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HomeMy WebLinkAbout1553A WORKERS'COMPENSATION DECtARATiON � � � �: , ! !-.=-:a �., .-";:^-: Fhet 1 `avc a cart:fic�:c a4 m::sc:�: io �--" , Ii insure,�or a certificate of Workers'Compensation Insuronce�or �hA�^�D _ � � � � � 21 . a cer➢ified��-copppy ther f(Sea 3800, qb C 1 ce eaa�aev.s:ai) /�p p �°q i p Q�� � PotieY No��.` qC�ompany �-GB.�i@ �U�.C�. �� rDs: ." - � . :... . ,/�9r I�.���.Vpd1�c1�����..f���'4��e _.,.:=` ....e,,.. .. ... ❑Certifie�tFs�y'v�.�bfebYfumished. .. . . . ... . . �C�1I��R.•..IEWAGE ���PQ����. •. �L �� � . . �Certitied copy is 4iled with ihe coumy building inspection COUNYY_AF_LOS_ANGELES _BU#L�INGAND'SAfETY '- - deparlmenL � � Dote$��.App�imnt �+��Ti .�go�ap fOR`APP4ICANT TO FYLL'IN ` ` CONNECTIOMDATA ` '. -"�" CER�tfiCATE-UPEXEMPTION PRUM WORKERS' -�� � � �� � ` � BUILDING �'�.. ' r . � 5TAi10N OEPrn . COMPEVSATION INSURANCE nooaess �� j ����� �,'� . (This section need not be compleied if fhe work involved by the D���a�� ptiqNHO�E REFERENCE � � �u�aER permit is for one hundred dollars($100)or Iess.} -- . . �OCnuTv �owea .. I certify that in the performance of ihe work ior whi<h this � : ceossssr. ;�ryf�� TraeoFcoNNecriorv �NGTHFeonn _ - Y_ CURB - P.L. IJ�.L.TO P l. � ' permit is issued,I shall no1 empioy any person in any manner ----- ----- �----- --'-" -.- � -. - a.C.No. � t�� � � so os m become subied ro rhe Workers'Compensation Lows. �.owNea co IMP No.� �oa no. ��vt+s v � - � ' ADDRES$ PO dJIJ.A-���J . TRUNK PERMIT NO. ROAD PEkMIT NO. Date_ Appiimnt._ . . . - 81� ���r �� AFFIDAVIT WAIVER EASFMENi RE.^nRD.INSTR.NG. DATE NOTICE�TO APPLiCANT: If, after making this Certificaie of � . arv �i�V3.I1�. ret.�o. 1 � �amption, you shnuld bemme subjeci to the Workers' - iE�y�� � � . . ;npensofion provislons of the Lo6or code,you must forthwith : oeSCRiPncN - ��r No. Hwv.oa sr.wiDeNw� _.,mply with�uch provisions or this permii sholl be deemed f2VOIC2d. _ �� 6lOCK 1NACT SiAiE FNCRUA(:HMENi �� LICENSED CONTRACTORS�ECIARATION ' rd-v.OF etOGS. p`r'��r Np. " _ _____._.___ ' � SIZE O'LOT NOW pN tOT �. !hereby affirm ihot I aro licens�d under pravisions oF Chopter � -;�SE oF--'— - 9�mmmencing with Section 7000�of Division 3 of the Susi- � gu�ioi�ues 1 c�+neces' ness ond Professions Code,and my Iicense is in full force and '�t�1ry��7�7 h� /� ef{eCf. ry e7 � CONLRACTOR �RJ;�y;u�j,�}yy .��ty�y,� CONNCCRION CHA2GE FEL �� i: Utense Number_ �i��itic Ciass �3� - aetrtnsuesetineNr eee ' nooeess '�� 8 0 86 �� R€?Pehwc�od T7r�„ � : ContYaC10�9_1'1�b�IDa.TI Date_r�_� �,'�'j'd, �}g}rj°yj, TEi.NO. ry (� r� ���TRIClNO. GROUG MAP. PROCESSFDBV �� CITY y HL�" G $ OK PG Z� F{ ❑I am exempt under Sec. of�he L.A.Co. ucevs�rvo. �� �87 cuss� (t,, v'u� � � NO. OFSCRIPTION OF WORK FEE — (j� PlumbingCadeand/or5ec. � ofshe F�N�� VALIDAT�Q(� -� Nouse seweK con�Nea�Ne ro I {J fl oAre ��,,f � m-. PJB IC SEW R B.E P,l.�e f0�}�e{OIIOwin9�EP50� SEPTIC ANK. EEPAGE PIT OR �^� �� {vR�A'.D/ R�..A,IJ i LD Fl(VAL /� _ ppte kdOJ$ WER ONNECriNG i0 $Y (0� r - Pkivnlc LiSV.)S4L SYSi�M `"� Si��q}V�8_ � CON4ECT 4D�IT�ONAL BL'JG.OR - � WURR TO HOUSE 5[WER OWNER-BUItDER�FCLARATION�. � . �t (JYFRF OW SEFPAfif PIT,DRAINFIEi.[J �hB�9hY iJf{��fti 1�it11 I pr�e�(e�p��f�Ofit PhE COl1lfdCiOI�S�iCQ�SC [X?f ESSVG�„JRYWE:i,MANHOLE _ _ . 4 Law for Ihe folfowing reason($edon 7031.5,4uisness and Pro- � at�.ea,aErnie oe nBANOON HOUSE . - � '3SiDn5 COdBJ: SEWER O'ti DISPOSAL SYSTEM ' � . . . = i C��.��.N -�I � �I,os owner of the property,or my employees with wages as � ,_ ` . �g _ their sole compensation,will do ihe work and the siructure -� ,�b - � � is not in?ended or ot4ered for sale(Sertion 7044,Business � �fr� � a {' : �y � and Professions CodeJ. OWNER`$ Pe�mit s ]„ Q ;- ; � �,�,^.,, � ;� �I,as owner of ihe properiy,am exdusively controcfing w�th AUSHURIZATION TOT1Ll FEE 2 � ' ' ; . litensed controciers fa wnstrud ihe projed(5ection 7044, _ i Hqve nr rws onre n coNreacr wirH THe Hesem NnM�o coNrenaaR io � a r� 1 :''�4` ."-� BuSinP.sS ontJ PYo{eSSionS Cotj2�. CONNECT iHE AeOVE DESrRIBED EXISTING OWELLING i0 iME PU&IC SEWER f CONSTRUC710N LENDING AGENCY �`�� � ,�"y -� �i'f��`�'�'"';i b � I-heteby oKirm ihai ihere is a consiruction lending ogency SIGNED THIS DAY OP - 19,_ - � for fhe performance of ihe work for which ihis permit is ov°NfROR _ � �ssued(Sec.3097,Civ.C.). . - owNERsnceN* (S`�-c-�.-.��h-a'-�-�1°"'��''""°—'^� .:. .._- =ADDRE55 �s" . . a ��_ . _ .._ .._.. � '':3.S Lender's Name - � - Lender's Address - � � � � � I certify ihat I have read ihis applimtion and state that the '- .. � above information is correct.i agree to comply wifh all County � � - ordinances and Sfate laws regulating Plumbing and Sewers, -. � - >�.��, and hereuy a�ihorize representatives of ihis County to enter . -- �pon ihe above-mentioned properfy for inspection purposes. ,,,; � � �� ��� ����� � � ; Jignoture ot Permirtee Date ���R�VER3E�6R E%�lANt1YORY tANGUn�E ���x�` . . o N� � ��cc "�`� N �1 o_ oz ... . . . .. . . . o� ��D9 Cp .p'� ,a� � � . . OZ �F p � 'm � .... �' . ' �� OZ pq Q As`c �O vi � , y,N Z�. 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