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HomeMy WebLinkAbout1554A (9) ��.. �' WORKERS'COM°ENSATION�ECLARATION -�5� 1�i 1 hereby aYTirm that I have a certifimte of consent ro self 1� Y`: , insure,or a certiflcate of.Workers Compensation Insurance,or - -��`64T0 � a�e.t,f,e�����f�Se�.38�,qt�}b�.} �=°B,RE�B,B„ APPLICATtON FOR PERMIT ;�". .Policy No Company ""'• F�ld _ _ . �`I ��Certifi c p �s�erebyfurnished, . ' , . SEWER - SEW�►GE DISP�SAL� ��Certified copy:�s f�led with the coumy buikdmg�nspection CGUNTY OF L�$ANGEL�S BUILDING AND SAFETY ��»' ��depariment �- . � . . .. -_.__ _ . �,� �'6me �+ �Q $�p�icant �-'+ `�'�eQ�a�- FOR APPLICANT TO FILL tN CONNECTlON DATA `"- � .�. CERTIFICATE OF EXEMVTION FROM WORKERSS. :,Bua�iN� �t � ,.d� � -�- � SiAnON cePiH . �� .�. �.:COMPENSATION INSURANCE .- •� � .�l.�"�J �[ � ''ADDRE55. -' � -�This seciton�need not:be completed5f'fh'e'Work Pnvol'v8d by the mwNr+o�E a=FEatNce LowE� - �-.�..� �.permit is-for one hundred dollars($1�0)�or Iess:) � � �ocaurr - ' : N[ARE�T TYGEOFCONNE:-tiOi� �N(iTHfRph{ ;�, -I certify ihot �n thc performonce o4 the work tor wnich ihis -_ . ceosss�. � � , _._ - �� - v. cuas P.�. r�n.�.rovi. ,�; �permit�is�issued;-1-shaH no�employ a»y person-in ony manner , - --� -- �- � F.c.No 7_{', . _y`. ��'so as fo be<ome�subjec?lo-lhe�'Worke�s'Compensalion!qws. � UwNEk ���i ��� CrR.�� co.vmo.h�, �oa No. �� °�6� . 4� � � � �.i� TJf�._�X_+'C 7.2(] iRUNK r'ERMI I NtJ. ROA�PERMii Np .�DPIe,__ A �ICant -� ADORE55 S V JJ 7 __._ .-._ '—'-- Np� AFFIC�AV!T WANER E45EMENT PECORD.INi7R.NG� DA7E ;;�- -� NOTICE TO APPtICANT: If, after making this Certifimte of - ��,Y :.Q�i . re�.No, 8 � -� , _ .. '�. -.���mphon, you_.should hacome.su�jec� to_the.�Workers' ; , ��E�� .;_ �; �-._ _ �� . ��� � Zpensotion provisfons of;)he Loborlwde,you musf fo thwith _ "-' a�.sce�ancu �°��-��or'Na-��-�"7� __ - � Hwv.ea sr.wioeNiNc _ _ : _,nply w�th such prov�vans ur this permit shoit be deemed x�e7�p - ''revoked. � - etocK� rencr � 1 �T 5?ATE ENCROP,CHMEhi . � - LICENSED CONTRACTORS bECIAftATION �vo.oF e�oGS. a�R,U,ii rvo. _ il:F O`I OT NUW OiV LOi .�I hereby ofRrm tha�I am licensed ander provisions of Chapier : usFoc C�+'j���p� PQS1C�$Y�S'.°E ' " 9(cammencing wlth Sectian 7000)ot Division 3 of fi+.e Busi- suim�Ncs cvqaGcs - � � � `� ��-�ness and Frofe;sion:Code,and my I!cense is in 4ull force and - . 'c�>�-cnHA'n 7�`ts/� c+((� - " ':�effect. . . f�. .. . . Q . '.. cOUrFa.iOa �xLL'L'i'intV� l.V�wi l= rrVNE.7!JM CHARGE FfE .., � + __ __ ��i[Ense NUmbef ���"�� �iC.Cfass ��( _ �ADDRESS . � ;� 4EIMBURSEMcM FEE _ _'�.� p/n/��p/ OISTRIrfNp. GaOIIF !J�A4 PROCESSEG6Y . � con�,Qao,T Fre�man oa�e U ��� �o `urr .(�].�i3�7 O�c'� n�.rio �]_ - 2 aK ec � . � �.� pi of the L.A.Ca. - srAif �1 'S' ( UG e .� . -�� , ..❑lamexem underSec__ ucer�s �. -y88 cin�< �i��s � +7 �f; ; �NO. DESCF.IPTIONOFWORK �� FEE �" � Plumbing Coc�e andlor Sec- ., of the -. — "NA� �� � r,r�s �ew=.z cohnectin�c ro oaTe VALIDATION a�' . . auaur sewea �- �� �S"��- --- B.8 P.Code for the fo��owing reasort`.___ seen� nNe SeEPa�E aiT�n 6 . �� - _�t' s ra!c Gan�nFiEto FlNaL . . _ ��C OU& EWEI.CONNECI"ING'D �9Y �..�� � - . PR�JAtFtJIGFOSAL5Y5?EM � � � � -� � ... Sl9nature _ J\� �AL T�, �tB�DC OR . . '� .. � OWNER-BUILUER DECLARATIO?d woex ��N.c n ea- ______ _ _ OVERf OW 5 PAG PI D4A�.NFIE'.0 � �A here6y offrtm that I am exempt from the Contracto:s License Eav,.ess=�,�����vai t�narvr;cie y �.� � . 6: t ��'�J�f 1 �.:�' � �Low ior the follow ng reason(Sector 7037 5 Suisness and Pro- airea a.anie oH ABnNooH nouse _ ._. ' -;�ons Code�:. . -� .,__ , _ _; ' SEWER OR OISPOSAI.SYStEM s-' � g --'E . ���fk xt°a� =v 1(,7 .� E„ .9,as owner of the property,o.my employees w th��rvageo as��� n :3 � � � Iheir sole compensation,will do ihe work and ihe strocrure _ ���°�"=.��`�'t� is nof intended o�oftered for sale(Seciion 7044,B�siness - - - - and Professions Code). OWR}ER�S Pe�rniT $ . . . s ��;%? j,.j i, `, .��l,as owner of the property,am exclusively controcting with AUTHQRIZATI�N '�QYA�FEE �\, `� � � -. �ticensed conirodors to consfruci ihe pra�e<t(Section 7044, -�y{qvE p;rH�g onte n coN7anCCNnM'Me HeReN NAMEO��oN7kA�tOa�ro - ��� ' � � -- - - �" ^���"� f�- -�.BUSinB55 Cif1CI'�PIOfBSSiofi4 Cod6�.� - . � � �CONNECT THE A60VE�ESCRIBED fXISTING DWELLING 10 iHE iURt SEWER�. - - - n w. ,�'�� CONSTRUCTION�iENDING AGENCY�- � ' . �� ��. � . t� I hereby affirm ithat there'-�is a construcho� lending,agency SIGNEoiHl5 2 �.___a . �DF�� _f — - _.. . -- - . ._ u - . . � . . . . ._.. OWNER OR - ��'For tha perfo�mance of the work for-�which�3his permit.is. -. owNea�nceNr ��� '� '4� � - '' � - issued(Sec.3097,Crv.`C.1. B(?fa,G}1Wap(} Z'y* g3t$ jL1'd ' . .... . ., ..,..___' -ADDRE53� . . ;,. . .._..._� . :. Lender'sName:_____._— ____.___._— .. . . _ . . . .. :- , , . . � . . _..._ ____. . . _ .. ,�, . . Lender's AddressT � � . � � � - . `� I cerfify that I hnve read lhis opplimiion and sfate that the, _,_„� ,-,_.,,., ' k .=:.. . .- - - - � .:` . . . � � ''�. - above-informatinn islcorrect.-1 agree to comply with-alI Counfy ' . . -�" " `.�. '.�: ^.�- � ... .�.. : . . . . . . ` ordinancez and Stme:laws reguloling;Plombmg_:�pnd.Sewers„ ` . � �� � ' � `"� - -� . . � - - - . � - - '�� ..and-hereby�authorize'�represenimrves��f ihrs Cdunfy-io ente�� ., -- " ...�`. ' .:. ' '. :- �--�� ,:� ��-�.. . .:.�. .. . , . _ _ .. . ,. u . Yhe above ntioned proPerty for.inspeciion p pase. , - ' •�- _.�. .. . ..: � .�-- -. . . � .. .. . . ,. , �� �� � ���.��>��� _�-�_ �i �.�ignature of�Parmtltee. r �Dafe ` �- 5EE REVERSE FOR EXPLANA70RY IRNGUAGE . . . . � . ,—�..�., . , _.. . .� �..: .. �.�;,��Y. �;.�� ,� a v_.. :r M. ��.;.�� .1��..:_4,�....��.�.: �W. �w�,�.�.�.�u�s�:��.��.M.�.. - �� �.,��. . . v�,.s,,� -��,'°�.��; °' 6�°��s �,�" a � �4 a� �,Q��,� �.,�:�� . ,��,;.: � �o o a,��� "�'°^�'� �'� � c._.,� � ++ ��� � � � � h eu y � }y O � � � ��.',� ,�va�,+N1 F� �a O � a a �� , C �, a. � a3�+ � � 0� � o� c'K' �.� �te.�a ���^'Q � �.�a1 A�i� .. ;;��g. ��e�..�•�i � . . ' � . _...,. .. 9t U ���' 8'°', �,e"n a�. Ql �` � � pa m p CE��A''°'� . .A1,� � 3i C �•� aY .�i P..a iY � O �� Q' �` C �: �•,m,��:�'`{y�.pm���.�,�c�� ."O��a' �*4^a,'"".+;,�;�-» . . . � , � ,..� ��- � � � y �'�y°� �..� �p„,F�.,' � s„ °�vq�y,� � ����" � __ � ���' �.�``� � '�D � q.;m �.� �•$�1� +a � "•. 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