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HomeMy WebLinkAbout1233A (6) IWORKERS'COMPENSATION DECLARATION � � q I hereby affirm thot I hove a certificme ot consen� to ulf � � , �` insuro,or a cartificaro of Workera'Compemo�ion Inaurance,or ?�`6d�o . !S °`°'"`'�`��'�°�`���a„�'re�ont �ncle�ity . �,�`�`�°•e" APPLICATION �OR PERMIT Policy N . .. . . - ❑ca,��r��a�oPY i�hereby furnished. SEWER • SEWAGE DISPOSAL �]ceriified m is filed wiih rhe coun�y b Id�ng inspection 53u/ COUNTY OF I.OS ANGELES BUILDING AND SAFETY de�P/��lEsy��6 RCR By: � � Dote Applican� ��L,U.�Yo FOR APPLICANT.TO FILL IN CONNECTION OATA CERTIFICATE OF EXEMPftON FROM YVpRKERS' � �,ioi� �' � COMPENSATION INSURANCE � �nortFss 1 si�rior� �� o[oTH � � � � � (This seciion need not be completed if the work Involved by the �p�,tiTY Diamond� Sar r.v„x+ae a[�rserxe - � . urvea permit is for one hundrod dallan(f100)or lea.� . � R ��� 1 cenify thoi in��the performance of tbe work for which fhis ��ou sr,� - TMPE��NK-"�- - ��tH faon+ permi�ib if3UQd,I fhpll nm empioy any penon in any monner Y� CURB P.L. M.t,i0 i.l. so os�o become sub'ea�o the Worke�i Com n�a�ion Lawa °��'�"O� �/�� . � P° owr�R [o.iMr.No. �oe no. . . � - . MI,IL ' TRUNKPfRMItNO. .. . -- ROADPERMITNp. . • Dafe Applimnf . ' �� aooRE% �fICE TO APPIICANT: If, o4�er making IhiB Certificale O{ ��jy ' COVl.n 818-y67-9541. AfFIDAVIT WAIVER EASFMENT ItFCORD.INSTG.Np. D�1TE ' .rnp�ion, you should become subjetl �ro tha Workers' i�Ai Compenso�ion p�ovisions of�ha La6or code,yau must forthwilh� pt5tmvriora t r+o. / ` HN'Y.ORST.W�DFNING comply wi�h such ploviaions or this�permi�aholl be deemed � revOked. ' � � � � - , . BtOCK T CT SiATE EfJCROACHMEM . � � UCENSED CONTRACTORS DECLARATION . ei PERMIT NO. 512E OF l0T ON LO7 I he.e6y affirm�hat I om licented under provisions of Chapter �� � � 9(commencing wl�h Sx�ion 700�)of Division 3 of Iha Busi• eunortves 1 payt�s � neu ond Profeuiom Code,ond my licenee ia in full force ood .. . effed. 336�k28 C—:iG �o'+TR^�'oR �OMNKiIONCHARGEfEE y � License N c CI � llID lri�� AC REiMa�ps�,ouNT r[E � p ����j ���-�- ADORE55 V Corllf0[IO� � l�te � ' OISTRICENO. CRW� MAo VROCESSEDBY ' t � [I7Y . t. Z ❑ . . . STATE UC. . � BK PG � O I om exempt undx Sec. � � bf the L.A.Co. uc[Nst na. ' • ' � cws _ � N�. DEKRIPTION OF WORK FEE � Plumbin Code ond/orSec. of the „ous�s�weR ca,�rnr,c ro /� o�".i` / VAUD TION d 9 WslltSEWER �J �� /�'/�'2'"/� y� - -B.&P.Code for the following reoaon gPT��T�NK$EEP�GE�t pP Z � PIiS AND/OR DRpINF1EL0 FINAL ��� IqUSE$EVrER CONNECi�NG 10 BY ' PRIYATE D15 Y M Signo�ure torvN[a�woinowu eioc.oa - OWNER-BUILDER DECLARATION W�K 70 HIXISE SEWER Rf�OW P� PII,OQAINFIElO �-�eroby offirm that I am exempf from ihe Contractor's License - ' [rzrN..ceSSR�a,arvw[u,mnNHo� - - . . :..�2�j a �for the follawing reoson(Secron 7031.5�BUiSl1055 Ot1fI Pl0- M7ER,RFGAIR OR HlANOON HOUSE � ...�SIOl15 COt'�l�: SEWER O4 DISPOSAl5Y5TEM � � " �a •�• .�I,os owner of the properfy,or my employess wifh waqes as � � � � 1 O iheir sole compenaotion,will do Ihe work and the strucWre � -- � � -��1a a G'],5 Q � is not inrended or offered for sale(Section 7044,Business � ond Professions Code�. OWNER'S Permit s /B 0 . Q t��,�(J� ❑�,as owner of rha property,am exdus�vely cororacting wi�h AUTHORIZATION TOTAL FEE �rJ jj L licensad coNracron to cons�ruct the projecf(Section 7444� �HqyE qT THIS DAiE A CIXJiRAR WITH TME HEREIN NAMED CON�RACipR i0 � �'fl��.�`��8 b Business ond Professions Code). coNn[cr iNc asove o¢scmeto cxisru.w ow�tuNo to iNt rueuc SewEa. CONSTRUCTION IENDMG AGENCY � " � � - � � � - � � � � � I hereby affirm tho� �bare is o constructian lending agency SIGNED THIS DAY OF l9_ � for ihe performaace of tha work for which this permit is - �'�"'1°°OR - � -�� � iuuad(Sec.3097,Civ.C.). . owH[a5 aGENT . . ADD4E55 . _. Lender's Noma � Lender's Addreas �� � � - � � � � � � � I certify thot I have read this oppliw�ion and s�ate thot the � - � above informollon is carett.I agree b mmply with oll County � , - � �� � - . � � - �-� � ordinancas ond Sfate lows roqolaling Plumbing and Sewers, � � � and bereby a�thorize repreeen�mives of fhis Counry to anter - -� � - � � . � � ypaq�thppy:p menlioned p�p peHy for irtapqc�o�pu/ppyes _ . . . . . , . . . . ICl•R D 1'����(\ � o io ao . �1 1 � l �A�I�L S�gna�ure of Permiflee Date SiF REVERSF fON EIfPIANATORY IANGUAGE ` ��aoxs NOTes OWNER-BUII.DBR D�CLARATION APPROVALS oah INSVECfOR'SSIGNATllFE IFl2fffbL}'8Hit01L}IAIIAL1CYtO�P�ftOOtSI1lCORCf�CY0�6 �,�,���R ., Liceoce Lasv for the fiolk�ving reuoai(S�cfioa 7831.5. � . . . � 'H.uiwass owd PM/�at Cm4k Asy cJfy�or cousty - w����-. . . - . . .. . . � . . . . .. .. . . �u�bicb'rsq'riw a pe�rnrt to co�spst+R Jt�s,i+rtprow. , : 'denwlirb.or»palr ary strwean,Mior to Jts�wawcr. M�ioi�DrtT���'ioTlsl . � .- .� . . . ... . . .... . ... . ...--. .. . . .. .alro reqrbu t!w apdNqqrt jw sreb pnn�it!o file a ; . �swoa p .aerwEu p ._ ..... ._.. ._ . ..� � . . . : �. ., . . sfgiwd staarr�rr ebar b.b lfe...rd prr,rmse lo zbe . � ' - � .. prouiirorr of tb Cowacle►'i Llcau�Lau/Cbaptsr 9 �, utEn.xrs��p,se�oR . � :' (com�x.we:�a witb S�ctios 7000/9�7)iuurow 3 oJ tbe ' SEWAGEDISFOSALSYSTEM.. . .... . ._ ._ .. _. � � Bw:.su.aad Ayferslo.x Cod.l or.lbst b.ts awn.pt ' . �i+ane se�wert�..- .. . . ._ .. � ... . . . ..-, � . .tbanfroin awd ta.am:r jo.eb.awd.d ara�,paox.Aey � e�aru SM�c t�wcs❑ � , .. :� � . , vio7otiow of Ssction 7031.5 6!'�y�PO�'�t jnr a penwit stv.m s o assrcas o -. _. .- �. - ._ . _. __ .. ., .. .�. ::., .�.. �:. �. swbjecu:b¢appJi�art to o ctotJp�aJty oJro:iwors tbm. __. . . _ _ _ __ . ... . Jius bwMdrad doJlar(i300�: r �i.u t6e owmer of t6e ptapert��viU do the we^'�.snd , , .. � . _..'�� --.-._ •.. - . . . . -.- -, . the sfcacture u aot ioteaded or oHered for ule: ,. _ _ ._ _ ,fSQc. 7044,Bwissu m�d liv/iaamu Codr. T7x Car .- . . .. . .� .. 1, 1. . . . . . hactor'f LfceMn Lwn don wot yrply to ar wor�r oJ . .. . .� . . . _ . � . . . /maperty wbo batldr or Jinprrwef Hunow.ord wbo dosr _ . .. . aueb wori bieu��f p�oddrd tSst au6 Jspronan�tr - �-- � art wot iwtMd�oI O��IMd for tO�e..{�;Ilo/WwI.tbe � . .. ....... .. . . . _. .�. -, . . . btlt�iqi(OI' �Mip/OW/11/It��i 70�tYjlblM OAt'yt01'Of . .... __ . .. .. _'. . . . __ . . . ... -�-- - . . . CO/M�17fiOf{� �f OYM�tI��M�ttlfu�W.�I b117f�fA , . .. . . ... .. .. . _ .. � ' - ,�;'O��MVI1�g d�Gl jlt 1�MOf�DI'�IMp/01N fOI'1�I �. . .. ,_ _ „_����� : . . ; __ _ . . I em eicempt nnder 5ec. � �_._ . . . - B&P.C.for this rea�on , _ , \ _ _ _ , � � . c., ,r.. _., � , _ .. Date _. _ - Owner , � INS►EQOR'S NOTES ... � . . . . _ . . — . . . � � �. . ' �� � ._' . . . . . .. _ ... . . ... . ._ .. . _ , � i, . 'v.' l�'r „