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HomeMy WebLinkAboutNo Permit Number WORKERS'COMPENSATION DECLARATION � � � A ' I hareby affirm that I have a certificata of consent �o self ��7p � 1s � insure,or o ce�tifitole o/Workers'Compenwtian Insurance,or °`°";',�`oPy'""'o"�`.'e°°,`ob`, "�`R`�.B,", qppLICATION F4R PERMIT Polity No. Compony 0i i ❑ce,,;,;�a�,vY,s hs,sby,�,�;,n�a. SEWER - SEWAGE DISPOSAL ❑Cer+ified copy is f�led�+��h+he counry buitding inspec�ion • COUNTY OF L05 ANGELES BUIIDING AND SAPETY � departmenl. - � � � � oar� ApplicoN FOR APPLICANT TO FILL IN / f _ �3 CONNECTION DATA CERTIFICA7E OF EICEMPTION FROM WORKERS' euuw�c �I f� LEINON t-�C SuraN l�� 0 oevTH / � COMVENSATION INSURANCE .+mitEss 'Y J (This settion need nol ba compleled if�he work involved by the �/ G/7" , �up�t�FEa�r�c� p,�3/ ` a � � -permil is for one hundred doliors(E100)Or less.) � - ���� I certify that in the performance of the wwk for which this c�sr. �7L� CQ'-/M/� nPEOFCON"K��O" �"w�"�'. � ' r. cuae i. M.�.To v.�. } pe�mit is iasued.I thall not employ ony penon in ony monner y�a��'^' �f /�f P.c.�. � O so as ro bacome wbject�o�he Workars'Compensa�ion laws. ow�a /�'-�-"'�T �F .�c �,�y�.fF. � to.u�na.r�o. �pe r.p. V - - �'� ��•LC/X z20�'� TRUNK VFRMIi NO: ROAD PERMIT NO. � Dale Appliconl • nDDRES..` NOTICE TO AVPLIGANT: If� OE}Of makin 1{li5 �C��1{ICOIB D{� � ARIDFYIT WAIVER EPSEMENT RECORO.INS7R.NO. DATE 0 9. ��, ,er �TF�.�.�i�f 5�0�..GY� � ption, you should become s�bject to the Worka�s' i�� � �U —�` u _ pensalion provisions of tha Lo6or code,yoo must forthwith cesca�vr�po���or r�o.- - Hwr,oa st.�vnoer+ine . a � tomply with such pravisions or this permit sholl be deemed p/' y fOVOkBfJ. - BIOCK TRAC7 07��� S/AlE ENCROACHMENT Z UCENSED CONTRACTORS DECLARATION r�o,a e�o�a veRxuT rq' . 512E OF LOT, NOW ON LOi g ' I hereby offirm iho�I om licensad undar provisions o(Chop�e` �� AM �/ ���i�/y/• o�f,l�� � � 9(tommenti�g with Section 7000)of Division 3 of the Busi- eunonaG5/UFfit/ �/�/��F+�f�%�/�y /77�� p���s . ness and P�ofessions Code,ond my license is in full force ond ��,L`, �/,K � effeci. ���j�� eor+taneroc in1l �v� r eo'+�+eeriou weac�� � license Numba�-�"��w' tic.Clau C�� � BZZ¢ �E• /Iry,'��/�'/I. /�hJ^' qpp�s5 REIMBVRSEMENT iEF COn�1OC10f„-"'ry� DOI! ���7 FJ J CIIY .� (rt(/(�%j�� 7EL.N0.//f �8/��T�/ O4TRiCI NO. GROVo MAP VROCESSED BY �, ' ❑I am exempt under Sac. of rhe L.A.Co. �A�� ���� ��,�� 4o R.��- .� a �3 �%iyi� � � NO. DESLRIpf10N OF WORK HE � ' � PlumbingCodeand/or5ec. ofthe F�� � �//��I ATION &K SF4�VEA CONNFCTING TO ' DATE ///Z3�} ' . B.8 P.Code for the following.eason p�K TANK,SEEGAGE qT OR �� � � PITS AND/Oi OWINFIFID FINAI � . �o1e �q{)g SEyyER CONNECTING TO . Bv ' � ' PRIVAT DISPOSIL SYSTEM . . $i9nOtufe - COH7ECf ADDITIONAL&OG.OR � OWNER-BUIIDER DEClARA710N � woc�c ro'au5[s�wEp � . . - I hereb affirm rhar I am exem i from iha Contractor's License ���OW SEEPAGE PIT,DRAINfIFID � Y P ExiN.CEsSPapt,qtYN'Ell,MANHOLE . . law for the following reason(SeNon 7031.5,Buisness and Pro- uhR,a�r,.�zoa neewaa Noust - � - �..,�ioas Code): s�wea«e o�so�osn�srsnrn �I 1 2 3 A � oscw•;�,��•��p:cpe.'•,•,c:�^ycmp!oyeaswi•�v:c-y�scs � � . their sole compensation,will do the work and tbe structure � +�`. � .v� (1 is not inlended or offered for wle(Section 7044,Business �� � -- � - ; ond Profess�ans Code). OWNER'S PBrmit f � � � �2�j� ❑I,as owner of�he property,am exclusively contrac�ing wilh AUTHORIZATION TOTAL FEE � � � ' ' � : licensed contractors�o construc�tbe Plo�e[f(SeC�i00 7044. I HAVE AT h115 DATE A CONT4�CT WITH TIIE HEHIN NAME�CpVTYwppR i0 • " •2 7.5�_ Business and Profezsions Code). cor+nea n��eove oescaieeo exisnn�owewr�io TNc Pueuc sewtR.� �- ', CONSTRURION LENDING AGENCY - C , O b,1 b-�3 � heroby affirm ihat Ihere is a conzlrutlion lending agency SIGNED THIS � Of_ ���`�'�- I _ - �- . � for the performance of ihe work for which this pe�mit is o°�NEa , - ', issued(Sec.3097.CiV.C.�. OWNE N[ � . ADDRESS Lender's Nome � � ' Lender's Address � ' . ' I certify fhai I have read this opptitotion ond sto�e thot tbe . � - � � - - � . . obove information is correcf.I agree fo comply wi�h all Coun�y . - � � � . .. ordinances and Slale laws requta�ing Plumbing ond Sewers, � � � . . . . and heieby authoriz presentatives of this County�o en�er � . . upon " ned prop ty for inspection purposes. � � � �r/��v� . ._ _.. .. . . Sig ure of P�e � J ���1ot�, � � SEE REVfRSE fOR EX/IANATORY UNGUAGE , _ � � �il.�A�/�el , i � , ", , � . 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