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HomeMy WebLinkAbout1235A (6) WORKERS'COMPENSATION DECLARATION � - . ' I hareby affirm thaf I have a certifimte of tonaeni to self . � � ; � insure,or a cerfificoie of Workeri Compensotion Insurance,or 7ena�7o . � � - � Pol ty Nts�'�'K'��`j��r`emont� �nde�ity-. �,�'R`�.e,B'' �_ - ,� . ppPLICATION FOR PERMIT � ._, ❑Certified copy is hereby furniahed. - . � SEWER • SEWAGE DISPOSAL �- .. . -. . � � � �Certifad mp is f�led wiih Ihe co�my bw'Iding inspecti Rn COUNTY OF LOS ANGELES BUILDING AND SAfETY a°�9�'fiEr/'�6 RCR By:L.(7�l.�iJ�[ (l Da�e -Applicont �l , fOR APPUCANT TO FILL IN. � CONNECTION DATA - CERTIFICAiE OF E%EMP�ION FROM WORKERS' euno�w� � COMPENSATION INSURANCE a�u 4 . O POlTIt 3C2 $TATION ' DEPLH - (Thit sectioa naed nol be comple/ed if the work invoived by ihe ' MyN�ro�E k��x�r�CE uwEa � parmif is fo�one hondred doilars(5100)or Il3S.) , , ����ry R I certi(y thot in iF+e performance of��he�work fo�which thts � c�rso�qsT, . TYr�°F�°"`''ER'°"i ..�r'+�T'+F�^^ . . � � permit is issued,I ahoil nof empioy ony peraon in any manner . . �� �Cuae V.L M.L TO P.L. ' so os�o become subject�o the Worken'Compensofion Lows. GO.LC�211 S rin S � ' � �, � �����'1O� . OWNER ' P � CO.IMi.NO. JOB NO. O Dole Applicanl � - DDRE55 Ou O1SL1 Z y OTP. - TRUNK PERMIT Np. RpAO PERMIT NO. ' � .. . � �iICE TO APPLICANT: If, ofter moking �h15 CB/ilfi[d10 Of ��TY • T AKIDAVIT WAIVFR fASEMfNT NECORD.INSTN.lq. pA1E inption, yoJ�ahouid bacome subject to the Workars' � �`_ � C6mpensolion provisions of ihe lobo�code,you muft forlhwifh DEXRIRION ' LOT .I � ryWY,pR ST.WIDENING ��tomply with such provisions or this permif shali be deemed . rovoked. �- � . .. . aGocK TP STATE ENCROACMMFM � LICENSEDCONTRACTORSDECLARATION 425g � � ffRmrtr�o. � SIZE OF LOT � � I hereby affirm thot I am liteosad under proviaions of Chap�er � �a � � 9(commencing with Setlioe 7000)of Division 3 of�be Busi- euiioirics - wna�s �� ness and Profesaioee Code,and my liceroe`is in fvH force and . °"«+. '336428 C-36 �ONTRACTON CONNECfIONCMARGEfEE Y 6 �ICBn59NUp1���IC.�C�SYILISL�_ ' AOORESS � n 1,• . . • ' REIMgURSEMENTFE[ . O 1�v1\ �1V(Ci�— � �OlIffOC10� �O�! ��7y Riverside � ,E�.,.�/14-371-5000 DISTRI[TNO. GROUP MAv CRpCE55EDBY V ❑IamexamplunderSat, - oFtheL.A.Co. S�Ny� �L� C-3b � � � � O �. DESCRIMION OF WORK rEE PlumbingCodeand/orSec. ofthe � / _— DAE� /� /� V FqUSE SEWER CONNKTING TO �i VALIDA ION d � vueuc SEwta - y . � B.8 P.Code for Ihe following reasan - , � / f9� z . $E TIC IANK,SEEPAGE%T�4 DItS AND/OII qiA1NF1ELD By A� DOfe FIDUSE SEwER CONNFCTING i0 PiIVAiE DI Y 7 Signature � CpyHFCT App�t�ON,�A gLpG.Op . � . � � OWNER•BUILDER DECL4RATION wouK io�qus[sewen . reby offirm tha�I am axampt from ihe Con�ractor's License E�%TNF��ES$Pppl,pqYWEl�IpMANMOIE ' � ' •�^..� 'Z.A 5�, xT �•for the following reason(Secton 7031.5�BUiSnBbE OI1CJ Pf0- AUFR,REPAIROR ABANDON MIX15[ - � . .�70�5 COCIC�: � SfWER OR DISPOSAL SVSiEM . � . . ��'��e s w 1 O � ❑I,os owner of iha property,or my employaes with wages as . lheir sole compensotion,will do the work ond the strucWre � - � � e o'2�,�� is no1 Inrended w offered for sale(Section 7044,Businass � and Professions CodeJ. � � OWNER'S P9�mif � S Q 5Q , � - ,- +�L 2 7,Jr�� ❑I,as owner of�he property,am ezclusively contracting with AUTHORIZATION TOTAL FEE �'O ' � p licansed contractors ta consirucf ihe PfO�BG�($@CilOfl JOd4,- - �HAVE AT TH�S 0.4TE A CONiRACt WIiN iHE HEREIN NAMEO CONTFACTOR f0 ' � �O E�2 S'O'U 6 _ BUSinBSE anCl PIOf@SSlons COdeJ. �pNNER TNE ABOVE DESCRIlEO E%ISTiNG OWHIING TO THE PUBIIC SEWER. ' � CONSTRUCTION LENDING AGENCY - � - � � � � , - � . � � I hereby affirm Ihal thera is a construclion landing agency S�GNEDTHIS �AYOF 19_ . for the performance of the wo�k for which this permit is � °'^'NE°o° . , � , . OWNERS AGENT iss�ed(Sac.3097,Civ.C.). , . ' lender's Name � ADDRE55 . _ lender's Address � � � � �� - , . � -� -- I certify thol I have reod Ihis applimtion ond sfote thol Ihe � � � obova information is corretl.I agree fo comply with all County - - � � �- � �. ord�na�ces and S�ote lowa regula�ing Plumbing a�d Sewers, � and haroby authorize rapresentatives of this Counfy fo enter � , - .--- . � . � .. ypppihq,y�me�ti��ro ar�r inspptyqn,pu/ppfes. , , . . .. . ,. . . . 1«+« � p� O/1OJ00 w'i . �l �t, 1 . . . . . Signature of Permiltee Date � � SEE REYERSE FOR EX►LANA70RY UNGUAGE � . tNSPEROR'S NOTK QWN$R-$UII.DHR DECLARATION APPROVALS oar¢, iNsv�aoc s s�cranTux� . , . I hereby aHim�thxt[am esempt from the Cootractorb � Licence Law for the foilowing reuom fSsttion 7031.5, '. hEW IqUY SEWER . . � ' . . , s.�,:».� �r�.,� cad.k e.y� a�.:y , aora�ta�oanaui . tubick*�4rirss a.p�srwit m cn�trnct.alar,anprotw, ��i ' gmc r,vrc,sar ar�sl . . �..- . . .... . ' . �, :". .de�olisb,or ret�ar awy t4rcla»,Prin�fo Ja iarewc�. r ' uuoiatowxari�io ... . . . .. . . . . ..�. . .. .. . .� ...:._..�, -. . . - dso rvgr&rr tb�app/ia�t jor irtb prnnit to jilr a ecswooe O- werwen p . � _ , ..,. � ., s:gned stat�a�ert tLut be 6 Ikwsrd pwrww:to tbe -- . . . . .� prouiaio►s oj e&Cowdretor'i lionur Lom(CbqPte+'9 Ktue,qer�iR,sEw[a oe . _. . � (rnn.n.ewriwg viitb SreAios 7000J 9�Dhdriow 3 aj tbe � SEWM'aED�5PO5AL5Y5TEM ' ' � � ascowaaxucrrio�. . , - . � Brsiaus aMd P►nfiuiows CodeJ or tbat.ba.ii axrwspt �anwaa�ausE s�wFa-- - . -��....... . . .. . . .. --: ... --- - ,tbere/mnu mid Jbr baris jor rbi etlgsd az/sptia�.Any. e�cv.crtisrncrnrHcsp. . , -,. ,-:_,�"-, ��., �._ �.:� � � svolotiowofS�ctiow7031.SbY�Y�PP�'�tjoraprrnrlt � str,m s❑ auroas p - . . . . ._. __. _.. . - . _._. .. ... rwbjaea tbe appUcawt ro o ciuflpnuley of wor nurre ebow . five buwdrod do$ois(lS00%: , �-- . .. - . .. . ..- ._-, . � . . . _ . �:� � � ..�. . � "�I,�c the owner of the property vlll do the�vw�.end . , - . . ., . .. .. � . :;,r. .-. the stroctutt ic nM ia0eaded or ofkred ior ade: _. . _ .. -- . , ' "._ ' rs�..�o�a,a�..d r►�.�..c�:ra,..-ca.- �. � .. . . .- . . _. ..� _ ._ _.. . . na�tor's.r.k..x.Laru dw.wot.�pJ,ly M a.owwr oj ... .. .. . ._ ..._ -� -- --.. . . _ . ProOB�tY wbo brtldr w lrprows tbmo�.m�d wla Jow I . . _ . .. . __ .. .. . . ..:_� ... ... .. . , :reb work bi�u��prouid�o!tb�t.eicb 6aprowmewes are»oe iwterdd or ofJsrd for ra4.)f,bo�oewr. tlw - . ... . ._ .. ----- . .- ..' brildiMg or�iiwprou�eiere&.told witMx ow�Jvm'oJ ... ..._. . . _ . ..._'.''. .. _. . . - -:�- ' -- ' - cwnpktlor.,t!w otaru�brJldn v�l!baa� tbe bYrdoK . . _c .. � of Aroviwg 3bN bi did wot 5wld w&wpnow for tbs _ _ . __ .... 'prrposa oj�al�.l . � . , . . .. •�. .. � ...:�...�. ,�. , . , .. � . �I 8m ez2tllpt aOaPl SBC... _ B&P.C.far this reeson - -: . � _ . . , � ,�� , _. _. Date . , Ownet .� INSPECTOR'S NOTES. � . � ' -. � . . . �, � . . i. � ... ' . _ . . . , '' �I . .