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HomeMy WebLinkAbout1778A �. -�.-WORKER$'-COMPENSATION-DECLARATION� � � f here6v-�ffirm ihat I h a ce�f c_te ef coasant ta s�!f -jl ' msure,or a certifimie of Workers'Compensatio�Insurance,or �an�e�o �' � Po��o�P_�p��mpo�"` `'�.,J�-, C'-�,-- �E�09 n"�,,��� �►PPL�I/CCpATI�N/�F�R PERMIT In-1.Certified copy is hereby furnished S�iiGo'a =� SEWAi9E D���OS�C . ❑=Certified copy ls tiled wi�h ihe county building inspection COUNTY OF LOS ANGEI.ES BUILDING AND SAfETY ��department - Date � � Applicant ��}s�� FOR APPIICANT TO FILL IN CONNEGTION DATA CERT FICATE OF EXEMPTION FROM WORKERS' eunoiNc ;1 I . COMPENSATION INSURANCE nooeess j��,�.eqjy STAT�ON OEPTN (This section need not 6e completed if the work involved 6y rhe nv.NHotE aEFERENce uP°ER , permit is for one hundred dollars($100)or less.) � iocnuTv iowea I cerrify �hat �n the performance of the work for.which this Nr°'REs' rvPeoFmNNeaioN ��rHFaaM . CAOSSST. f Y. NRB P.L M.L.TOP.L , p�rmii is is5ued,I shall not employ ony person in any manner v.C.No. so os�0 6ecome subject�o rhe Wofke�s'Compensotion laws. �wNE_ `��_�� co iMv.No. ioa No. � �'�� TRUNK PERMIT NO. ROAD PERMIT NO. - A�DRE55 pqie Applicpnt �� � N�710E TO APPtICANT: If, after mtl��nc� �h15 Ce�ijflCtlfe Of ��T� TE�NO AfF�DAVIi WAIVFR FASEMENT RECORD.INSTR.NO. DATE . rnption, you should become svbjec! fo the Workers' ��s - � . LEGAL i��pensation provisions of ihe Lobor code,you must iorihwiih pEs'ceiPnoN �OrNo. �� Hwv.oR 5T.WIDENWG � comply with such provisions or this permit shall be deemed '. revoked. e�oCK ?RACi U. STAiEENCROACHMEN! , NO.OF BIUGS PERMIT NO. LICENSED CONTRACTORS�ECLARATfON s�ze oF io* Now oN ioi '�� I hereby afflrm tha�!am licensed u�der provisions of Chapter uSEOF �� 9(commencing w�th Section 7000)of Division 3 of ihe Busi- eunow�s � - cHaRc,�s �. ness and Professions Code,and my license is in futt force and . . e{{eGi. '�yy py� CONiRACiGR CONNECTION CHARGE FEE _ LiCCnSe NUmbOr )d I7� LiC.CIOSS � q00RE55 �� �REIM6URSEMENT FEE �„ COf11fOCf0! Dp12 ) OiSTRiCT NO. G20UP MAP FROC�SSEp BY n^ CITY TEL.NO. `c d7 T' .� 8K PG V : ❑I am ezem f under Sec. of fhe LA.Co. SrarE uC. Q tay�5 P LICENSE NO. C1R55 La �� ,x IV �+\ 6i �' NO. DESCRlP710N OF WOftK FEE Q - Ptumbing Code and/o�Sec - of the Fir�n� � �,,,, F10USE SEWER tONNECTING i0 DATE . VALIDATION � PUO.IC SEWER � � B.&P.Code for fhe following reason S�Ptic rarvK,seeance ait oe � R - :ii5 AMPIOQ JRAINFIEL6 -F�NA� Y1 Dote HOVSE SEWER CONNECTING TO BY�:t._3.`a..�++'�"'^^� � n'+IVA?E`JISPaSAL SYSTEM Signaiure CONNFC'AppITIpNAt BLOG.OR � �. OWNER-BUIlDER DECLARATION woaK to�ouse SewEa . OVERFIOW SErEPAGE PIT.DRAINFiELD � I here6y affirm that 1 am exempt from ihe Contractor's License env. cessP���,oerweu,rnnNNote � Law for ihe following reason�SEC}O!1�O3�.S,BUi3l1C55 4ltd PIO- ALiER,REPAIR OR A&4N�ON HOUSE - ' �ions Code): SEwER oa oisvcuni svs*enn �,�I,as owner of the property,or my employees wiih woges qs � . � iheir sole compensation,will do the work and the structure is not intended or offered tar sale(Sedion 7044,8usiness ow�ER,S PBfmit $ s'�j �i ']7,^�ti � � and Professions Code). . , ❑I,as owner of the proper�y,am exdusively contracting with AUTHORIZATION �TOTAL FEE � m �, � � licensed c�nfrottors b.construct ihe projecf(Section 7044, . -�HqVEnf rN�s-*]nte-�a mNTRnCr w�Tn rHE HEREw NnMED coMP.CTOe ttJ � BUSIIlBSS anCl PrafC55ion5 CO()2�. CONNECi THE A60VE OESCRIBED EXISTiNG OWEL'.ING TO TME PUBUC SEWER. � CONSTRUCTION�ENDING AGENCY + � ���j��� �SIGNEDTHIS DAVOF 19._ ��._, - r�.z� � I hereby atfirm ihai Ihere is a wosirudion lending agency �owNee ok �� g °���'`�����'� - for ihe performance of the work for which �his permit is .owaees n�eNr..- - �,�C���� issped(Sec 3097/,3C"i_v."�J� .AU�aE� . ten��IJarr� u,m�.�n�__�j, .... � . . � �,� ��� '�, len er's Address � � i certify that I have read th� appiicatio a state�ha�the �� � above information is corred.I agree ro comply wi�h oll County � � � ordinances ond State laws reguloting Plumbing and Sewers, . - � and hereby authorize rep sentatives of ihis County to enrer �� uponJ bove-menti � --erty for inspeciion purposes � � 0. �° - -Signature of P �mii'� -��T Date �EF�@VERSE!-0R E%PLANATORY LANGUAGE . � ...._�. . ... .,,; - . fy,� �DO �ny ..� D�-CY1 �� T Zn D � �r��Q g y-,. 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