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HomeMy WebLinkAbout1254A (6) WORKERS'CDMPENSATION DECIARATION , ��.rol,� �FFj..., ;;.;�; ;;;y� u ccri;iicpre o�Conscni iO azii II msure,or a certifimte�of�Workers'Compensation Insurance,or �dA6G2U ZS . a certified cop iher ! Sec.3800,Lob C.) c[aon�uzv.s:et�. �pp���qTl01�1 FOR P�RIUlIT � Pou�Y�1�86�2i3`$�mpan�remont zndemnity ��� SEWER - SEWAGE [)iSPC)5AL ❑Certified copy is hereby fumished. �]Certified ropy is filed with the coanty uilding i�spo ion 530/ COUNTY OF LOS ANGEIES BUILDING ANU SAFETY deportmenr. � � i _____ �ote]�L�l{$eppl�cant�r� F�R A?�LIGAtVT TO FILL!N CON[VECTt4N DRTA CERTIrICAiE OF EXEMPTION FROM WORKEkS' _����,:n;;; -`�— COMPENSATION INSURANCE nooaess J �!� �f s`^'i°'� `E''n _�.�CL..--_!:s� ------ � This section need not be mm leted if ihe work involved b ihe uPFER I p Y iocn!nv D11I110T1C1 BciY rlaNHo�eaereawc� - iowea pennit is for one h��ndred dollars($100)or less.) ,____—. I certi4y ihot in the performdnre of�he work for which ihis ckossst. GOZC�.ETl Springs/Carpio rvr=oFce+e,vecnoy ,En�iyFRp.N, permit is Issued,I sh�,ll ne!emp!oy cny pe;scn In any manncr =_=-- _ Y Cuka i�: i+�i ���.�. so os to 6e[ome subjecl to the VJnrkers'Compensation La�vs. 1I1�E E1T1� - a c vo owntR :�iMv_rvo �oe r�o U;J�,�� � —__—'— M41'. /' TRUNk PERMI;NG. '�20AL�'ERMIT NO Dnte ._Applicant------- auoufss_._.._.�,_.�7._3.�s3.r�S_V12W_DY, ______ . .._-L— �TICE TC: APPLICANT� If, ofter makin fhis Cerlificale of (; (� A;FiDAvir wnivee [ns..H�hr ep[evn�,asTc�C n�'F s ��,r ovina �N�,:,,�0967-_541 - :mption, you should bemme subjed ro the Workers' ��qi --"— �r�' . __ � —�— Comuensatian provisians of the Lobor cnne,you must f�rthvoith �E;,^Ki�rin+: '-c��tiG'� Hwv pe sr wie=Hin�s — _— mmply wiih s�ch provisions ci ;nis permit shall be deemed — — revoked. , niocK �Hnci�; ,sTaiF ENcaono+:,��Nt c '�w.� '^�tic�cr s:oc;s ;�zaM�T No LIC..NSED CONTRACTORS DECLARATION � ..;R+��" � ��-- -- siz=_or loi ' NUw<;�v io* I hereby af�im•tna+I am li:ensed un7e�provision>of C6epte! �------- ------- SF nF 9(commenciny with Section 70001 of Division 3 of the�3usi- eunn!NG5 R e]Z 12.1 cHqkGts ness and Profescior.s Cade.and mv Ucense is in£oll 4urce and �,-`--------- -------- --- ' � c ..fFeci. i -., , �.,, �.C+.�. �Zt1IR�lY1� IT1C. .<;�r�rr,-�c�cNna,��c� �,. .. ,: _ ,�,._�-aa.T.,a r ---- �-------�- � L�censeNumber_„___�q�LicClass__ �, � �Hn�REs�gnol�ia �V2. �zF�Nai,asrN.iurF�c ..'�j � co„i.o�,A�_P.LIJMHIDIG_oafe7/�1 /R(� �t2'i�7e��i�e ...,, ���--g-�-8-�---- ��S=R��r�o �R;�,:� � N:A�� �4aE55=�3� �a irr -a.o. , � I� om ezempi under Sec__ _of the L.A.Co. u�irv5e an ��nss �� a� � !'"'e�,^ � _ ����> r ,��..�,�r�tiaF�-�uY: ::r � _.._...----.._ _.__ �___ � PIum6�r.rg�od�and�or5ec__ cfthe — _..__ rvq� j --- �f� v v oaNecnv To ��,j�—��V�on.. ��'/�'��a � 1/ALI�AT40ld � B.8 P.Code ro�the 4oilowinc�renson _ = E Y'�- - fT�I _ � � f rM1K ' E AC P� )4 —�� )� � � �S AN )P)V NF'L� _ _"__._"__�O'E � � '. lJ R .'�V4 '.NG ___ _' � ` � �J Av . rl J-R'!A J- 'Y h _—__'_�--.y.._'—�— $iynofve ____ ___ 9 C.'ti[ . .�a a�o c," � .�� ON�fdEf2 BUI��ER DECLAR�TION t8 woue �HoiSr�EN�u � �!^I;v nr'T Ihn��dT..?n,�(fr (' ��WL�ElL(,Y4 SE,AGF P�i�RAINFIEL� o., �o nt•nc`or'sLiconse :�'. tiS � � v�" Hn���;�iF , for fhe tu la ir�g rea on(Secfo 7031 5,3��:sness and Pro� rE4 kF n.oR cBanoCN .oUs[�� . .ssons Codal , �'+e ne> >os� svs Ev t I -1 I,as owner of ihe property,or my emplpyeos with wayes os i�_„___ _� .. �I ���':,�N ihair sol=cnmrensation,will do�he work cand the siruc7ure is nct irtendeu cr offered for sale(Sec!ion 7p44,Business — - � --------- � . ., _ a , . and Professions Code�. OWNER'$ PP.�mit S L ,��[} � ' '�]I,as�wner of rhs properry,�m c�xdusively coniracting with f ��f���IZATION TOTAL FEE �r �}l' .� " "� �,�, !icensed mnirpciors ro construct ihe projcct(Secfion 7044, ;. i,�p���cr rHis na?E n mv�w:'r�.v!��,���,+v r!F2e'��:?��'�.m Co�uTanC�oe ro Business ond Professions Code). (. :euaFcr r!+.e aaove oEs�u!seu=.xis:�ti'r,ow.i;�.�;c ro r�ie r-uRuc s[vna . � �%�(.:.;',!��, � CON57RUCT!ON LFNDING AGENCY . . I hereby affirm iha� the�e is a construcfion lending agency . SIGNEDTHIS UAYOF__ 79_ � ;;'j r.ii"�(? far ihe performance of ihe woik for which ihis pennit is • '��vucHoe � owN:es n�e�i---.-------_ --— issued(Sec 3D97,Civ.C). - � �� nnozEss Lender's Name � Lender"s Address__,_ i cerfify thot I have read this application and state�hat ihe above information is rorred.I ayree to comolv wiih oll County ordinances and Stafe laws regulnting Plumbing and$ewers, and here6y authorire representatives of fhis County to enter upon fhe abo}5e-mentioned prop ty 4or inspeclion purposes. t RCR BY;l 7,/31 8 ����,_._-_ � 6 Siynature or vermittee Uafe SfE REVERSE FOR E%PIANATORY LANGUAGE Yn+� DO �'� .�+. DSC+.Cna f m � v� Dn A� �n a� oL � � � �:-' OZ ^�'m O a� Zm g � m Zm Oo D G�� C `.�, �„y �x OD m '0 � p� ���g�c�CJ �' p$ TM -o�' � n cr � Tm �~ � y mC � y AC 1 � t W R mZ yc1'^`! 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