HomeMy WebLinkAbout1256A (6) WORKfRS'COMPENSATION DECLARATION 4,
I here6y affi�m �hot I have a certificafe of mnsen� fo seff �
;nsure,or a certificote of Workers'Gompenaotion Insurance,or '�'p �s
o certified o rhereof � 3 �ae�., �����8�81� APPUCATION_FQR._PERMIT
P,,;�„k����3233��w„�'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 QF LOS ANGELES 8U1tDING AND SAFETY
depa�tment. - - � �
Do�e 7_, /��pplimN FOR APPLIGANT TO Flil IN CONNECTION DATA
CERTIfICA7E OF EXEMPTION FROM WORKERS" �ipi� /
COMPENSATION INSl1RANCE nooaess sranor+ oevne
(This sec�ion need not be complated if the wwk�nvoVved by the i�i�Tr � -- � - rewN�ap RevEa�Ncf o�R
permit�isforonehundreddollars�5100}orless.) �A�ST rv�ppcoNNecria+ ��TN� - -
1 tenify thar�in the�Perforinance of the work for whicfi this cxoss sr v. cuaa P.L M.l To r.�.
petmit is iss�ed,1 shail�ot employ any penon in ony manner
so as to 6emme suh�ec�b�he Worken'Compensation Laws. �ER The Anden Grou P���N0� C)��
P co.imr.rro. �oe rm.
,w,��. ._..-................... ... .
' """"""_'_ "'_' TRl1NK PERMIT NO. . 40AQ PENMIT NO. '
Doie-... .. .APPlicont �E�
YICE TO APPLICANT: If, ofler making 1}t�s Certificote of C17Y 0 • AFFIpAViT WAIVER EASEMENT RECORO.�NSTR.NO. DATE
.emption, yoo_ehould.bemme subject to the Worken �E�� ,,,,, �
- -Compensation provisions of Ihe Labor code,you must forfhwith pegcvtvnpN ior�o. Hwv.oa 57.wioeNiraG
comply with such provisivns or�his permit ehall be deemed ��
revOked. BLOCN Tpq 42586,r STATEENCROACwMEM
;��&�. PERMIi NO. -
LtCENSEO CONTRACTOR5 DECLARATION size Of[oT ` Now ore irn �
- I hereby oftirm ihat I am licensed under provisions o(Chapter ��
9(commencing wiih Section�000)af Division 3 of�he Busi- auiioiru�s pat�
ness ond Professions Code,and my license ia�n iuil force and
effed. cvMaARpt CONNERION CNARGE FEE ' 6
Licenae Number ']�.�LiC,CIO35 �� ']� ���RE55 1'L REIMBURSEMENT fEE O
n � C {�/� v
COf���O[�y�� PT.iTMRTN(:Dote 7�3�l86 '371—JOV�/ WSTRt�1Np. GRWp MAP PROCfSSEDDY 2
�,r, Riverside��.,,p
❑I am exampl under Sec, of ihe l.A.Co. l�eNy tap � u�i�,qbs lz, eK vc O ,j
Plum6ingCodeand/or5ec. ofthe �'�O� �ESCRiP K �E � FINAI w !'
Fql)SE SfWfR CpfJtJ[CiING TO � DATF �,Z`I� VALIOATIO N Of
B.&P.Code for rfie followinq reason waiK ScwER r,
SEVi�C TANK�$EEPAGE GIT OR ciNAl �
P:T$ANDiOG DR4INFIElO
Dote Fp�SE SEyV(R coNNECT�f+G To 8Y
PRIVAIE DISap$Al SYSIEM
$igllQture CCfJNECi 4oDl'IONN BL�G.OR �
OVVNER-BUILDER DECLARATION H'ORK TO HOUSE SEWFR �
, WERROW SEEPA[�pi.ORn�NFIELD
' reby affirm that I am ecempf from the Coatractor's license Ex1rv.,cessvo��,oerweu.nvNHote
�for the following reason(Secion 7031.5�BUiSnE55 Ond Pfo- ALTEN,REPAIR OR qBANDON HOUSE �
SSiOns COdB�: ._ SFWEk pt OISPOSNL SYSIEM _—.__,._. -
0 1,os�ewner of the property.or my emQloyees wi�b woges as - �-�-�-�-- r i � ,��,(j P; �
Iheir mle compensolion,will de fha work ond�he tkucture r
is not intended ar offered for wle($ection 7044,Business . {;�• e5 w � (?
and Protess+ons Code). � OWNEi!'S Permit S �
❑I,as owner of thc property,am exclusively contract�ng with AUTHORIZATION TOTAL PEE I �o � 7.S� �
(iten7ed conh�ctors to con9ftucl Ihe projecf(Seclion 7044� 1 NAVE AT THIS OATE A COtJTRACT WIIH THE MERpIN NAMEU C�NSGACTOR TO �
BUsifl�%Orld PIOfB55i0115 COdl�. CONNER THE ABOVE DESCPiBEO F%ISiING DWELLING TO THE PUBLIC SFNER, t:�`�,�--'' ���,`�'�`�
CONSTRUCTION IENDiNG AGENCY � �
I he.eby affi�m fhor ihere is a construdion lending ogency SiGNe�TH15 Onv OF 19_ . G� ����(�
f0� �he parformance of the work for which ihis permit is � �W�R� � � �
OWNERS A(�ENT
issued(Sec.3097,Civ.C.). � �o��
Leader's Name �
Lender's Address ''
I cenify tfiot I hore reod fhis application and srote thar the
above information is mrrect.I ograe to comply wi�h all Coumy �
ordinancea ond Sta1e Iows requlqting Plumbing ond Sewers,
and hereby outhorize reQresentatives of this Couay ro enter +e
upon tha abov mentioned propMy for inspection porposea.
RCR BY;��L��� 7/31/86�
Signat�reo4�ermittee Date SEEItEVERSEFORExPLANATORVLANGl1AGE
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