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HomeMy WebLinkAbout1908A (11) WORKERS'COMPENSATION OECLARATION I here6y affirm that i have a cerrificate of consent to setf e,ry� insure,or o cerdfimtep o��f�Workers'Compensation�nsurance,o� :eaee:c ' � �� ���ca��f� ��"�e,/5y sa��,LoeC�� ��a���"`�,ro" pppIICATION FOR PERMtT � RSlicy���"(:ompony . `��� ��` �+ p ❑Cenified copy is hereby farnished. - �Eri��� ' SE■•AVE DISrOSAL � ����, ❑Certrfied ropy is filed with rhe counry bvilding inspection COUNTY�f lOS ANGELES BUILDING AND SAFETY depart enc�,q�/. . Dare,,;���rrApp�icaM � fOR APPLICANT TO FILL IN CONNECTION DATA ERTI ICATE OP EXEMPTION PROM WORKERS' aunowc � COMPENSATION INSURANCE � nooaEss �� STaTioN �vrH This section need not be com leted if the work invoived b�- the UPPER � � P Y LOCALITY � MANHOIE REiERENCE tOYhR - permit is for one hundred dollars($100)or lass.) teN�iti FeOnn �I cenify thm in the performance of�he work for which this ckO55ssi � Y TrveOFcon�NeciioN - � permii is�ssued,i snaii noi empioy any-persOn in any manner CURB v.L. M.t.ro v.t. P.C.NO. �so as to become subjecf to the Workers'Compensotion laws. �wNER ' � � CO-IMP,NO. JOB NO. ��.'+�O � ��� TRUNK PERM�i hq. ROAD PERMIi NO. AODRE55 Dtl1E APpliCani i�� AFFIDAVIi WAIVER EASEMENT RECORD.INSTR.NO. DatE NOTICE TO APPLICANT: It, otter making ihis Certificafe of atv � 1�} Tei.No. $ [7�`� --,emption, you should become su6jec! to the Workers' tE�A� �� .,mpensation provisions of the laboc code,you must forihwith oesceivrtora tOiNO. nwv.oz sr.wioeNiNc - �omply with such provisions ar ihis permit sholl be deemed IeVolted. ' BLCtK TRACT_���_ STATE ENCR09CHMENT . � LICENSED CONTRACTORS DECIARATlON - nn.oF sincs. veunnir No. SIZE OF LOT NOV1 ON LOi I hereby affir:n that i am licensed under provisions of Chapter u5E OF � 9(commencing with Section 7000)of Dlvision 3 af the B�Si- BUIl01NG5 `' � CHaRGES ress and Pro`aricns Code,and ny licerre is ir`ulI farca wnd � . eFTeCt. rg'+��g CONiRACTOR CONNECTION CMA4GE FEE LiCenseNu+n6P.f Jf�✓C� �iC.C�aSS AOORE55 `r � -REIMBURSfMENTiEE � � COlItfOCiOf L'� ��f. piC lg�.y� ❑ISiRICT NO. GROUP MAP VROCESSED BY � CIiY � iEL.NO. � / p BK/ PG � ❑1 am ezempt under Sec. of the LA.Co. Scerise Ne. ,J� c nss �J �� �� *:J �=��-� - � - Plum6ing Code and/or Sec. of ihe No. DESCRiPTiON OF wORK �e FiNAi � �HOUS[SEWER CONNECTING TO DATE YALIDATION W 8.&P.Code for ihe foilowing reason a�auc sewea �7 � _ .:� „��.` .t� _ �, t SEPTIC TANK,$EEPAGE��T OR fINAt � P:T$AND.'OR�RAINHELD Date HOUSE SEWER CONNECTING TO 0V � . PRIVATEO�SPOSAl5V5TEM '�'" /�`"�""" � .. Si9natUlf NNNECiADDIiIONALBIDG.OR , + - � OWNER-6UIt0ER 6EQARATION W04K'O HOUSE SEWER OYERfIOW SEEPAC�E PR.DRAINFIEID ���Ie�E���qT§IffY1 that f am exempt from the Contrac9o%S ZI[B�SB E%TN.,CESSPOOL,�RYNlEIL,MANHOLE . r -�taw 4or the followi�g reason(Setton 7031.5,Buisness and Pro- - �--- atrEa,-REPaie oa nenNDDN NOUSE . --�� - � � �eiOnS COdE�: SEWER OR�ISGp$At SYSTEM . �` �I,as owner of the propefty,or my employees with wages as . iheir sole wmpensation,will do rhe work and ihe structure is noi intended or offered for sale(Section 704d,Business � and Professions Code). �WNER�S Permii E f � ❑I,as ownei of the property,am exdusively conrraciing with AUTHORIZATION TOTAL PEE 'y `� ���'� licensed contracfors to Construct ihe prolect($eclion 7�44, -1 NAVE AT iH15 DAiE A CONiRACi WITH THE HEREIN NAMED CDNTRACiOR TO �q e o 0 1 C Business and Professions Code). -mNNecr rHe aeove uesceiaeo exisriNc oweiuNs ro?He Pueuc 5ewee. � - CONSTRUCTION 1ENUING AGENCY )-d +�G 7��J�.� I hereby affirm that ihere is a constrociian lending ogenty SIGNEDTHIS DAYOF 79_ �� � for the performance of ihe work for which this permit is owNea oR ��-► o � m �/ -��u_ _ UWNER$AGENT � /.v' issued(Sec 3097,Civ.C) � ' �y � � � }� ' nooaess 0 3,0.• 8 U. lender's N�ajme�p� Y�l..-, �p.., � lend�er�s Address�L 1L __���L,� - . �. �. .I certify that I have read this applicatio an state that the -.above information is torred.I agree fo comply wdh all Cooniy ordinances and State laws regulatinq Plumbing and Sewers, . � �and hereby authorize represanta�ives of this Coumy to enter _ " opon ihe above-mentioned property for inspection purposes. - - PiFt..n �`��'�w`� ��f`) �� $ign u�e of Permittee Dafe SEE REVERSE fOR EXiIANATORY LANGUAGE - � . . . ... - ., .. � . . . . . , < . 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