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HomeMy WebLinkAbout1765A (10) � ,. � WORKERS'COMPENSATION DECLARATION j I hereby affirm tha� 1 have a certificnre ef«,r�s<�± ta self � � insuref'rq«<r}heyr.e of Wcrkers' t bCnsation Insuronce,or 'fi^6''20 a_�7�JB���,�� �� ��, ��,� �`a°e,RE�"�3; �►pplICATION FOR PERMIT �'S�'cy No. P.._!2— o pany . �tg ❑�Cerfi4ied copy is hareby furnisFed. SEWER a 5€IRi1�4Gf DIS�OSAC � d ❑Ge.tHied:copy�is filed��with the"�coun�y building inspection CDUNTY OF LDS ANGELES � BUILDING AND SAFETY � � 'deportmen. - . �_ . oaie�APP�i�anf_`���'i.°� �Q[ ' FOR APPLICANT TO FILL IN CONNECEION DA7A CER IFICATE OF EXEMPTION fROM WORKERS' eunoirvc �'. � .�.COMPENSATION 1NSURANCE - - nnoaess sTntioN oemr+ . This section�need not be com leted�if ihe work involved b the UPPER � ( P -� � Y LOCALITY M4NHOLE REFERENCE LOWEft ! permit is foi one hundred doilare($100)-or less.) ` � 1 Cerfify �h(r1 in the performan[e o(rhe.work for,wh�ch�fli5 CkO55S5i. iYPEOFCONNECTION tFNGTMFROM �. �, permil is issued,I shall not employ any person in any manner Y� CURB a.�. M.l.ro P.t . �.C.NO. so�as-to become�subject�o the Workers_Compens�tion laws. owr�ea �y_,_�r..{�� + co.iMP.No, �oa No. �, - - � ��� qp��I � TRVNK PERMIT NO. ROAD PERMIT NO. ', Date f�P�iCOnt ADDRE55 : � 0.FFIDAVIi WAiVER EASEMENt RECORD.INSTR.NO. bATE � NOTICESO.APPUCANT:��If, afrer making ihis Certificate ot cirv rei.No. -g- p � �mptio�, you shauld,become sabject to ihe Workers' ���A: � � . - ;�ipensotio��proaisions of the Labor code,you must forthwith oesca'ivrioN toT tao Hwr.oe sr-wioeNiN� � compiy with such provisions or.this permit sholl be deemed '�. fevOkEC�. � � . BLOCIf tRACi S1AlE ENCROACHMENi ��. �UGENSED CONTRACTORS DECLARATION rvo.oe eioc;s Peam',t rao. . I hereby a4firm tha'I om licensed under provisions ot Chapter. S2eovtOT Now ON ior , USE Of 9(commencing with Section�Q00)of Division�3 of Ihe Busi- gUitDWGs CHaeGEs ness and°rofessions Code,ond my license is�.in-full-force and ' e{teCi. COMRACtOR � � '�f�. GQNNkCiION CHARGE FEE - � License Nu�m,bper-�'7-`�-J-�—Z?�iC.C�O55 ADDRE55 �REIMBURSEMFNT FEE � '� COnirtlCtO/ F� Ofe ` y(,p v � DISiNICI NO. GFOUP MAP PROCESSE�BY o CRY TEI.NO. > . ❑�am exempf under Sec. of ihe L.A.Co. u�eNs�NO. uc. {�,� � ex rc � . 1 G� �.A55 ��`, ,td ` � ��. . PlumbingCodeand/or5ec. offhe No. DESCRIPTIONOPWORK FEe FiNat „ � �� NOUSE SEWER CONNECTING TO DATE `� �.. "°� VALIDATtON � 8.&P.Code fo��he fvllowing reason vueu[seweR - � � - � pfTIC TANK,$EEGAGE Pli OR .IiS AN�-]ipR GFAiNi1E1D HNA�—� y - � uate HOUSE SEWER CONNECTING�O BY �-. PRIVATr piSfC'iS4:$YS1[,V� . Signature CONNER AO�ITIONl+lBLDG.OP. � OWNER-BUILDER DECLARATION moRK 7o House sewea �� OVERFLOV.`SFEPAGE VIT,ORAINFIELO � �� � I hereby offirm ihal I am exempt from the Contractor's License ex'ra.,cesscoo�,oavwe,i MnNHO�e i Law fcr thr fallowing reason(Secion 7031.5,Buisness and Pro- aitea,aevnirt at aanNooN House � � '":ons Code): seweR oa oiscosai srsrEM - �'�1,as owner of rhe property,or my employees with wages as .„ iheir sole wmpensalion,will do ihe work and the siruttore �Is nat intended or offered for sale(Section 7044,Business a�d Profess�ons Code). OWNER'S Permit 5 � b� : �'� 7�Jr A . ❑I,as owner of the properiy,am exdusively contrading with QUTHORIZATION� TOTAL FEE 'j �'jt,3 � � �/� litensed coMroclors to construct the project(Section 7044, �MqvE nT rn�s oaiE A COMRacT w�TFI iHe NERE�N NAMEo coNTBAcioR to �� ° ° '� � v BVSine45 and P�ofe55iOn5 COdCJ. CDNNER THE ABOVF DESCRtBED E%i5T1NG OWEtLING 70 iH6 PUBUC 5f'NER. ' � CONSTRUCTION LENDING AGENCY - f ° °�C Z 5 O I hereby affirm thot there is a conslruciion �end�ng qgenty SIGNEDTHIS DAYOF 19,� � x owr.�a oa ;► s o e t 7,5 Q o for rhe performance of ihe work for which this permit is awNezs aceNT_ ' � � issued(Sec 3097,�C{iv.Cp.). nooaess ���2��-�Lj Lend�er's Na�j'e L.FM't'7� � �� - tende'r'•s Addres�� � ' g� -� _ . I certify ihat I have read ihis application nd stote that the . i above informotion is correcf.i agree to comply with all County � ordinances and State aws reg�lating Plumbi�g and Sewers, � �. ond hereby oulhorize epresentaiives of this County fo enter �- � upo obove-ment operty for inspeclion purposes./ � . ��i F �'� �a' � ��.` 1 � . . 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