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 � . -
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