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HomeMy WebLinkAbout1545A � WORKERS COMPENSATION DECLARATION � - � S? ��� 1 hereby of+irm iMat I h ve n r.rf��f? 04 ro�saM !.^. =.e!E. � � � } sure,oca ce;ificafe of Workari Conperrmotion Insurance,or Z°f`6d�� � . : , . .. � a certified cpV ihereof(Sec.380D i.ab C.) .. ce.apa.lee'v siai).... _., . -- - :-���ttCATtO�F9R'_'P�ItM'IT � ... . � Pofcy.Nq. Compony�'r.F].t'.E 1�L121(�.__._�_ `°-�s � � . ._ i -yC S@W@R - SEiNAG� DISPOS�4L � ❑Ce tifiel fiSp � e eby f�rnished. - - . - _ - COUIVTY OF LOS ANGfLES "'BUtLDlNCr'ANI�SAFfTY x �Certified��copy+s�filed�witk the county building inspection " � � I . p _. .,.... u .;. department.�.�.! . � .� � S oote-_. ��Z��licont_T. FZ'BffliiaTl _:.; FORAPPClCANT.TO-FILLIN: CONNECT14�1[)ATA ' ` � -- — . CfRTIHCATE OF EXEMPTION fROM WORKER5 . nwioiNc � f � �� �� STATION QEPT'� � 3 ����� � �- �COMPEhlSATION INSURANCE , nooaess .�,3 • uPPER . ��w, (Th�s sedion need not be co.mpieted if rhe work imolved by Ihe � �o�tii�TY nnnNHote keFe2eNc: . - ipwER �; perm�t is for one hundred dollors($700)or iess.) � N�AREST -�' � --p-�''� ivPeoFcorvNecrioN �[N�rH Fkood . §' I certify tha� in ihe performance of the work for whl<h th�s cunss sr - � �'� �J v. cuae P i �n.t.io v�.t. permit is�ssued,I sha�l not employ any person in any manner - -- ---��-���---- v.c.no. ��-� r�1 ^� so as!o become subie<r to the Workers'Compensation Lows � �wNER T�i.' j�17 '� (x"�Q� ca var.Na. �os no. b�� ADCR�55 ��J yy�/��2� �R'JNKPFRMITNO. ROACPERMITNO. �� Dafe .4pplicant pfFIUANi WAiVFR EASEMENT RECORD.INSiR.N�. �ATE � NOTICE TO APPLICANT: if, after making thls Certificate of �� - aTr -OV1Ii'd TF��-��- 8 � 6 ` �- ;�npiion, yau shouid become subject to the Workers' � ���A, �pensation provisians of�he l000r code,you in�sl forthwitn � � -nescaiaTioN ___ior No. [g� Hwr.oa sr.w�oenru� � , ,i�ply with s�cn provisions or this permit shall ce desmed .�- ` 3�754 -- _ �9VOkBfJ. BLOCK 1NACT PTAeiME�NOOACHMEM . � iiCENS[,^�:.OP�lTRACTORS vECLA2ATION N'�.a.s:o�s. --�---- srze eF to* ow eN�er i here6y atfirm Phar I�m Ucensed under provisions of Chep?er : �Sf ap �� 9(wrnmencing with Sec!ion 7pqU}of�ivision 3 ot the$�5� . ' eun�ir��s �,31 @��"�C�BT1G� _ cHacG[5 . ness and Professions Code,and my Lcense is in full torce ond � '� e{feCt. CGNTRACTCR �j�in}���ryp �/��T CiINNcCTION CHAkGE fFF _. _ /��'j O (1 /� �Loi1JL`1'1111tl _ V1Y��;,y __ p�, � LiCenSeNUmbe(.!]�_1 V� �.0 C�055__v�`Y AUORESS .[����_yl�',�(;tL�Q{�l2_,Ll� nEiMRV25EMEYTfEE � � i.0I11fOCtOi i S`reP.�a� Dote ��GQI��7 p�y p ry DISTRICTNO. GROUP M�1P P'+OCESSEDBY ,. OTY �yy y`�., 0��. �CLfJO. � '�VQ/y'�'q L BK PG � � P SiATE A*7A881 CA55 �-/�`f' � � .� � ❑I am exem 1 under Sec. ._of the lA Co �� uCCH�NO. Y f�Y d � � Plumbing Code and/or Sec �of}he '- �NU. DESCRIPTION OF WORK �E' _ '�' � RNAt W `�cuse ve�emraNEcri-vcro ], Q on?e ,� VALIDA710N � '. R.&P.Code for the tollowing recson i?�z�� ewea � ��y��" —"-��-� �� € SEPr C TA�,dK,SEFPAGE PIT OR FI��p� p4tE� .. Fi �N .'7::D�A\flC!J'__— 9V o � _.T 4C J E 52`NER CC'NNCCTING TO M FR'VAIEO.SFG5AL5Y5TEM_ ` . SignaWre ._.�_. � W n . �n�* ra�t¢�_ec.�CR-- OWNER-BUItDERDECLARATION W tK ���us ewea .. - CN RFLOYJ SEfGFGE PIT DRAINFIELD , �,�.�� . I hereby affirm thaf I om exempt from!he Con'racbr's L�cense � e�rv .:.zaoo R wt�_�,nv.Nt+e�e _ .�aw for ihe foliowing;�asan(Secton 703i.5,6u sness and Pro �+.TER RevAiR CR neqnooN nousr � . - ''sions Codel: � s_wed ox ciseosa.>rsienn f; : :: e� ( 4 ,31,os owner of the property,or my employees with wagFs�s.��� :J c s��],;En �'- their soie compensati��,will do�he wor'R and the siructure-'� "'v' is not imended or offered for sale(Sec+ion 7044,Business � ' .' and Professions Code). OWNER'S Pefmit 5 `7� � � � % '=> ❑I,os owner of the properfy,am axdvsively mntrn<ting wiih r. AUF�'I�KIYATION TOTAL FEE `Z Q ,, � �F4 :k:. licensed confro[tors to construci the project(Section 7044, -. i rnVE ar Ttiu�aTE a C.,NraA:r vlaN rre�H.aEiv unrmeo coN'encroa To Business and Profe�sions Codej. cor�Nc_ci THe neovr o�.�.uixF�ExisriN�oNe�.Nc�o rHe vuauc sEwER. � , � �'� CONSTRUCTION�ENDING AGENCY .y�� �'`� I� ,, � � � �rS I hereby affirm ihat fhere is ❑ construUion lending agenCy � SIGNEDTN15 DAYO 19_ . . a�,� for ihe erformance of the work for which ihis rmit is �: owNee oa .��+,,,,�- . . P PP pWNERSAGENT - issued(Sec.3097,Civ.C.). � � - � ,� ADDRE55 Lender's Name__ � . � . : . Lender's Address - � � . . �;'. I certlfy thaf I have reod thls appiicolion ond stote ihat the�` . - , . Sa(; above information is mrred.I ngree to[omply with olI County -- - - '� ordinances and State lows regulotmg Plumbing and Sewers, �-� � � _ _ .- �{ und hereby outho�ize representaGves of ih�s County to enrer _ . � . . : � � � � . �� upon the-above-mentioned properry for inspecfion purposes . . � � �- � - �= �_�_�R�� �-�s�.� � , ��n Sigr.ature o Permiitee Date SEE REVE2iE FOR E%PtANATORV tANGUAGE . . . *;� . . . ... .. . � .�4^ , ,... __._ ._._ m ..... n...,.� ..�..._f,� .;.,.._...,_ �.�,-�:,.�..:_ ., � w..,.�. .U.:.a-,.,w.� . .�.�._�v �� Do S� ['� �Z� �O � �T Z Q A.�ro� Yin' O 2 . �F OZ mz 0-a Z� n Nm Zf1 O—v � �OZ �~ � � S—i �"D� �,>c �D � . �= O.o p u ❑ A� �� r � n �� zm �� � � n D -,�, D� m o— N z �^y �m Q o:� x� � � 9 N e�'.z fj/��� � 8� �� �R � �^ � Z N � P � � � � en Q � � a ~ � !41 C4E z N � . ' ... �. � ��p'S,+� � � Y A ' ..._ . . �� V+ � � q D ° m .. . .. \.. . � . !'��.i . . .. �� � � , �.1 " � %i' ' m . � . � C,� _ ' � / �.;.. . _...� .. ... � _ F;:: � ' � - -a • � � � . 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