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HomeMy WebLinkAbout1212A i ` � . WORKERS'COMPENSATION DECLARATION I hereby affirm that I have a cer�ifimte of consent io self � � � � insure,or o certifimfe of Workers'Compensation Insurance,or �baaa4D a certified mpy ihereot ec.3800,�ab� �E B��RE°.e,e,; qppLICATION FOR PERMIT � Policy No..���mpany .� � . . .Pis L�'certified�opv�s here6y fumished. SEWER - SEWAGE DISPOSAL ` ❑Certified copy is tiled with the munry uildinq'nspect�on COUNTY OF LOS ANGELES BUILDING AND SAFETY , department � � ` Da�e Z-1�7 Applimnt_.,__ _ ,_ __._ FOR APPLICANT TO FILL IN CONNECTIO DATA f g. � � CERTIFlCATE OF EXEMPTION FROM WORKERS' euaoivc + ' L Y - COMPENSATION INSURANCE aooREss 1 ( N C�Q,pf'/` sTntioN oEPTH � (ihis section need not be complered if the work involved by ihe � r�nNHoiE REFER,NCE ,/ ucaea permi�is 4or one hundred dollors($100)or less.) ���A�'�r� NnJN� �7 � � �U`!' iowea � 1 certify that in the performance ot the wark for which this ceosss ./ `�— iv�oFcoNNecrioN iENGiHFeOrn � �"TJ�", � 'V"i Y. CURB P.t. M.t.TOP.L. ? permit is issued,I shall not employ any person in any manner / P C.NO. so as 10 become subject fo the Workers'Compensafion Laws. py�,NER a�P ,. h� /�sf' CC.imP.No. �oe No. _- �'�� �g TRUNK PEkMIT NC. ROAD PERMiT NO. _ Date Applicanl aooaess �1, e � �w /�' '�� j � AFFiOAVIi WANER EASEMENT RECORD.�NSift.NO. DATE � NOTICE TO APPLICANT: If, after making this Ceriificate af crtv Wa.t-h-�� ie�.No. , Ezemption, yoo should become subject to the Workers' iE�q� _ Compensation provisions of the�ahor code,you must forihwi�h oesceiPnoN io�No. Hwv.oa sr.wioewN� comply with such provisions or ihis permit shall be deemed ' fCVOI(2CI. B�OCK TRACi �� � SiFlTe ENCROACHMENT � IICENSED CONiRACTORS DECLARATION uo.oF a�ocs. �RMir No. SIZE OF.OT NOW ON LOi � 1 here6y affirm rha�I am licensed under provisions of Chapter use or . 9(commencing with Section 70p0)of Division 3 of the Bosi- eu��towcs ctink�es ness ond Protessions Code,and my license is in fuli force and �`� effect. �7�- f �phiRACTOR /j�� �-y CONNECIION CHARGE FEE � License Number N�`"' Lic,Class � � i '} ADDRES$ � M f` REIMBURSEMEhTfFE O COft�lOCiOf G� t�� Date ���'—� J . . �ISTR�C�N0. GRUIIP NWP PROCESSED BY V C�TY tEl.NO. ❑ I am exemp�under Sec. of ihe l.A.Co. LICENSE No. �2-}�.�(1 a.ass +O BK aG �� o l F N�. �ESCRIPTION OF WORK F[E _ PlumbingCodeand/orSec. ofthe FiNnt W r�ousE scwER coNnecriNc To oo,e VALIDATION Pueuc sEv�a (� ������ 4 B.&P.Code for ihe foliowirg reason -eaiic innK,SeEvnc6 air oa y FIiS AN�/OR DFAINFIELD FINAI ���/ ? �ate HOUSE SFNE'H CONNECiiNG i0 BY X ' PRIVATE DISPOSA�_SYSTEM 9 r�1 $IghpfVlE CONNECT A�DIT'ONAL SI:IG.OR , z f G 1.G P, � OWNER-BUILDER DECLARATION s�oaK ro House sewea OVERfIOW SEEFAGF PIT,DR4INFIEID �• � o o � n g 1 hereby affirm ihat I am exempt from ihe Contracior's Llcense exrN_,[esscooi,ozvweu,mnNHo�e t. 9 Law for the following reason(Secton 7031.5,Buisness and Pro- atrea,aEvnix Ce aBallooN House � fessions Code)� sewea nz oi;aosAi svsrcnn ( e Q�?v Q , ❑I,as owner of ihe properfy,or my employees wifh wages as m�j,v�J ; their sole compens�fion,will do fhe work ond fhe sirocture � � g� 7 - is not intended or affered for sale(Sedion 7044,Business � u�.,,,� � �� � and Professions Code?. OWNER�$ Permit S ((� � - ❑I,as owner of the property,am exdusively contracting with AUTHpRIZATION TOTAL PEE � � ��iCCnSEC)COt11�Ocf0�5 t0 mnstruct the P�0�0C1�$BC�IOfI��QQ, I HAVE AT T415�ATE A CC�NTRACT WITH iHE HEREIN NAMECI CONTRACTOR i0 BUSin235 and Profe55ions CodCJ. CONNECT THE A80VE DESCkIBED EXIST�NG DWELLiNG i0 iHE VUtlIIC SEwFR. - CONSTRUCTION LENDING AGENCY q� ► 1 hereby affirm that there is a consiruction lending ogency SIGNEDTHIS ��D YOF "� I�,� �. tor the performance of the work for which fhis permif is owNtuoR �v� �7 .�, , issued(Sec.3097,Civ.C). .. owrveas aceNr r1�/" , AODRE55 . Lender's Name �. Lendar's Address - '��. � I certify that I have reod this applimtion and siate Ihot the . I, above information is wrrect I agree to comply with ail County , '�� ordinances and Stote laws regulating Plumbing nnd Sewers, ���� and here6y authorize representatives of this County to enter I upon t/Fy�)above-nmentioned�rop y or inspeciion purposes. '�.. / °� X/G' '�. 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