HomeMy WebLinkAbout1212A (6) 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. '�..
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S�gn re of Permiftee Dote SEE REVERSE FOR EXPLANATORV LANGUAGE �'
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