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HomeMy WebLinkAbout0697A WORKERS'COMPENSATION DECLARATION lZ q I hereby dRirm tFwt I hove a certificote ot consent fo self ��������87 ' • I� ' 76/.6apD insure,or o certiiimfe of Workers'Compenwlion Insurance,or �E� � - LS - a certified copy�karoof(Sec.3800,1���. ���r� �� - �� -APPLICATION FOR PERMIT Pol"�r o. �^pany �_ . ' . � ❑c�.°� �oPY„ ,`�3Yf�,,,;sh,a. SEWER • SEWAGE DISPOSAL - � ❑Certifled copy is filed with ihe counry buildinq inspecrion COUNTY OF LOS ANGELES BUILDING AND SAFETY - d nme 5��7 � � Dore Applicant � FOR APPUCANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' �iioi� . . , ' COMPENSATION INSURANCE � noo�ss �O StATKKJ . �EVfH �Thia section need not be complerod if tha work involvad by the - C-- MANHpIE REFERENCE �Q� permii is fo�one hundred dollors(5100)or less.) �«°'°T� . . . M1EACEST . TVPEOFCONNKTION ��p{Fqpµ . I tertify ihm in the performance of the work for whith this CROSS ST. � Y. --- ._ .QJpg _- V.L: -. .M.L.TO P.4 ' . . . permit is icsued,I shall not employ ony person in o�y manner P�N� � so os to become subject�o the Worken'Compe�wfion laws. - owr�a � m.iMv,r�o. - ioe rio. .Q d . .. M41L TRUNK PFRMIT NO. ROND iERMIT NO. Do1e Applicant ��u/1 � . NOTICE TO APPLICANT: If, oker Rqkltlg 1h15 �Q�Ilfl[OIC Of QTy ` TE�NO �C �q AfFIDAVIT WAIVFR EASfMFNi RECORD.INSIR.NO. DAIE F-amplion, you should become so6ject to the Workers' iE�At ` �pensation provisions of tha Labor coda,you mus�(odhwifh pp$�RIPfION totNo. � ryy/y,�q$t.WI�[NING _. ply wi�h such plovisions or thla.permit ahall be deemed revokad. . siocK TRAR � - STATE ENCfAACHA4NT IICENSED CONTRACTORS DFCtARATION � � � � � �r/°.°F&°cs. . ffaMiT r�o. � I ha�eby affirm thai I am liwnsed under provisions of Chapter SREOFLO7' NOW ON l0T . usE oF 9(cammencing wilh Secfion 7000)of.Division 3 of the Busi- euiton�s - � O�aaGES ness ond Profassions Code,ond my licensa is in full force and - ef{eC�. � ��pAR� � CONNECTION CHARGE F{E ' licenseNumber , �I�,��OSS� , p�pE� REiMBURSEMENTFEE } � a M OISIRICE NO. GROVP MAP PROCESSED BY � COflhO[fOf Dole ��TY _R1roTEl.NO. � � U � I 2��� SIATE IIC. j'� BK _ � O ❑I am exempt under Sec. ofthe . .Co. ��r�Ns[nip. anss (� PlumbingCodeond/orSec. offha � "ro� DESCRIVIIONOFWORK � �4E -� - � F�NAi W � FqUSE SFwER fONNECTING TO DA�E/�z 7—�� - VAIIDAT N � B.8 P.Code for the following reason� WBUC SEwER . � . SEPTIC iANK.SEEPAGE VIT OR RNAI Z PITS AND/pR DRAINFIEIO �'/,/ Dote �ipU5E5EWEftCONNECIINGTO gv � �/�1� ' ' PRIVATE DISPOSAL SVSIEM Sianafure � _� . .. COMNECT ADDIiIONat eIDG.Orz , OWNER-BUILDERDECLARATION �. � - � wocKTONous�s�R ' � - �� ' I hereby offirm�hat I om exempt from�he Comractor's license E�X`7Nf�aCESSPODL,DRP'YWEILpMANHae . Law for Ihe following raoson(Setton 7031.5�BUIS0053 OlICJ Pf0- ALffR,flEPAIR OR ABANOON HOUSE - � SE WER OR DISPO$/U SYSiEM ' ' L �cions Code): � ��J 9,7�1 1 . ,.._. .... _ ._�. . . . .. . '�._JI,os owner of the property,or my employees with wages os � #• • • •.� O their so�a compansolion,wiil do the work and the slruUure . . . . . . is not intandad or oHarad for wle(Settion 70M,Business and Profess�ons Code�. OWNER'S Permif 5 I • •2 7,5� �I,os owner of the property,am eztlosivaly tontrocting with AUTHORIZATION TOTAL FEE � o ,�7���` IIClfI3Qd COIIhOCtOR�O CO(IS�fVt�IIl@ P10�0C�(SEC110f1 7OIA, I NAVE 0.T THI$DATE A CONTNA�i WI7H 7HE HEREIN N/MED CONTRACiOR IO . . _ p p Busineas ond Professions CodeJ. _ corar�tcT rHe nernF p[SCFIBED Ex15I1NG DwfItING i01HE VUBIIC SF�"1ER. O�%O 9—V d CONSTRUCTION IENDING AGENCY r� ►. . I here6y affirm Ihat there is�a conshvction lending agency SIGNEDTHIS DAYOF_� �?�19 � � - � � -� � � � - for the performance of the work for which this permif is ��R� issued(Sec.3097.CiV.C.. OWNFRSA . . , _ �.�.. Ao�Ss n lender's Name � - �- �� - - . - � . �� lendei s Address ��•A�,�. . : . . . .. . . . . . . . I certify that I hava reod this opplicatian nd state lhat the ���� . . above information is correct.I agree to mmply with all County , , _ ,_ - _ ordinances and Stata laws regulating Plum6ing and Sewers, � � � � . and hereby authorize represenmtivas of this Counly to enter - - upon fh obove-menfioned property for inspettion purposes: - ' � � � - � �- -� � � "- - � �-3� _ _ . _ S' natore of ermitle D le SEE REVERSE FOR E%PIANATORY LANGUAGE � �i�n� �� . i �-. . - • . . - . 1A%' 4 i�,t 1� �� �� � I i.. ' i , Q � DA Yn o� 6Z i I s� � m' 5� � , � �� ��C oD x �� c�i2 � y � � �'n � � '0 , i I �� $� �� �o �� � � 70 � � ; . , , � . �o��a "� �' 6� n� D 8 � N � ` i N - � v�i i � , ' �I ' ! �� O . � � � � i _ � g z _' � � � � � , � � � - -- � � , . , ' � 3� , . ; , � � __ • �¢ :, i, . �� � ' ' �- �- . ` � � • � , m � . �_ m - N 0 � . � ' � . - � . � . N i ' . ' . � , , - ' .. . � i. . ., _ , ' " . ' 'f . . " .. . . , ., . ' � � � � � . . . � � . y 't? 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