Certified copy is filed with the county building inspection •eowEss J UPVlN
department. �ocw��rv p�� qJD 4�R MiINXOLE NEiENBNCE LOWER
Date ApplitaM Heewesr 'l �/�� Q /� TY�E OF CONNECTION LENGTN FROM
CROSS 8T. S v��� ��)Syj��(J Y, CI11�B •.L. M.L.TO Y.L. -
CERTIPICATEOF F%EMPTION FROM K'ORKFAS'
COMPENSATION INSURANCF � r.c.no.
. OWNER CO.IM►.XO. lOs NO. }
�Th15 SCC�l0�1 �ICC'� 00� be CO(f1p�C�C� /��IC W�Of�C IIIVO��Ed ROOPEBB � � TRUNK�ERMIT NO. R011O MCRMIT NO. a
by the permit is fm one hundred dollars (SiflO)or IessJ � ,F,o.,,, ,,,,,. ,.K,,,,,,,,.�o„o..,,.r,,.„o. o..� �U
c�rr �.no. — �
1 ceHify Ihat in Ihe performance of Ihe work for which this LFGAL � -
permit is issued,I shall not employ any peraon In anY manner D65CRIGTION LOT NO. NWY.Op ST.N�IDENING �—
xn as to betome subject to the N'orkns'Compensetion Lews. ,` (�
OLOGK TR4CY (J STATE fiNCR0IICNNEHT (y�
Dete ADP��cant No.ov atoos. °BAM�r Mo. d
91ZE OF LOT NOW ON LOT N
NOTICE TO APPLICANT:If,after makine this Certificate of 2
IixemD����n, yoa should become subject tn the Workers' � uea oP �pO$ GM/1FGE9
ComptnEation ptovision5 of the Labor C�de,you must forth• eui�o�nac .
with rnmply with such provisions or this permit shall be conrwwcroe ��,'l, CONNGCTION CMARG6 rce
deemed revoked. '
LICENSED CONTRACTORS DECLARAT[ON woowecs O � /O O/ RE�MBUR66M6NT cse
I hereby aff'vm thet I am Iicenud under provisiom of Chepter `, . /�^ p� �*• ..e o.o.. ... 4 r. <ess�o.. �_
9 (commencinQ wi[h Section 7000)oLDivislon�1 of t6e Rusi- eir. �y - T6L.NO. (p4��7/ ,
ness and Pro(essions Code,and my license is in full force end srwTfi p.� � ��e. � � �� �jP � M� P �,��/ . i
efYect. ueensc no. J/ e�wss
NO. OlSCR�lTION OP WORN .Ec VALIDATION '
FINI�L I
LicenseNumber37� Lic.Class e L� NMeGTiNcro � oaTe 3 �
Contractor���...,.,,,,��,.�..�•ate �- � � �o�a�'o 0o FINAL � �
c sew�w c . a�.
� 1 am exempt fmm fhe licensing repuirements as f am a co�xcer wooirio..w�.�� o. �
licrosed architect or a registered profa.+ional enginrer
acting in my professional capacity (Section 7051, Hus-
iness and Prdeacions Code). e���
Lic.or Reg.No. Date
HOMI OR'NER•BUILDER DECLARATION �
I herehy n(£rm that I am exempt.(rom the ConUactor's OWNER�$ Permit f ,S�(f ,
License Law fur the following reason (Section 703�.5,Husi• AUTHORI2ATION TOTAL fEE aJ-�
ness ane vrofessions Code): 2 O 9 g,a A
� 1,as oumer ot the property,wiil dn tHe work and the e•.c.oeuc sew�., e.�ove oa•cwn� #'••• .,'0
structure Is not intended or offered for saie (Seclion S��neo rHlS nwv or re '
70aa,Ausiness and Prnfessions Code). � •�2 2 5 Q
CONSTRUCTfON LISNUINC AC[NCY �ews ece � _
1 hereby a(firm thal [here is a construction Iending agency •�� �2 2 5�� •
for the performance of[he work for µ�hich ihis permit is �+21 �i 81
issued(Sec.3097,Civ.C.). . .
Lender's Name
Lender's Address
[crrtify that 1 huve read�his ap0�������n ond state[ha[Ihe �
above informatioe is correct.1 agroe to comply with ull County ,
orJinsnces and S[ate laws regulating Niumbing and Sewers.
and hcreby authorize reprrsen tives of this County to enter
upon th���-me�ne�'perty forinspection�'����. �
�� SBG ftEVERSF FOR EXPLANpTORY LANGUAGE
���S�gnature of Permittee Date
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