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HomeMy WebLinkAboutNo Permit Number WORKERS'COMPENSATION DECLARATION . -� ' Q I he.eby offirm thm I have a certificote of tonsent to self , � . , . . _ � , _. - �� insure,or o tertificole of Workers'Compensolion Insuran[e,or lenaa7D � ' . LS a tenified copy�hereof(Sec.3800,La6 C.) �E��Q�.e,e„ � APPLICATION FOR PERMIT � � � Policy No. Company �s � � ❑Certified copy is hereby furnished. � SEWER • SEWAGE DISPOSAL � , . ❑Carilfied copy is filed wi�h rhe county building inspection � COUNTY OF LOS ANGELES BUILDING AND SAFETY deportment. ' oa�� a,PPucan� FOR APPLICANT TO FILL IN �,�,��,{�/ CONNECTION DATA . CERTIFICATE OF EXEMPTION FROM WORKERY � ewt�n,�c �/� COMPENSATION INSURANCE �ooqeu �r7� S, �1�/4✓E• sunaa ���.�C' �viH 6/ - � (This section naed no�be comple�ad if the work involved by the i��ir ��`��T MANNOLE RE�EREN[F f •O3� � u permit is for one hundred dollors(5100)or Iess.J r1 IA � I certi(y that in the performance of Ihe work for which lhis ���p5�,55i. LE/I��L GQ�/'/� irvEO�COHNECiqM �r.KrNFvpM � Y. CURB F.L. ' M.l.LO Y.l. �" � permit is issued,I sMall nol employ any perwn in any monner � C. ' v.c.No. ao as to become aubject�o�ha Wo.kers'Compenaa�ion Laws. � p����� � ��� `�1-/�, �p,i�,,,P,pp, ���, : ,j 0 , ADOREss/JO'��( �?�� TRUNK PFRMIT NO. ROAD PERMIT NO. � Doie Applicam •• . g . � ^�- / ��/,n'O�M AfFIDAViI wAiVFR EASEMFNT flKORD.WSTR.NO. DATE O . NOTICE TO APPIICANT: If, afrer making this Cenificu�e of pT �AC� TEL NO. �1'`V S6�(/ v ' - �p�ion, you sho�ld become subject to the Workers' LEGAL w npensafion provisions o(Ihe Labor code,yau must iorthwifh pe5tc�vr X LDTNO. MWV.OR51.WIOENING � �' -mmply with soch provisions or this permit shall be deemed �3^A - �� revoked. � eiocK TRAQ tT STA7[ENC50FCHMEN� � � LICENSED CONTRACTORS DECLARATION � rq,a e�Ws. / �Rr,�T ra. I here6y affirm thot I om licensed under provisions of Chaptar sizeorior raowwioT F�L�;yv /� � � 9(commenci�g with Sedion 7000)of Divi�ion 3 of the B�si- p�iip�s��� SrNG� F�/�'1/L f��%7JE � a 5 neas ond Profetsions Code,and my licanse is in full forte and p/�,�,,�/ - Licfense Num6e��`��lic.Class C�l y� A���t��� !�����,r r ���1ON c�wacc�e . ,G- S rT ae�MeuuseM[r�rt r[e COfIIfOC�Of '•-����� �OIB ������ CITY �i/��,lO�'f 7rQ ���� p5���. �� �P PRp�E55ED BV TEL.NO. ❑I am exem 1 under Set. of Ihe L.A.Co. SinT[ � �� uc G-� 34 � . P ������. «,� � �3 .�.P/�// � Plumbing Code and/or Sec. of the �'�� DESCRiPf�OM OF wORK ' r�e F��i ; �+ousc sEwea ca+r+ecnr+c To � DATE �� �� VAL DAT10N � %1&I�$EwER B.B P.Code for the following reason PTIC TANK,SEEP�GE i1T OR flNAI� � � wts u�o�oe ow�ir.��e�o Dote FtlUSF SFwER CONNK7ING tp BY VRiVnlE DISPOSAt V57EM • � , Signature crlrN[Q woo�non��i&oo pt � `�.� ,�.�� � OWNER-BUILDER DECLARATION - Wo�To F+ous[s�.v.ta - _ I hereby�affirm�har I am ezamp�from�he Comractor's licensa EXiEN.�CFSSP00l,ORPIVWELLp�AMN�MIXE . �nw for tbe following reason(Sec�on 7031.5,Buisness ond Pro- uhc,rs�rni¢at ne+.rlooN nou5� �� � - �T'• • ' " � G swns Code): . sewea oa oisaosn�svSTcrn � � , n )� �., .27.; U i,os owner oi�he property,or my empioyees wi�n wages as � Iheir sole tompensation,will do the work and the structure � �,���j�? is not intended or oHered for wle(Section 7044,Business � � . and Professions Code). OWNER'S Permif f � � ❑I,os owner of the property,am e=dosive�y contracring with AUTHORIZATION TOTAL FEE 0�� b—fj 3 Ii[8n58CI COIIIf�C10f5(0 COf15�NC�1I12 PfO�¢C��SBCIIOfI 7Q44, �HAVE AT TNIS DATF A CONlRA�T WITM iME MERE�N NnMFD CONiFACTOR 10 � � BUSin255 011d PfOfBSSiOnS COdE�. CONNER TME ABOYE DFXYIBED E%RTING DWFILING TO T11E PU&IC SEWfR. '" ' . CONSTRUCTION LENDING AGENCY � � �[�-� ► I hereby offirm thot there is a construcrion lending ogency ��DTHiS /� Y�� � 1�Y'� � - � � for the performonce of the work for which this permit is �'M1'NFR . OWNEIi • �ssoad(Sec.3097.Civ.C.). - ' . . A�� - . �. . . . . Lender's Name . Lender's Address ' � I tertify that I have read this applicalion and state that the ' . - - - - obove information is correct.I agree to comply with all Covnry � � . � ' ordinontes ond Stote laws reguloting Plombing ond Sewers,. � - - and bereby ou�h � represerootives of�his Co�nry lo enter ' - . . � upon� v Iione perty for inspaction pvrposes. �, . � . � . . . �/C--6T3 Sign u�e ermillee �� o�NS,�' SEEREVERSEFOREXMANATONYLANGUAGE � . - ! � . . .. �� - ' �� D� N➢ M g� cp m i . a T n y� t"n v� oZ � � __ , i � �f �o m, x nn 7'., z '� ?5 �a ciR �c D � �K z� o� on or m "� �:n � �, _� o � � , . �� �n o� �� �� � � �m -� �o ,I _.. ' . ' ' � • Yn]c �,Z '�i.x' "P �,—Ty xD O . • . . � �j N •.p -+O � In D . . � ' . � , . O❑ � ;� � � H - N . 'i � ' ' ❑ ❑ N � 1 . 'O f� � . O O D . . � _, � N z _ � � ' . . . ; N .._. .... .. . . _ ... N . , � , � n . . . � � ' � � A . . • N . N � � , C1 ' j , D • c , ' ' m ,I . . � ,(. . , , . , . . . �. � _ �J � � !" . ' . 1' �� /, r ,, � . , . � ' . � '1 vi � I . . 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