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HomeMy WebLinkAboutNo Permit Number WORKERS'COMPENSATION DECIARATION � � . � ,I hereby oFfirm thot I have a teriificore of consen�to seif _. . � , , . � - . ' ins�re,or o certifitole of Workers'Compansation Insurance,or . ��i6i�� a cenified copy thereof(Sec.3800,La6 C.) �E��pE�.e,e,� � APPLICATION FOR PERMIT - Polity No. Compony �' � SEWER - SEWAGE DISPOSAL � ❑Ce�tified copy is hereby fornished.. - � j ❑Cenified copy is filed with�ha munty buitding inspection WUNTY OF LOS ANGELES ' BUILDING AND SAFETY • � �depar�ment. � Do�e nppl�cont FOR APPLICANT TO Flll IN ,3, CONNECTION DATA CERTIFICATE OF EXEMPiION FROM WORKERS' . eunw�+c/Ar/.L � �r_M�� / ��� „ _ SIATION I � .�t�/JJ oErTN 6/ ' COMPENSATION INSURANCE /•��`+�` `Y �"G�'� �v (This aection need not be completed if the work involved by the i�i�r f(�I���^� � MANMOtE REFERfNCE � � ,r,� � R permit is!or one hundred dollars(SI00)or less.) . � � � . I mrti �hat in�Fe rformance of the work for which Ihis � �'4�ST n�atOr+n�Ct�av ���pq�p„�,� r� � ��5,. GF..iYlON CA4�rt7,�4 �. ��,� o.�. M�..o o�. > permil is iuued,I 6holl nof amploy any person in o�y ma�ner , P�� Q O so as to become subject to�he Workers'Compenmtion Laws. o�R �.���f sv, �(1fF �p.��v.rq. �oa r+o. %�of � V ��� TRUNK f4RMlT NO. ROA�FFRMIT Pq. a Dale Applimnt � aooxcss P . z`l�'� t �y AH�DAVIT WANFR EASEMEM RfCORO.IN$TR,NO. OATE O NOTICE TO APPLICANT: I{, after moking Ihis Ceniiicote of �iT�t/(/��Qs�"�✓TELNO.���✓�"wc7� � V �.}mption, .yoo shovld become sobject to the Workers' npensolion provisions of the Lobor code,you m�sl forlhwi�h oFuc�ri /�-wrrw. .3 HWy,pp ST,WWFN�NG - ^� comply wi�h such provisions or this permit shall 6e deamed 'j /� '� revoked. - . eiocK TRACT �JV�7�� STA1E ENCROACMMENT � z . , LICENSED CONiRACTORS DECLARATION ND'�°1D�' � ���i�� v I hereby affirm that I om licansed under provisions of Chapfer siz¢atoT riow ora�or r�Lt^�r� ��30 � 9(comme�c�ng wilh Seclion 7000)of Division 3 of 1he Busi- e�uiionuGs /y�V��L�'GE`i�/����E a�na�s . neas ond Profeasions Code,ond my license is in full force and CONNF[TIdJ CNARGE fEE effect. y . � CONTRA�TpR T(J �/VS � � License N�m6e�.��� lic.Clopas���( /�J ppppE� g�z ~j ll✓E. REIMBURSEMENT fEE ConlfO[�O�//�/�-+�'1�/V� DO�G CJ�O`�`J CITY �u�/V� TEl.NO./� %�7��Y'�/ �ISTNiCI NO. P MAC VkOCE55ED BY � 2 BK 7G ❑I am e.empt�nder Sec. of the L.A.Co. iI�H��� ? �"��- �!� p� ,(J �!F/.y` (� PlumbingCodeand/or5ec. - ofthe �� DFSCRI�fIONOFWORK �e RNp� �J ' � �����R conir.rterrtac ro o�*e //�j�� VAL ATION B.8 P.Code for the following raoson ����T�c s[�o�Pii ox �S � PITS ANDiOR ORAINFrtLD FINAI � Date wust s�weR ca+r+ccnr�ro er � vaiv�h o�soosu svsr� ' Signalure ca+r.iECt�oarqNwi yoc.ce . .. � OWNER-B�IIDER DECLARATION �"'o"aus�se'"aR . - . . . ' ' ONERF� 5[EP�(�E RT,DRAIYfIFID � I here6y offirm thor I am e.empr irom the Comroaor's L�cense E%fN.,CESSA�OL,DYYWFIL MI1NNOlE � . Low tor�he followin9 reason(Set�on 7031.5,Bui5nes5 and Pro- MTER,RE7Mp OR ABnNWN MOUSE �� ' � <��� 2.�� . �SiOnf COde�: SEWER OR DISPOSAL SYSiEM . ... . . -._ . .. .. ' • • ��1,as awnar nF rhw pm w.n�,n mploy• wah wage!�s "+• : 7 n their sole companwtion,willydoVthe work and Ihe atrocture . - � . � ' is no�in�ended or offered for wle(Section 70M,Businesa .�'• •G 7.�ll � ' and.Profeesions Code). - - � OWNER'S . Permit S � O . � . ❑I,os owner of Ihe property,am exduaively conhac�ing with AUTHORIZATtON TOTAL FEE � � � � � . •�• °2 �•'�n' � licenaed conrmcrors fo mnstroct the project(Secrion�OAI, I NAVE AT THIS DATF A CONTRAC7 WITN THE MREIN NAMED COr11MA�tpt TO ��, o_8 3 _ Business and Professions Code�. , [or+N[cr TH¢�eovt o[sca�eeo exiSTir+G owewr+e ro tNc ru�ic sEw[R. �� � � CONSTRUCTION IENDING AGENCY - / p ►� I hereby affirm thot there is a constroction lending agancy SiGNEDTH�S • � OF � If�� � � � � � �. for the performa�ce of the work for which this permi� is tr`°'�R � - - OWNF AGEN is�oed(Sac.3097.Civ.C.�. � nppc�ss . .. � Lender's Name � � � tender's Address � � I certify thot I have read this applimtion and state Ihat ihe � � . � � - -� - � . above informa�ion is correU.I ogree lo comply wilh all County � ordinances and State laws regulaling Plumbing ond Sewers, . - � -� � � - � - � and hereby authori epresentalives of this County to enter opon the a ve- n ned ro arfy for inspection purposes. � . . , . . . �iJ'"'�6��J� Signo re of e�miN e Dole SEE REVERSE FOR EXPLANATORY LANGUAGE � . ,ra,e /�GYsd<.f/'S �, A � . � . qro�GPZ L �� r� 'G ``n �^ o �' 4� � o- �,-� N -o Yto imp � c+1 D�'o � A �. ��$�. �p a y�L�, 4 0 . . 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