HomeMy WebLinkAboutNo Permit Number WORKERS'COMPENSATION DECIARATION � . � �
I hereby offirm �hat I have o certifita�e oF consenl to self . . � � ' -
insure,or o certificnte of Workers'Compensotion Insurance,or �w+aso , � � -� ' �
a certified mpy thereof(Sec.3800,Lab C.) � ce eoe IR[v.eiat� ppp��CATION FOR PERMIT � � �
Policy No. Company �s
❑Certified copy is hereby fomished. SEWER • SEWAGE DISPOSAL -
�ce���t�ed copy�s filed wirh�he counry building��sPe�ro� COUNTY OP LOS ANGELES BUILDING AND$AFETY
deparlment. . � -
Date Appliconr FOR APPLICANT TO FILL IN �}`'� � 3CONNECTION DATA
CERTIFICATE Of EXEMPiION FROM WORKERS' � ewiouac/ s' /�M�N��E'� STATIpN J/'�3� cevrN � �
� � COMPENSATION INSURANCE ADDRE55 L.T�i• ,
(This section need not be mmpleted if the work involved 6y the i�i�T� ����j M4NHOlE REiE4ENCE p,�3 �
permit is for one hundred dollors(5100)w less.) '�.—^^ /�j� ��p
I ceriify fMt in the parformance of the work for which this cRosssr. �/// '� [�/[��/J � iYPEa���11ON ��'HF�a+
- "� `"'"'A V. NRB P.4 M.I.TOP.L. �
permit is issued,I shall not employ any person in any manner � C.
so os to 6ecome su6ject to the Workars'Companwlion Lows. ��.—�r� /�/ Al , o.c.u0. r �
OwNEa rf'C�+�L•GT � —a�. C+�f'� CO.IMv.NO. JOB NO. .!� V ..__
Daie Applicont �J �j��/� �j/�
ADD'Rf55 •�• �"v/� `��/ iRUNK PERMIT NO. ROAD PERMIT NO. �
g � � TfLNO./I S�V�TJSVC./ p`FFIDAVII W.41VER EPSEMFN7 RECOQD.INSTR.NO., DATE O
'NOTICE TO APPLICANT: N, ofler mokin this Cenificate of H
�mpiion, yov should betome subjecl to.the Workers' , U
penw�ion provisions of the labor tode,yoo must forthwith oesc�� N �oT�. �6 NWY,pR ST.WIpENI1Jp d
comply with such provisions or Ihis permit sholl be daemed . /� v�
revoked. � . � - e�oCK TRACI ��7�� SiATE ENCROACHMFNT L
LICENSED CONTRACTORS DECLARATION Np.OF&DGS. fERM1T Np. �
I hereby affirm thal I am licensed under provisions of Chap�er SaeoFior . nioworaioT `IL.� ,vo. �7/�,�8 - �
9(commancinq with Section 7000)of Dwision 3 of Ihe Busi- g�iiDrtres N�1 s/NGL�FiF�'IiLY /� cr�A 5 '
nass and Professions Code,and my Ilcanse is I�full force and ��� ���
effec�. �(��j�y3 G / � CONTRACTOR a /NS- CO. CONNECTIONCHARGEf(E ' '
Litanse Number 4� liC.CIaSS�y � ,e,ppq�y�8'y7L� ��y`/fS (/L�NU ' Rc�MBUR5Fl�1ENT f{E � '
�/ � !��� �
COAIfOC�Of I/�S Date ~ DISTRI�f IJ�. GROIJP MAV PRpCE55ED BY
��T. �ma.vG.� ,��.�.7� 9g''r-.5431
� � '/�
1 ❑I am exempt under Sec. of the L.A.Co. iKE�r,p. �Q 53 ti�55C^�z � ,G��y,
� PlumbingCodeond/or5ec. ofthe "p� DESCRiPfIONOFwORK RF qNq� �� JJI
1 11p115E SEN'FG CpNN(Cil1lG TO a 7 DAiE �A�3/�� �(�
B.8 P.Code for the following reason � °1�a'��`"ER �i d'� VAL ATION �Y .
SE I T�NK, VAGF PI7 OR pNAL
� � P�15 ANDiOR DRMNi�EtD � .
DOIB . NDUSE SEW[R CONNKTING TO !Y . '
N2IYATE D SYSTFM �
Signorure tormtcr,wonio�wi gip�.ou � .
OWNER•BUIIDER DECIARATION • `Na+K ro�+ous[s�w[c � .
GIERfIOW$FEPAGE Ri,OFAINFIFLD
I hereby affirm thot I om eaempt from the Conhocror s License E%M.,CE551'OOI.DiYWEIL MANHIXE ' '
'nw for rhe following reason(Secton'7031.5,B�isness ond Pro- �anR,rserux at.w.noori�ausc � �
�s�ons Code): s�wea ae oisros�i srsmM �1 1 2 5 11
� -L�I,ns owner of Ihe property,o�my employees with wages as - � .
` their sole compenwtion,will do Ihe work and the slrocture �° � � � � �
+ is not intended or offered for sole(Section 7044,Business � r
' and Prolessions CodeJ. ' OWNER'S Permit s D � • '����� :
❑I,as owner of tha property;am ezclusively contractinq wirh AUTHORIZATION TOTAL FEE � . • . .�j,�O u
licensed contractors b conshuct�he project(Sac�ion�a�� I HAVE AT TNI$DlITE A CONiFrl�l WITM TF1E IFRFIN NAMFD CONTRAROR Tp
Business and Professions Code). . cor.�r�cr tri[neovc oe:a�aeo exisrir,c owFwNc ro rHc ru�ic sEwea. - �� � � O�1 �—�J
CONSiRUCTION LEND�NG AGENCY � - - / � �i,�'G/,S+r^ p� ,
� heraby off�rm rhor �here is a consvoction lend�ng ogency SIGNEDTHIS AYOF ta'�� - ,
( for fhe performonce of the work for whith this permit is O�'NEa , . .
OWNER
issued(Sea 3097,Civ.C.). � .
ADORF55
leadar's Name ' .
Lender's Address � . .
I certify thot I heve read this application and sfote thot tbe ' . �- �
obove info�motion ii corred.I ogree to comply with all Counly � . . � �
ordinonces ond Stole laws regulating Plumbing and Sewers, � - ' .�
and hereby au�ho Fe representa�ives of ihts County to enter � �. �
upon 1 v Flioned roperly for inspection purposes. � _ - . _ ., . .
b'-/6�� �.
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