HomeMy WebLinkAbout0873A (4) WORKERS'COMPENSATION DECLARATION. � - ` - � � 1 hr.rehv nffirm thot I have o �ertifirnte of � rnt tn �Pif.� 92-coo2 nPw aie�� , � insure,ar a certificote of Workers'Compensation Insurance,or.� . i6'404�° � • a certified copy�hereof(Sec.380G,Lab C.) �t�e - �ppLO��TiON fC3R PERAl11T � Qol�ry No. Company (@; - : ❑Certified copy;s nereaY,r,,.,,;st,ea. SEWER • SEW�GE DiSF'f?S�►L_ �Ce�tff�ed copy is filed with the counry bulld�ng inspection COUNTY OF LOS ANGELES . BUILDING AND SAFETY _ __ department � � � . Date ai . f3 Applicom `�I�iY1 D12S�', � s'a�S2� l32C�- F(>�{APPLICA@J7 TO FiLt 1N !`).f—�f ,� GONNECTIQN DATA CERTIFICATE OF EXEMPTION FROM WORKERS' - euimiN� � � � - COMPENSATION INSURANCE nocuess :s > ��+ �'r" (iA11�1'�;L;� �1,'.. SrAri°r� /.f-J� �E°'"� .�'��_ �« .�.,`;�Y � . (This settion need not 6e compieted if the work involved by the - �n�,Y ���ma�q� �ja,�+ � ,vaNHot[2cFEkENCE f�,^i'� j ~ - �� permit is for one hondred dollars($100)or less.) - �--------- -- - �� `��WE� � CCfilf that in ihC 2ffOfmanCC of rhe WO�k tOf W{tiCh ihis�. NEAREST 7YPECFtONNECTION f - �ENGTHFROM - . Y P CRCSS ST. Y. CURB (P.L:-� M.L.TO P.L .Fe {`j :. permit is iswed,I shall not employ any person in any monner - --�---- -----�---------------�� su as to become su6'ect�0 1he Workers'Com ensation Laws. 1'J�1'i1.a CSYS � '�� � y��,e'�",Y� - i n � owuea ��� m.iMv.r�o. ��oa Ho �"� ' � M'��� iRIINK PENMII NO. ROAp PERMIT NO. Date Applimnf A���r� AFFIDAVIT WAIVER EASEMENT RECOR�.INSiR.NO. DATE NOTICE TO APPLICANT: If, otter making this Certificate of �iTv re�.No. Exemption, you shoald become subiect to the Workers' � �EGAi 94 - Compensation provisions af the Lo6or code,yoa m�st fcrrihwi'h � ocsceiFnon; �Or no. P 1 1 U __ '�`,H`NY.GR Si.WIDENiNG � ��' comply wiih such orovisions or ihis permit shall�be deemed �� -- �+, t� _ __- I � .. .�CVOkCCi. . . ... " .. ..._. ... . .... . . . .. ... BLOCK iRACi ' y�r��� � �STATC CNCROACHM[Ni . . : . !lCENSED CON'RACTORS DECLARA?ION - -`� r�o.oF s�ocs. aeuNr No. . SIZE OF LOT IJOW ON tOT +r^ Jt_'( . I here6y afficm that I am licensed undPr prowvons of Chopter - �:u�E oF --- � ;�.�.l�7""0/�{-%� •.��--- i%J'!� . 4(commencing with Seciion 7Q60)of Division 3 of the Bosi- . nu�.mwvs �, �.� � cr+aKc;es ness and Professions Code,and my license is in foil#orce and � —�-_— . efietf. . . . � . ,comrancroa :�'+r.�aieN�Hnece=ee t n � . !icense NUmber 1�����Lic.Class 4� �� . �qooaEss A A �Ia 'v� "ni1 R=.i,uaukSE�eENr FEE � ._ �Tan ui.�st 9��4/ r — �� ..-�"�e_ �ve — - COn1fOGi0( Dflte � � � � -Y �T(y JF � �j�m�A d�� DISTRICT Nn. GftOUP MA� PRO;ESSEO HY [j .. ..�� ` EK vG � : � A STA.E �,IC. /-' f,l'� p ' ❑I am exempt under Sec. 'of the LA.Co. ii eNse n0. 7 '1 A C�n55 � �.:'� -� a 'y ND p��RIPT�ON OF WORY. =EF � ��j V � PiumbingCodeandlorSec � - ofihe - �_ — F'�Nn� ,>usr v a coNNe-rir�e ro '� ..�j4' onre '7 VAilDATION � 0.8 P.�ode for tha fotlowinq reason_� � Furuc Fw k �e'j��.4--�r' - � � � � SEPT;C TAN%SEEPAGE�IT QR � P�ISAND.'JR DFA!NFIFLD FiNAI - r'�t` � -^JS S�JyER CGNNECT�,NG TG BY ��/� ' %R:V�;=CISFOSA:SYSTEM $iJnptU�e ' C,ONNECi--0IiIONAL BLDG.OR. I - OWNER-BUIIDERDECLARATION � v+�-,zKro,e�u5e5eaEe � I hereby affirm ihat I am exempt from ihe Coniractor's License � Exini���es5aoo�GokvwEunMaw o�_e � � - - Law for ihe fol!owing rea�on(Sedon�037 S,BWmes;ond Pro- � uT�k,sePaie oa a9ancord�touse . tessions Code): sEw_R oe oisnosa�svsrenn _ _ � ❑I,os owner of ihe pmperiy,or my em�loyees wiih wages ns --� 'J��s�t ��- �3 � their sole compensation,wiil do the work and fhe siructure - � �. ,�;; � is not intended or offered for sale(Sedion 7044,Business - y , �t.c s u e � and Professions Code), �� �.?WjH�R'$ Pefmit Si ��^ � t' � ��; ❑I,as owner of the properry,am exclusively contracting with . " AUTHORIZATI�N Tp7/!C PEE �e V - ' � c� t,.''i i: �'� . licensed mNroctors to ronstruct the project(Secfion 704d, �HAVE Ai iM�S oAiE A CON'RAC W�?M :HEREW NAMeD cC'�TFacroR�o � � BUSIl1C55 Q(1(�PfOfB5310f14 COCl2. CONNCGt iHE k60V[DESCR BEO EXISiING DVv1tING TO THE PUBLIC SEWER. � 0 � n��ry" �; . ] L� f...i iJ U; _ � CONSTRUCTION LENDING AGENCY � � "�� I hereby affirm that there is a consiru:tion iending agency �SIGNEC THIS OAY Of i9_ '� �-;, --�-r � _� OWNER OR for the performance of ihe work for which this permit is .�>,NyEatiacervr � i` -' iss�ed(Sec.3097,Civ.C.). . - . - . ADOftE55 � . Lender's Name_______ _____ . Lender's Address - - - , I ceriify ihat I have read ihis aoplimtion and state that the . � . - . . . a6ove information is correct.I ag�ee to comply with all Couniy . � -� � . ordinances and State Iaws regulnPing Plum6ing and Sewers, _ , and hereby authorize representatives of this Cnunty to enter upon e above- ntioned property for inspection purposea � � � � .3� : ,} . S. !I^_lU��_ ?frtli�inc f,�..e�— ;EF REVfQ[F i[1R�XPI ANATf_}RV�ANP.�Iq3F ' __.._- z � v�� c$ � . �` K;y�Dm� ��. n d� az x 'tg� n .. ... ' �T�z� ��.. rv„ '�`� 'n� � � .,o_ 02 mrx.1. . 4Z p� ^ '� � . . 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