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HomeMy WebLinkAbout0875A --�WORKERS'COMPENSATION DECLARAT70N � 1 herebv�affirm ihoi I hove o certifimta of r wnt tn sclf aa-0002 o?w ain� � • insore,or a certificate of Workers'Campensation Insurance,or ieFeneu . � . a certified capy thereof(Sec.3800,Lob C.) . �E B� -��F►P�L1��ITION�� F�►R PERAAIT � � Policy Na. Company � �a � '� _—_.__.._ 1� e ❑Certified copy is herewy fumished. � ���E� n ������ 4'-°��r���� �Ceriified copy is fi�ed with the county building inspection:. COURiTY OF LOS ANGELES BUfLDING AND SAFETY �9�3 ���' Date � �''e qpplicant Y�t1 �:C37,��� &' S0z3p TnC o FOR APPLi�ANT TO F(LL IN �.''� CANNECTION DATA �:� 4� CERTIFICATE OF EXEMPTION PROM WORKeRS eua�inc - � � � � COMPENSATiON iNSURANCE - � nooecss ��j�slk� +, �$.'LF�1,°�A �Gt7'C:.'�"��+` �e snr�oN ;.,J t"��_1 oErrH tr'�� (This secfion need not be completed if ihe work mvolved 6y�he m a M.nNnO�e REFE<eNc ���� r i-" �'�_ permit is�for one liondred dolfars.($700)or less.) «�A��T� �:s.c'''.dil0ll�. }�:3Z' � rSr'� � ,,,..�- tOwea � �� NFAREST ?YPE OF GONNECTION �^t �EN6iH FROM y^ � I certify�ihat in ihe performpnce:of the,work for wfi ch this+ caoss sr. � y, cuqA P.i.,,i m.�.ic c.�.. '� .� � permif is issued,1 shaA not employ any.person�m any.manner-. � . so os to become subied io the Workers'�Compensation Laws °-�-N�- %-j-� . .. .. _.. . . owNeR i+]SBLr�Q3'2 co.inav.uo. �on rvo.F!_F t'-`��> � rowa DatB Applicant ADD2E55 TRUNKPCRMIiNO. ROADFFRMILNn. AEfIpAVIT YVAIVER EA�EM1IENI RECORD.:NSTR.40. DATE NOTICE TO�r:APPLiCANT:-:If, after�.making this'�Certifim4e of". �irY F,_N� .Exemption, you should�become subiect to the-Workers'�' ,��.� Compenoatior provisions�oz:the L�zoor mde,-you must7orthwitn-: � UescRi t�ioN toTNo. � ��Hwv oasr.wineN��NG wmpiy with.such provisions or ihis permit shalF be,daemed` ------- '--- - revOkEO�. � - . -BLDCK TR�Ci (k��'� �5'A7E ENCROACHMENT NO.OF 9L�JG5. aRMli NO IICENSED CONTRACTORS D�CLARATION sizeoF�01 Naw oN�oT ' ) � 7 here6y affirm thnt l.am.iicensed under provisions of Chapter� '..��seoF - ��U' d f�i--".- .G^'7.+ /� �"� �9-(mmmencing-wiih Seciion.7U00)of�Division 3 of ihe.Bus�-; '. svitoiNGs p<; � a-��.eGes ness and Professions�Code,and my license is in full force ond'.'i ------- .— ---___.__ effect. �y���g t.coNremaok ��2Xb �'��'.'�'.� k� �0�?. �32Cm coNrvecr�or.rHAkce Fee �icenseNumber��__ticCl�ss � �� n �� :e.EiMeuesemeNr�e � ��aooae:s ��� 4 HE,�1lrier �ts'P� � A y, P! ,dl a ,erf �?�� ����y ��h`1��� CIIY i�3�CQ TEL.NO. �/-� <�.G D:STRICTNO_ CiI20U? MAV YnOCE5SLU3Y 4 Caniractor Date. "�:., .,��„ BK r1 �x�N � s u I am exempt vnder Sec____ of ihe L.A.Ca��� S;cE�vse Na anss � 1,.-- ��-�� � ���� � xj � NO. DESCRIPtiON OF WORK Fee H Plumbing Code and/or Sec __of the� — -- — ---�"NA1 � y/�`ODATION � � MOUSE SEWER COYNEC�iNG TO � ppiE &.&P.Code for ihe following reason Pusuc scwea ���r�' —.�.._ � _ $: EPT AYK SEEPAGE IT Ok j: � IT�AND�CF�RR N.f D P�FINAI 2�.. � - G�� HO'i�5 SF NFk�ONNe��ING TO � x gY ��`�� � `� cFIVPTf D'•S�OSHt SVSTEM ��� . . �?� $ignq�Ur@ COh K 1 AD�TIOIvAL BLDG.Oa �-� OWNER-BUILDER DECLARfl710N ' -%� u�.� se sev:�a c�v�e �,�,�sPncF a�r azamaFiein �; I hereby affirm that I am exempt trom the Contractor's License-� �exrN r aoo,ozvvteu.v✓,NHo;¢ Law'or 1he follo�viog reason(Sec'�n?031.5,Bui;ress and Pro-�� � n�re eeFa.ie oa aanhoun HGuse ��� fessions Code): SEWER OR Di5PO5AL 5v5iRA � ❑1,as owner o4 ihe property,or my emplcyees with�vages as' � *" �iheir sole mmpensa�on,w'I�do the work and the strucWre� _�L., � is not intended or offered fo�sale(SecM1on 7044,8usiness. ,� - -�'`�u� �� and Professions Codey + (��NNER'S Permil S s�., r :�. ❑I,as owner of the proFerty,am exdusively contracting w�+h:�i �� Al1TH�RIZATION TOTAL FEE �g 0 � � f �3 �'13'� licansed contraciors to mnstruct the projetl(Sedion 7044,- i Have a.r Tkis eare a rcNTencT;vliN rNE HER�IN NnMEo mrvrRncTOR To j a o G � �`'� _qa�.' Business and Professions Code). - c�r.r�Fcr rHF t,3ovF nFscaieF� xis_iN�otvEt�:iNc;ro rt{E a�auc SEwER. 'i' ,...��. � CONSTRUCTION LENDING AGENCY ' a � �'f��,—T .�� I hereby affirm that there isA construttion Iending ogency�� � SiGNEDI'HIS DlaYOF 74^ : . for the performance of the work for whith 4his permit s" < <�wNtu ce � � �7 �- iss�ed(Sac.3097,Civ.C.). " owrieesncereT � Q�L+�"�'� � R,_ noou�ss .}�, Lender's Name - Lender's Address I ceriify ihaf I have read ihis applicaiion and state ihat the� � ;s,: .above information is correc9.I qgree Io compiy witn all County>; � � s; ordinances and State laws regulating Plumbing and Sewers,;{, �;�.� ��and hereby a�thorize representotives of this County to entei�- - , � -upon the above m ntioned properiy for inspedion purposes. _ � �= �' �� ��3e7L$�1 LL '. � S��afure o;P`rmit!ee n fe �/ /" ; "'"v`J�p�c,�cno cvo�e.�e.poy�,�NGURGE 'a: z �,e r� ZR CS x � . �^'-y m '.�i,.�. �- an Qm = ��,io �=° � a^ czi^, D '� ro�, OZ a'�- (�� �R �o tn `� . . .. � ' ✓9O� bp `^'! mm�<� � � . . Ov O• Op �.p � .. . 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