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HomeMy WebLinkAbout0915A _.. _ . . . ._ ... ... _.... _. _ ._ _ WORKERS'CONIPENSATIOf�DECLA�RA71�N���������� � � - � - I hereby a4firm thot ! have a certificate of consent ro self 7� insure,or o cenificdte of Workers'Compensa�ion Insura ,or 6A642L` � � � . �� . II . . .. f 3JR�REv ie3� . . w . /��K.� .w,w . ; ..,..._ . . ... . .... .., ll a ce�t fied copy thereof(Sec.38�0��Lo G� /�pP�'eA���/,\'��0��P"�R�1111�- P°"`Y{,"I'�����f�"Y SEWER - SEWAGE�`b`1SPbS/�iL ❑Cert le op i e yJornished. . . � �-- � --- �� ❑CerriHed copy�s f�led wiiM the count�buu '" in ctio tOUNTY OF LOS ANGELES BUILDING AND SAFETY � .,.. , ,. _= -,...,... . . ._ ...u,:..:.. de a men .. .. .._. �...Y . . . - ... _. ... . Doiej Applimn� ,� FOR APPLICAN7 TO FI 1N CONNECTION DATA � TIFI ATE OF EXEMPTION FROM WORKERS' _ euaow� STATION �errH . COMPENSATiON IIYSURANCE �� � -�� � "nooaess —� (This seciion�need oot be completed if the work involved by fhe iocquT MP.NHOIE REFERENCE t�0 ER permi�is for one hundred doilars(8100)or less.) rvaeoFcoNrJECTiON � -tE�GrH Faon+ NEAREST I cerfify ihat In ihe perPormance of the work for which Ihis CkO555r. �' Y. CURB Pi M.L 70P.L. permii is issued,I shol�nol employ any pErson m ony manner � � v.0 No so as+o become su6ject to the Workers'Compensat+on laws. owNpR CO.IMP.NO. JOB NO. ,,_, ,_ � . Mqll TRUNK PERMIi NO. ROHO PERMIT Np.��� - Dtl1E AppiV[ant ADORESS AFFt0.4VlT WAIVER EASEMENi RECORD.INSTR.NO� DATE NOTICE TO APPUCANTi If, ofier making�ihie��Certificate of �irY Te�No. . . .............._, Exemption, you should become sabject to the Workers' ECA� �., . - Compensation provrsions of rhe Labor code,you must forthwith oexaianoN :oTNo of� . Hwv oasT.wioeNwc cqmply with such provisions or th�s permit shall he deemed q � . . ��" � revoked. - e�ocK TRAGT �UQ 1�j . . , , STAiEENCROACHMFNT� � � ���� n � .. . . ,.-........ .. ... . NO.OF tllDGS. �ERMIT NO � �LICENSED CONTRACTO'R�'DE'CI.Af�ATION`�"� sizeo=ior NOW ONLOT I he�e6y 6ffirm��1Foi I om licensed under provisions of Chapter u5E OF - � 9(commencing with Section 7000)of Division 3 of rhe'Busi- euiioiN�s �HAqGES _- ness and Professions Code,and my li<ense is in full force and ) . � effect. /,_r � � CONTRACTOR� / �,� CONNECTION CHARGE FEE � � License Number YJ LiC.CIOSS A�DRESS �'G RF!MBURSEMENi FEE , �7. ' � ^f �/ DISTRICT NO. GR04� MAP PROCESSED BV V CO�fiQCfO � CITY .. iEl.NO (v L� � ❑I am ezem �under Sec. of ihe l.A.Co. �qTE `C //� ) BK � �'/ � P LICENSENO � CU55 '� 7 � !�� �� 4�4 O Plumbing Code and/or Sec. � of the �� DESCRiPTION OF WO FEE FiNq� � " .. �ouse s�v�a coNNecnNc*o onre J;�± �(f VqLIDATION � B.8 P.Code for the fo(lowing reason � - � auauc SEwea � '/�/ �/�/ " -� ,oN^ SEPiIC TANN,SEEPAGE PIT OR � .�+(f FINAI Z ' ' ' ' PITSAN�-ORDRAINFIELO BY � � ��e HOUSE$EWER COIJNECTING TO � ' . � PRNATE'L'ISPbSAL SYSTE 4�� ��� Signature COMNECiAD�i7lONPLBIDG.OR'. ... ..-... ....-._•-...,._,-�.••-..:'�..'..'..-.'. WO0.KTCHCUSESEVJER � OWNER-BUILDER DECLARATION ovcaFiow st�ance vir,oaaiNFieio I hereby affirm thar I am exempt from the CoMraclar's License ex�N.,cessvoo�.oavweu,tiuNHotE low for 1he 4ollowing rgp50n(SECtDn 7O$1.5,BUISnB55 pf1CJ Pfo- Al*ER,REPAIR OR ABANDON HOUSE . fe55�On5 COCIEj: SE'NER OR�ISP05.4L WSTEM �09i,5A ❑�,as owner ot tha property,or my employees wirh woges o5 �'e n e • � a their sole compensation,wil�do the work and the struct�re is no1 iMended or offered for sale(Section 704a.Bosiness . �� � � • •5�5� and Professions Code). OWNER�S Pe�mit S 1P.S✓r f � a� _ ❑I,as owner of ihe properly.am exduslveiy rontracting wiih AUTHORIZRTION TOTAL FEE � S`✓" ��O� J'S' p licensed contro<to�s to consfruct the project(Section 7�4d, I MAVE A1 THIS DATE A CONTRACT YVITH TifE�NEREIN NAN(EO CONiRACTOR TO 0 1,0 9`U 4 Busineis On(�PrO;ESS�ons COcIC). CONNER THE PBOVE OESCR19E0 ER7511NG'UWEIC�NG�YO YFIE`G�l�BLIC SEWfR�� . .. . . ..............:............... , CONSTkUCTfON�CEF7D�l(J�G AGENri'" �"� , I hereby affirm Ihai Ihere �s a constru[lion lending ogency S�GNE�THIS DAVOF �9, for the erformance of the work for which this ermit fs OwNeaOR P .. . . p OWNERSAGENT - issoed(Sec.3097,C�v.C.). � nooacss lender's Name � . .-....� ....- . . . .: � ' . . �. . . .., .. . Lender's Address ����- -- ��������-�o[U�l1 I tertify that I hove reod this applicotion ond state that the � > � above informotion it rorrect.I agree to comply wiih all Counry �� �1 ! �L��j �• ordinances and State laws reguloting PI bing ond Sewers, .. ��j ,Q,4� c�,��F,/ and hereby autho�ize r presen�otives his Coonty ta emer "-1J.�-�,c-u-^�- �� � r%N upon�he above-menY ed pr eny � spection purposes. � ��1 � l�C ��f ign �ure of Permiftee Dofe , SEE REVERSE FOR EXPLANATORY IANGUAGE�� i � _......... .-,. ._. ., .. ._;. �..,. ,,.�:.c.- ,..:�.>.. . ., .. _ - " '- ..�...:a:.a s ra.,. .t'5.,..,. �... -,_:.,. "" ,w. .._ ,�._,.._. k �,. . :.��:. t';r ,_ , , ; __.. ..—. __ s�s��r.res�•2ra�r�s _--- -- E3t*r!�E?$-diti�1;6?F'It'I��E�1,���8:#3'IJiI.e..... ; ; , :.� _.__ _ ,��..._a�..a,,.��r.,.�..,. M., � ��. : ��P��`}af'��,$ �J�.�TE n,5�'CFCR 5 ki NATUCF . . ' . -.. .. 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