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HomeMy WebLinkAbout1345A � I � WORKERS'COMPENSATION�ECLARATION � - - -. - . � �°#' }� ' I-hereby affirm that I have o ceriificqte nf . �-�Pnt�to self F - � � insure,or o cerlifiwfe of Workgers'Compensotion Insorance,or ��anen20 �. polcy�fNo.co y�-�K�e ��pah��L���i--Lt5--__ '3�Seoaixed.eiatl .. P1PP�L�1/L��►TcIO*A[Id/��-.� FC)tt nE'EcRMIT - u Cerfified copy is hereby f�mrshecl. . � � �SEYrGR � �i�ii7�v� W��f�`lA� � ���; �Certitied copy�s filed wirh the county building inspection i COUNTY OF LOS ANGELES BUILDIkG ANlD SAFETY �, depar ment � � - ._ : oate��Appliconf_�L67 �s���7� y FOR APPLICAPIT TO flLt IN CONNEtT10N DATA > CER FiCATE OF FXEMPTIpN FROM WORKERS' suamNr, �'� - COMPENSATION INSURANCE �� nooaEss �j srarion; `�'f�- ,,;�?� oePTH . �-?�. This section need-noi be com leted if ihe work involved b ihe �J ��` ( p Y � tOCALIiY /J�ANF10tE REfERENCE aO�. , �y'�p . .. permit is for one hundred dollars($100)or less.) �#' NEAREST TYPE OF CONNfCTION IFNGTH FROM �� I certify that in the performance of ihe work for which fhis Ce05557. __ r. � cues et. n4.�.iOP.t. ��J,d' �' ,� - permit is issued,I shall not employ any person in any manner �' . - � = "�` N.c No, so as to become subject to the Workers'Compensation Lows. � ONNER - m.innv.No. ioe Na �'�.�'� ° �'�, � . 4 �IL TFUNKff.RMIiNO. ROAOPERN�ITNO. _ � Date Applimnt 1 nookEsS . � ' "' AFfIDAVii WAIV:& EASEMENT RECORC.INSiR.NO. DATE ���y�, NOTIC't TO APPLICANT: If, afier making this Certificate of , ,- ��TY �. TEi rdp. „. �,` _ ' � Exemption, you should 6emme subject ro 1he Workers' . �wA� _, � ,.r` Compensafion provisions of ihe Lohor mde,you must forinwiih .- `c aESCeivrioN �oi No. � r t7�' Hwv.oe;T.wioENMG - =�^ tomply wi4h such provisions or this permit sholl be deemed '�"' Y2VOIC2d. '� BIOCK 1RACi ' � ' STATEENCRQACHMENT- � � MG.Of 6LGG5. PERf.nl?NO. 9 LICENSEDCONTRACTORSD€CiARATION ' szeo�ior - n�owoNioT � � • 1-hereb a`f�rm ihaf I am 4icensed undar roaisions of Cha ter —�� � Y A P ����F oF .�.. .�:,�L%�� .,!'O 5�'� 9 tcomrnenang witn Sedian 7(�O)of Urvisiun 3 of ihe 8usi- emio�Ncs_ �- �c�`�pyyz "� ana�es . ness and Professlons Code,ond my license is in full force and - - —'— — — @fFBCt. ^y+ y,,�,� ��CON4RACTOR ' � - �. � CONNECTION CHFRGE FEE LiCenSeNum1ber �fl..3 C 5' LiC.CIasS � - � ADDRE55 ? r r ;��' �` ftEIMBURSEMENTPEE COYIhOC10� //l�g���y C`3/�ifDpYG'_______� .��CITY h .._�FL.NO. �I4['� "i� ��ISiRiCI NO. CROl1P MAP CROCC$$[0 8Y �� �a l �p` — s� BKp PG ���"�^""^"` ❑I am exempt uncier Sec of the LA.Co. _ . � tiCENsc No J q J�C�, c ass �y- ¢(j �� „�!j ,,,g� NO. OFSCRIPTION OF WORK FEE -�� — Plumbing Code and%or Sec ___of the .— .�iNn�_ PBLSC SEWER CONNECi1NG TO �El DAIE VALIDATION ,{,� .B.&P.Code for the following reason . - sePi�c raNK,SeeanG=v:i oe j �� � i�.rs nr��roe QeniuFie.o_ � FiNn� / �_ Ddt2 � HOUSESCWFHCONNF{_iNGTO BY � .P2NAtE�ISPOSAt SVSTEM � � �S191YOtUrB_ _ � (S>NNECT ADOlilO'VAL BLDG.OR ► � OWN[R-BUILDtR DECLARAYION � � `NoaK Tu Ho�SE sEwEp _yi�.- � OVERiLOV�``EEFA6E P'T,DRAINFIElO. I hereoy affirm that I am exempt from ihe Coniractor's License ex?v..ces_Pooi,oenveu_n4nnHu�e � � L�w for fhe foflowing reason(Secton 7037.5,BWsness ond Pro- a�reu;uevnie oa naqNooN iiousE fessions Code): - . se�,veK oe o.scc'sa:_svsr�M �� � ❑I,as owner of ihe oroperty,or my employees with wages as � _- . . �1 v�5� fheir sole compensation,will do fhe worx and tfie struclure � . . . is not iniended or offered for snle�Secfion 7044,8usiness . � - � � � and Professions Code). OWNER'S P2rmit 5 ,3 r_'� � - �`+ � • • 1 � ❑I,as owner of ihe properfy,am exdusively coniraciing with � AUYNORIZATION TQTAL FEE �� � w t 2��S�.. - licensed contrcacbrs to wnsiruct the project(Secfion 7044, . �� i HAVE aT rHis onre n coureaci wirH-He Neae�N r�anneo coNrRacroa ro -BU5ine5S ont�PlofeS5ian5 Code�. � CONNECT iHE AenVE DESCRIBED E%ISi1NG OWE�LING TO iHE PUBLIC SEWER a o n(,'G/��� . CONSiRUCTION LENDING AGENCY - �- -� , G J V SIGNE�THIS DAYOP 19, ,� _ rl - . � I hereby affirm thm ihere is a construction lending agency � ��L�� "��1 - � � for the performance of ihe work for wh�ch thls permit is - °�^'""-�oR � _ - owN�es nceKi � issued(Sec 3047,Civ.C1.). J � , . . Lender's Name�q�[��q.L-?1"fi�L-I . -�J�ij'}_�/�,_,)__ - aooeess ____ . ' - Lender's Address_�.t�j�_S_ ZA �j}('r1.��L�.81�4 �?„;,��, �j��-� � � I certify ihat I have read this application a d stat thai the� � � .,j above informaYc is correct.I uyree fo wmply with ali Counfy � - - _ � ordinoncas and t te laws regulafing Plumbing and Sewers, - � �� - ❑nd he aut r�ze representaiives of this Counfy to enter � � upon e d property for i soecfion purposes. � - �-:„1 / Signatu�nf Per_�„� _-� Dcfe o«.cv'ea>'e F�+R eXrLANATORY�wN4UnG� . . . . . 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