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HomeMy WebLinkAbout0915A (4) ... _ ., .. . . . .. ... ... _.... �. . _ _ WORKERS'CONIPENSATI01�DECLA�RA71�N������������ � - I hereby offirm that ! have a certifimte of consent ro self 7� insure,or o cenificdte of Workers'Compensalion Insura ,o� 'bAba?� � � � . " 11 . . .. f.3JR REv �83� . . w .. /��K.� .,....w . -, ..,..._. . . ... .... ., ll a certfied copy thereof(Sec.38�0��[o G 1 /�p��'eA���/,\'��0� P"�R�1111�- ... . P°"`Y{,"I'������"Y ' SEWER - SEWAGE b`1SPbS/�►L ❑Cert le op i e y urnlshed , . � �� ^ COUNTY OF LOS ANGELES BUILDING AND SAFETY � ❑Cerfified topy is filed wiiM the count�bwl ' in ctio . ._ . - ,_a,�,__._.. .. .. .._. _..._ . . _. .,.. .....�. ,. .. ..= '.,....,... � .:...� _ ...... ,,. �de a menj�'��� �"� '�� '"' " Doie/��i���/X�f nppl+mni ,9,� FOR APPLICAN7 TO FI 1N CONNECTION DATA TIFI�ATE OF EXEMPTION FROM WORKERS' euitoia� STATION �evrH . COMPENSATiON INSURANCE � � -�� � "nooaess —�� (This seciion�need oot be completed if the work involved by fhe iocquT MP.NHOIE REFERENCE un�R permi�is for one hundred doilars(8100)or less.) rvaeoFcoNr�EctiON � -��rH Faor,+ 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 pny manner � � v.0 No so ns�o become su6ject to the'Norkers'Compensat+on laws. owNpR CO.IMP.NO. JOB NO. ,,_, ,_ � . Mqll TRUNK PERMIi NO. ROHO PERMIT Np."� - Dtl1E ApplVroni ADORESS AFFt0.4VlT WAIVER EASEMENi RECORD.INSTR.NO� DATE NOTICE TO APPUCANT:lf, ofier making�ihie��Certificate of �irY Te�No. . . .............._, Exemption, you should become subject to the Workeri ECA� �., . - Compensation provrsions of rhe Labor code,you must forthwith oexaianoN :oTNo of a� . Hwv oasT.wioeNwc cqmply with such provisions or th�s permit shaU he deemed q � . � ._._. . revoked. - e�ocK TRAGT �V�1�j . , , STAiE ENCROACHMFNT� n � .. . . ,.-......... .. ... . NO.OFtllDGS. �ERMITNO � �LICENSEDCONTRACTO'R�'DE'CI.Af�ATION`�"� sizeoFior NOR'ONIOT I he�e6y 6ffirm��rFoi I om licensed under provisions of Chapter u5E oF - � 9(commencing with Section 7000)of Division 3 of rhe'Busi- euiioiN�s CHARGES ness pnd Professions Code,and my li<ense is in full force and J . � effect. /,_r � � CONTRACTOR� . / �,� CONNECTION CHARGE FEE � � LicenseNumber YJ LiC.CI045 A�DRESS �^ G" RF!MBURSEMENiFEE , �7. ' � ^f �/ DISTRICT NO. GR04� MAP PROCESSED BV V COn1iQCt0 � CITY .. iEt.NO (o L✓ n � ❑I am ezem �under Sec. of ihe LA.Co. �qTE `C //� ) q BK � �'/ � P LICENSE NO � CU55 " 7 � !�� "`��% ""�"4��4 O Plumbing Code and/or Sec. � of the �� DESCRiPTiON OF WO FEE FiNq� � " .. �ouse s�v+ea coNNecnNc*o onre J.�± �(f VqLIDATION � B.8 P.Code for the fo(lowing reason � - � auauc sewea � '/�/ �/�/ " -� y SEPiIC TANN,SEEPAGE P�T OR � �(f FINAI Z ' ' ' ' PITSAN�-ORDRAINFIElO eV % ' ��e HOJSE$EWER COtJNECTING TO � ' . � PRNATE'L'ISPbSAL SYSTE 4�� ��� Signature COMNECr t�ppi7lONPLBLDG.OR'. ... ..-... ....--..-...,._,--•••-....:'�..'..:..-... WORKTCHCUSESE�NER � OWNER-BUILDER DECLARATION ovcaFiow st�ance vir,oaaiNFieio I hereby affirm thar I am exempt from the CoMraclar's License exrN.,cessvoo�.oavweu,tiuNHotE law for�he fol�ow�ng reoson(SECtDn�O$1.5,BUISnB55 pf1CJ Pfo- Al*FR,REGAIR OR ABANDON HOUSE . fe55�On5 COCIEj: SE'h'ER OR�ISPOSAL SYSTEM �09i,5P, ❑�,as owner ot tha property,or my employees wirh woges OS �'e n e • � a their sole compensation,wil�do the work and the struct�re is nol iMended or offered for sale(Section 704a.Bosiness OWNER�$ Permit S 1P.i✓r � • •5�5�y and Profexsions Code). c. • a��,5 Q� ❑I,as owner of ihe proper�y.am exdusivefy mntracting with AUTHORIZRTION T�TAI FEE ,,>S' �� p licensed contro<to�s to consfruct the project(Section 7�44, I MAVE A1 THIS DATE A CONTRACT YVITH TifE�NEREIN NAN(EO CONiRACTOR TO 0 1,0 9`U 4 Busineis dnd PrO;ESS�ons COdf). CONNER THE PBOVE OESCR19E0 ER7571NG'UWEILiNG�rO rFE`G��78UC SEWfR�� . .. . . . ..............:.............. , CONSTkUCTfON�CEF7D�l(J�GAGENCY" '"' , I hereby affirm Ihai Ihere �s o constru[lion lending agency S�GNE�THIS DAVOF �9, for the erformance of the work for whith this ermit is Owr+eaOrt P .. . . p OWNERSAGENT, - issoed(Sec.3097,C�v.C.). � nooaEss Lender's Name . .-....� ....- . . . .: . . .p . . . , .. . abovr's Address �..-,-.-. ........ ��[L`?� .. ��- Lend I tertify that I hove reod this applicotion ond state that the o > � � e informotion it rorrect.I agree to comply with all Counfy �� �1 � �<�� ordinances and State laws reguloting PI bing ond Sewers, .. ��j R,4� c���f,/ and hereby outho�ize r presenfotives his Coonty ta eMer !-'11.��-�-'�"�- �� r%C� upo��he above-menT ed pr erly � spection purposes. � "✓ � l�C ' ��f ign �ure of Permiftee Dofe , SEE REVERSE FOR EXPLANATORY IANGUAGE�� i � _....... .-,. ._. ., .. _;. �..,. ,,.�:.c.- ,..:�.>.. . ., .. _ - " •. '- ..�...:a:.a s ra.,. .t'5.,..,. �... ,,. r,, .-,::.�. r,w...__ , .._ ,�._,,.��. ,. :.. . �,:..,: , .._.. .._ . __ s�s��r.res�•2 ra�r�s _--- -- . E3t*r!�E?$-liti�1;6?F'It'I��E�t_:��8:#3'Ie)iI'.e..... �. .'.' ..�'.;� G ' _.,��. � �..�_ _ _ ��P�.yeV�rtTLS 5�J Jr�TE t„S�cCFCR 5 kI NATL'GF . . . . _ . _�_ —'__ —_.. -..___..______. I I1C:2U}'AETP4'M+I9:3L I AIR Y.!(2rtS�:i�T01ri tPlC C.UFi(Ynl'LOI''ti r:ew Nouse s�v+=_s .,4,.... . Licensx i,ac, tor:he foilo+riitg rinsi+n (Src.in�: 7lt3l.i, �ecNNE-Ao����. � � -- — _ 7+e_i mtx unc Profesc�ans Co�lr):Ariy cils nr couiaty wdicF. �BU.tD�vc oa wo3K �� . . ... ,... ,. . ..,. . eqniree n pie,��rr%1Yo r,o�trlruct,at e,iinprovv.dernnlrrh,ar }sePr�crnnk.sFea. .��5:".�- ..--�-- — -- • .„ -- .�. _ r pa�r arry str�istiere,,r,.ior to i1s ias�aante,«7so:dqr;�-es ilie ANO O'Jka�n<FI'0 � . .: . .. . � � � . 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