HomeMy WebLinkAbout1256A WORKERS'COMPENSATION DECLARATION 4,
I here6y affirm �hot I have a certificafe of mnsen� fo seff �
;nsure,or a certificote of Workers'Compenaotion Inwronce,or '�`� �s
o certified o rhereof � 3 �ae�., �����8�81� APPUCATION_FQR._PERMIT
P,,;�„�p���3233���„�'remont Indemnity �„
----- - - SEWER - SEWAGE D15POSAL
II Cerlified copy is hereby furnished. . . . ..
�]Cert+tied copy is f�led w�th ihe coumy ilding inspac ion COUNTY OF LOS ANGELES 8U1tDING AND SAFETY
department. -
Do�e 7_. /��7�I u(G�pplicam FOR APPLIGANT TO Plil IN CONNECTION DATA
CERTIfIGA7E OF EXEMPTION FROM WORKERS' �ipi� /
COMPENSATION INSl1RANCE nooaess sranor+ oevn�
(Thia sec�ion need not be complated if the work�nvoVved by the i�i�Tr � -- � - rewN�ap RevEa�Ncf o�R
permH�isforonehundreddollars�S100}orless.) �AyEsr n'PEOFCONNECTION ��TN� - -
1 tenify thar�in the�Perforinonce of the work for wfiicfi this cxoss sr v. cuaa P.L M.l ro r.�.
permit is iss�ed,1 shail not employ any penon in ony manner
so as to bemme suhjed b�he Worken'Compensafion Laws. �ER The Anden Grou P���N�� O/�
P co.inw.rro. �oe rm.
,w,��. ._..-..............._.. -.- .
' """"""-'- "'-' TRl1NKPEqMITNO- � 40ADPENMITNO. '
Doie-... .. .APPlicant �E�
YICE TO APPLICANT: If, ofler making 1}t�s Certificote of C17Y 0 • AFFIDAV�T WAIVER EASEMENT RECORO.�NSTR.NO. DATE
.emption, yoo_ehould.bemme subject to the Worken �EG� ,,,,, �
- -Compenwtion provisions of Ihe tabor code,you must forfhwith pegcvtvnpN iot�o. qwv.ap y�.�yipfNir�c
comply with such provisivns or�his permit ehall be deemed ��
TBVOked. BLOCN TW� 42586,Y STATEENCROACIIMEM
;��&�. PERMIi NO. -
LtCENSEO CONTRACTORS DECLARATION sze Of toT ` Now ore irn
- I hereby oNirm ihat I am licensed under provisions o(Chapter ��
9(commencing wiih Section�000)af Division 3 of�he Busi- euiioiru�s puacaa
ness ond Prof¢ssions Code,and my license ia��iuil force and
effed. cvMaARpt CONNERION CNARGE FEE ' 6
LicenSe Num6Er 7��LiC,CIasS �� ']� ���RE55 1'L REIMBURSEMErvi fEE O
n � v
COf���O[�y�� PT.iTMRTN(;9ote 7�3�J86 '371_GO/1/t WS�Rit/Np. GRWp MAP PROCfSSEDBY Z
ar, Riverside�i.ruo � ��
❑I am exam �under Sec. of ihe t.A.Co. �'°� � u[ eK vc O .
P i�Ns�Ho. c�iss la r ;j
No. �ESCRIP K FEE � V �.'
Plum6ing Code and/or Sec. of the Firut �µ
HW���RCprvNFCTINGTO � DATf tZ`I r VALIOATION Of
B.&P.Code for rfie followinq reason 5(pt�C TANK,$EEPAGE PIT OR FiNai � � Z
V;TS ANDiOG DR4INFIElO
Dote HOUSE sExrtR cot�NECTwc To ar
PRIVAIE DISap$Al SYSIEM
SigllQture CIXJNECi aODI'ION/+1 BL�G.OR �
OVVNER-BUILDER DECLARATION H'ORK TO HOUSE$EWFR �
, OVERROW SEEP�WF Pli.ORA�NFIELD
' reby affirm that I am ezempt from the Coatractor's license Ex1rv.,cessroo�,oerweu.Fw,NHote
�for the following reason(Secion 7031.5�BUiSnE35 Ond Pfo- ALTEN,REPAIR OR qBANDON HOUSE �
SSiOns COdB�: SFWEk pt OISPOSNL SYSIEM __.___.. -
0 1,os�owner of the property.or my emQloyees wi�b woges as - � �-�-� -- r i � ,��,(j P; �
�heir mie compensolion,will de tha work ond�he:+ructure r � ��
is not intended ar offered for wle($ection 7044,Business . {;�• e5 w � (?
and Protessions Code). � OWNEF!'S Permit S �
❑I,as owner of thc property,am exclusively contract�ng with AUTHORIZATION TOTAL PEE I �o � 7.S� �
(iten7ed coni�octors to con9fruct Ihe projecf(Seclion 7044� I NAYE AT THIS DATE A COtJTRACT WIM TME MEV.EIN NAMEU CONSGACIOR TO �
BUsifl�%Orld PIOfB55i0l15 COdl�. CONNER THE ABOVE DESCPiBEO F%ISiING DWELLING TO THE PUBLIC SFNER, t:�`�,�--'' ���,Ly'���
CONSTRUCTION IENDiNG AGENCY � �
I he.eby affirm fhor ihere is a construction lending ogency sic,r�eo niis Onv OF 19_ . G� ����(�
f0� �he performance of the work for which ihis permit is � �W�R� � � �
OwNERS AGfM
issued(Sec.3097,Civ.C.). �
a nooa¢ss
Le�der's Name
Lender's Address ''
I cenify tfiot I have reod fhis application and s�ote tho�fhe
above information is mrrect.I ograe to comply wi�h all Coumy �
ordinancea o�Sta1e lawt requlqting Plumbing ond Sewers,
and hereby outhorize reQresentatives of this Couay ro enter +e
upon tha a6ov mentioned propMy fOr inspection porposea.
RCR BY;��L�� 7/31/86�
Signatureof�ermittee Date SEEItEVERSEFORExPLANATORYLANGIIAGE
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