HomeMy WebLinkAboutNo Permit Number WORKERS'COMPENSATION DECLARATION, - - Q �
I heraby offirm �ha� I ho�e a cerlificale af mnsent to self �y,�yazo - - � � LS
insure,or a cxtifitaie of Wor4eri Compansation Insurance,or
o certified copy the�eoi(Sec.3800,Lab C.) �E��R�,.B,a„ � qpp��CAT10N FOR PERMIT �
Polity No. Compony - 9s . '
❑Certified copy is hereby fumished. � � SEWER ' SEWAGE DISPOSAL � � �
❑Cenified copy is fued wilh fhe counly building inspection COUNTY OF LOS ANGELES ., - � BUILDING AND SAFETY�' - � �
deparfinent. �
oore Appltccnr FOR APPUCANT TO FILL IN �G j��o•C3 GONNECTION DATA '
CERTIFICCO�pENSATIONI�INSUR NCE RKERS' � Bu,�ss /JI� /��//J�y�� ,/ S� p
I�/?�S. F'�.I��V/V � rE STAilOr1 0 OEPTH
(This sec�ion need nor 6e completed if tha work involved by�he ����n, �/�(f�fr MAWpIE REFERENCE �,j� �R �
permit is fo�one hundred dollors�f100)or lesf.) ' �1 r���� � �
I cerlify that in ihe performance of the work for which thiE cEcpussr. C.Y TY°�����7� ��'THFCOM
V. CUR9 P.L. M.L.TOP.L �'
permil is issued,I sha(I nol amploy ony perton in ony monner � �
�.�1� v.t.rvo.
so as to.become subjecf to the Workers'Compenwrio�Laws. pN,�q"���� v'�� t-/rc-�� [o.mw.r+o. ioe no. � O
. Mqll /Jur yy'��/ i�J/y) TRUHK PFRMIT NO. � RWD PERMIT NO. �� a .--
Dole Applimnt nonrs�ss r e�b�n �.-+^c.�ei .
�1 � AfFIpAVII WAIVfR EASEMEM RFCORD.INSiR.NO. DA1E O
NOTICE TO APPLICANT; If, ofter moking this Certificme of �n./(l�j{/��/�TE�.ra. s�ej��SQ� � V �
� �m ption, you zhould become subject to Ihe Worke�s' i�µ.�C �/ � ;
,Inpensation provisions af Ihe Labor code,you must fonhwith �xmmip(� LOTNO. �`"S � HWY.O45T.WIDENING " a'
comply with such pravisions or Ihis permit shafl be deemed ��y�p y �
revoked, � BlOoc TRAR �'L�a/�^ STAIE ENCROACHM1�NT � �.
NO.OF ElOGS. ifRMR NO. �
LICENSEDCONTRAQORSDECIARATION siuoviot � ruoworaior � �
-I haraby affirm thol I om licenced under provisions of Chapler-- �-`� `�L�/YO. ��'3� .
9(commencing with Sec�ion 7000)of Division 3 of the Busi• g�uiioir�s Gov 5/V�sL�/� /li � puqc�s �
ness ond Professions Code,o�d my lite�:e is in full 4arce and �/ . .
effect. � /� - couTe�crox�`f�p GI/V S �COwJECT10N CHARCf FEE . .
license N�mber�%/J3 Lic.Class G l� �� A��u � /¢�/��C rteiMetwsen.tNr�e -
/�l•G✓/US ���3 ^ wsmierNo. c.�a�P ,w.P w«esseoe.
C011�fOtfO� �a�e CITY ry. fELNO. � ^� � ��,
Q� BK AG
❑I am exempl under Sgc, of ihe LA.Co. S�ENS�np �pc�3 � �ni s5 G-/ � 3 �/�.�/ � '
'�+0. �ESCRIPiION OF M/ORK FEE
PlumbingCode and/or Sec. of rhe ���a cwar.�ainc ro onTe y�.A� ` VA� ATION� � �
B.8 P.Code for the tollowing reason � °UB1���R � v! ���G; . . �
PTIC 1ANK,SEEPoIGF VIT OR f�A( �
PITS.NJ�/OR ORIINJF1ElD �
Date � Hous�sEwca co.+�ci��ro ar. .
PRIVAfE UI YST M
Signoture COHNECI ADDITION�I&DG.OR ' �
OWNER-BUItDERDECLARATION ��ortKTONovse ucc �
I hereby affirm thal I am exempt from the Contractor's License �N.,�CFSSPOOL.DRYWE0.pIMAN�MOLE . ' � �� � Z Q A --
�aw for�he foilowing reason(Secron 7031.5�BU�Sf1B55 Ohd Pf0- MTFR.RFPbR O4 ABANpOH HOUSE - �- , '
/�,S�Of13 COdB�: SE`NFR OR DISR�SAt SY57fM � $� e e � , O
--iJ�,as owner of�be proparty,or my employees with woges as �
their sole compensotion,will do�he wwk and fhe structure � ' '2 7�7� -
is not inrended or offered for sole(Sec�ion 7041,Bosiness � - - � � �
ond Professions Code). OWNER'S Permit S� 0 ,�� • • •C�.���
❑I,as o.�ner of rbe properry,am exdusively controtling with AUTHORIZATION TOTAL FEE " S1`J /� (� Z
licensed controctors ta construct the p�oject(Section 7044� I NAVE AT THIS DAiE A�ONTNA�f WITH TME HEREIN NAMED CONTRACTOR TO � ' U LV� V��J ,
Business ond Profeasions Code). Cor,�r�tt 1He nBove SCAIBfD EXiSTING DM�ElLM1G TO TNE Pf�IIC SEWFR. �' �� � " -- - -
CONSTRUCTION LENDING AGENCY �����.�.y ,
I he�eby affirm Ihat there is a conshoction lending oqency �GNEDiF/15� � voF v��'�/ �� � t _ � � � � �
for the performonce of the work ior which this pe�mit is o�+Fa .
OWNE AGEN . -
issued(Sec.3097,Civ.C.J. � ,�pREu �7 si
Lender's Nome
Lender'sAddress � � �. -
I terliiy thal I htive read lhis applicalion and slole�that Ihe - � � ' � �
above informotion Is correct.I ogree to comply with all CooMy � - ' . ��
ordinonces and State laws regulaling Plumbing and Sewers, , � � � � • � � - -� .
ond hereby author'e represenlatives of Ihis County lo enter - .
upon the above- lio�ed eny for inspection purposes. � - . . _ .
��6�
Sign re of ermilte� i!_..,.Duty�C,�. . SEE REVERSE FOR E%PLANATORV UNGUAGE � ' �
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