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HomeMy WebLinkAbout0874A WORKERS'COMPENSA?ION DECLARATION . Sl I hereby affirm tha� I have a certificate of consent to self - 9inaoo2uovw�ie� . � insure,or o ce�titiwte at Wo�kers'Compensation Insurance,or � " /� � a cenified mpy�hereof(Sec.3800,Lab C.) ' `E�e .�'1PPLICATIOt�I f�Ft PE1tl1IIIT PolicyNo. Company___ ._ _. �. �� ��y�Eti - S���a�►E �lSPOSAL. - ��Certified copy is hereby fumished. � � � . � �Ce�ti4ied copy is f'�led wirh the cou�ty buHdin9 inspection . COUNTY O$L85 ANGELfS BUILDING AND SAFETY dep�rjment' ,� ._. - - ... C} 8 Van .Uzeat & Son 3.no. -- Date f�', I ApplicaN __... ' Ft�R APPIICANT TO fILL IN � ���- ��f���'� C�NNECTION DATA _ r�„�,� _ __ r � CERTIrICATE OP EXEMPf1UN FROM WORKERS' � � ��r,o�nt�- ��.✓°'{�? �tP��';,_- - COMPEVSATION INSURANCE . a.noaEss c�.���fl is .T'i'L�YS_{i(?tZY!"�iS'}� S�T. srFnon ,Y., This section need not be com leted if the work involved�6 the . �i r�nyHo F 4EFERE'.,�E -a r.�,� ' uPv[ ( P . Y iocniiTv �.�:t`odSYGXif� �6.1" r�"l 1,V i wep ermit is for one hundred dollors $100 or less. -�-�����-- �-�--� 4' p � � � NiA2i5i TYPE CF GOM1NEC'ION �,�^'"� �ENGTH FROM.� - I certify that in the per{ormance of the work for which this [kossst. r. cuae Yv.i.J r�n�iov.i. ? `� permil is issued,I shall not employ any person in ony manner —' 9-- � P�q N �,;���'� C so as Po bemme sunjeci to ihe YJorkers'Compensaiion lows. �WNF� 1S�{�'£a12 co irna.NO. � - M411 „ ��iRUNK PCRMIi NO. ROAD PERMJi NO. Date_____ App�iCant no�RE55 A.ZIbAVIT WANiR EAiEMENI NE;'.<)kP NSiR Np_ �A�f NOTICE TO APPLICAN7: If, after making this Certificate oi ,. ��rY tei.rvo. Ezemptian, you shauld 6emme sublect to fhe VJorkers' iEGA� Compensat�on prov!sions of ihe Lobo�<ode,ycu:musl forfhw�iih oESCRiPrioN �C�No.j��"j _`__ HVrv.oR 5T.WioeN��rv� mmply with such provisions or ihis permii shall be deemed -��-- �- � u ^ .y/+� � feVOI(2(J. BtCCK _.__..TRA_T a{�{SiG. _______, �1A111! ROACHl.1ENT -�-- PERMII NO fJCENSE�CO�JTRACTORS D�C�AR.4T!ON na.oF e�.oes. --,t--- � sceoF�o, howoNior i _ l� ",� 1 hereby eff4rm thal i am licensed�nder provisions of Chapter �,;�., - � �" , - - 4(mmmencing wirh Section 70D0}of Div sion 3 of the 8usi- aU��DiNGs �!?� ____ __ nq�G S ness and?rofessions Code,ond rmy licer.sa is in fvll forcc ond — ."' _. _... �V�E�IM6JRi� . effecr, -- con�runcro� � 4�c`i3'3 L�.r.�b'� �Z `-Cfli .�I1Ca ccN iEcrioN chnac.e Fee , __ > �icen>eNumLer ��f���'� L�c.Class �' ��� �aeoRess �1`L�l/. ,�,sbII1a12:C` �iYP. �F E= , n�cN�FFE a Contru<tor u8.T2 .1�.r3c^,'�'i Date �f�d�J�'7 �� �RO��' a�av aaOCE55/Eottr Lt � r-� f t., �•h; �rG,�i rEi wo. "7 Z P.�71,A 7 � aK ac �R� Z ATF _ �il... - "`- ❑I om exempt onder Sec. of the l.A.Co. �c e;dse nto _ ���� c',nss , "� �7 �".� +� ^f�;g�%, � o Np. DES�RIPTICNOf N�ORK fFF � -' ' U Plumbing Code ond/or Sec. ___. of the --- — F�y^�• � � �no srwFe mniNecn�v�To ,� care ���� ��� N/�IIDATION B.&P.Code for rhe foilow�ng reason __ �':�B srw[R � N �SEPT C iANK SEF➢AGf P�T Oft � p�Nqi � � Pli 4n_ C�kL.i��LlC �_ , 81 � � . ____,____Dpi2 ____ �,)SE 5 YJER C��N C��G T(J i ' ' � �RI i �t POSAL SYSTFM � - - - ' $ignafUiC+__ C�V ECi ].T':NAtbLL.G.OR �,-� ► . � ONlNER BUIiUER DECIARaiION ��� � ���u t ev� JYCaFION E.Af 7�P,A!�ti�FIE'_D I he�eby affirm ihat I am ex=mpt from the Contractor's License .xTNWCe55?ooi,oerwru,nnnNHotE I � Law for the following reoson(Sedor,7p31.5,B�isness and Pra- k'.ie�.Reca,R oa�t�aatdoorv Hou5e � fessions Code)� _,_ sew-e o�;uisrosa�svsreM ❑I,as owner of the property,or ray empioyees wi�n wayes a6 __� � their sole mmpensation,�.vill do ihe work ond ine sirucfure i.t��.7.�. y is not intended or offered for sale(Section 7044,B��siness jpa (� �' �� and Professions Codr.l. QW[dER`$ Perrttii 5 �3 B -: AU7HORIZATION TOTAL FEE - '� ` � � "� ❑I,ns owner of ihe property,am exdusively coniracting'.vith ,,,_ ' '' .. licensed mntraclors ro mnstrud ihe project(Seciion 70A4, . - ��a,��qT+r+s cxie a ccNraa.,vnrr+ tieaEiN hn^neu�onre.ccroa�o � Business and Professions Code). cenuvcc.i,c art�ve oes��e_o ExisnNs o�eu Nc.-o�he�uoi�c sev✓ea- � ` �� �'`"e' � - CONSTRUCT�ON IENDWG AGENGY - , � � ���i.;7 li�.i I hereby affirm ihat thcre is a consiruction lending a9ency SIGNED�HIS �AYOF 19_ . for the performance ot the vvork for which ihis ermit is owNea oe /1 J� / P 1WNFRS P(;FM � V V��� ! issued(Sec 3097,Civ.C}. � � . �ODkE55,.__...._ .� . .. ..�.. Lender's Name --. � Lender's Address_ � � I certi`y thot � have read Shis application and stare tbat the . . . . above informoMon is corr=c!.1 agree fo mmp!y v�ith a;l County - � . ordinances and Siafe laws regulating Plum6ing and Sewers, � and here6y authorize representoiives of ihis County te enter -� - upo(n'�fhe abov�e(pyj�,�entioned proper�y fior inspe/cfion purposes. . � ' � � ]s..1..� l 1[�WW�/ i f ��/lJ� _ . - . .. $ignature Permittee D_te � cEE P.EVcogc epo cKo.�.��Tpoy�p!:GL'AG. .. . � . ., .. ' . _._.,-,. '_._ . :....... � .,'. .. .: f('g DQ "'y �`�++ D�fn' CQ m . ... ' � , . .._ �A D f 7 �m Z o �T ZpO DA. Y'n. On ^pz S ,'�-,tjZ '':n � � '�'� O v T;zm v� . �02 dp w � � Ct�loa �- �1 n� �g � � � m D m� y� rr� Aa � � � �""y �z �y�„A :;. °� "� � h . �^ R O �' ^u, 6.J � �A � N r L� � � � � � . . ' .. . ., D I � � ,..... . ._.,. ....... . _.. , , , y I l � � � � {g� � u� ro j _ . . .. .... , � � � .. I A � „II . . . .. . 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