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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�� �. Si oture PeLty�ittCC�`G'� CQ I � SEE REVERSE fOi EX►IANATONY LANGUAGF /�� r . , •;.. .. ' . • fC.� D� �� ^n' 7v Co m � . 9 T go >° .� o� �m o • • � �� 8Z mT �n c�� �c y� -- . . . � � . � � � N N Z� oy �n Oa m 'fl . . , , . '� _-• u ❑ Y' ,�o � � . ❑� O� 8�� ;^� oo � O �.� - , �c, . p _ � . ^`� mD N� � Vy �D G CA . . v' �O NO S u` N . . ' . ' .. � ' . . . � .� . �� � ;H f � ' � . . '. ... . ❑ ❑ . N • . '9 , � ___ .. ._... ! . , . D . N � • � O ' __.. 1 . . . . �1 N � ^ , N . . • I . ' n ,n ' � N i " y` . �� Z . y , , C A i . . - . 1 ' . , . ' . . , � . . �' � , : . ` �� � /' .1 ` ' . . 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