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HomeMy WebLinkAbout0506A (4) WORKERS'COMVENSATION DECLARATION I he�eby�affirm that I have a certif'icate of consenr�o salf 9�-�����B] � � lnsure,o�a cerr�fico�e of Worke.i Compensotion Insarance,or 76AWRD �1 �a certified co{y thmeof(Sec.3800,I L4b �'.�(� � �E� � - APPLICATION FOR PERMIT y� Po�cr 1 y No. � ComponY �^-•��� ' v 0s . - ��, � ❑Cerlified copy is hereby furnishad. - . - SEWER - SEWAGE DISPOSAL - . - � - . � � ❑Certified copy is filed wnh rhe couny bo��din9�nspeciton COUNTY OF LOS ANGELES BUILDING AND SAFETY � � deparlmem. 1� � "� ' I � poie '��� �+pplicom T��� FOR APPLICANT TO FILL IN CONNECTION DATA r � CERTIFICATE OF EXEMPTION FROM WORKERS' . euno�r�c srnnora cEaTH � � �OMPENSATION INSURANCE A�� 1 r (This senioo need not be completed if�he work involved by the i�iitr - naNHa¢rsEvexenice ��R permit is for one hundrad dollors(5100)or lesa.)� - � rE.�sr rrc�a cowtctioni . �r+cTr+FaoM � I certify�hot in�he performance of the work for which�his CROS55T. V. . CURB P.L. M.L.TOP.L. ' permit is issuad,1 sholl not empioy any pe.zon in ony manner p�� (� � so as to betome subjxt lo the Wor4ers'C0111PCOSOI100 LOWS. OWNER CO.LMP.NO. JOB NO.� -O/O ' ' t ��� TAUNK PENMIT NO. ROAO PFRMIT hq.. . ' � ADDIiE55 Dote Applicant � � � � AfFIOAVIT WArvER EASEMENT itECOND.INSTR.NO. DATE NOTICE TO AVMICANT: If, oNer making ihia Certifimle of �iTy - �lla�tE�,r.jp. ,� � ...� 1 ,�ption, you should become wbject 10 the Workers' IEGAI � penw�ion provisio�s of�be labor tode,you musf forlhwith ocscwivriow LOTNO. HWY.ORST.WIpENMG � comD�Y`�i�h soch provisions or�his permit shall be deamed - 1 revoked. - - siocK TRAR � SiAiE ENCROACHMEM j UCENSED CONTRACTORS DECIARATION r�o.a�o�s. a�RMiT No. S�ZE OF LOT NOw pN LOT j i hereby affirm Ibol I am Iicensed ondar provisions of Chapter � �� � 7(commenc�ng wi�h Section 700Q)of D���sion 3 of rhe Busi- �ii�s � � � -� a�nrsces ! neu ond hofessiona Code,ond my licenae is(n full force ond � , eHBCf. /`L(I� /�'�(,y� � ' [QNTR},[7pq � CONNERION CNAR(,E fEE Lice�se Number l!!/�(.+'L71.] �IC.C�au � REIMBUR$[MENT fEE � a �7 ADWtEiS �a-3� �G 1 �iSTRKi r�p, GROUv Mnv VROCESSED BY � CoMraUor�Da1C Clri - 1.N0. tL— U . . S7AfE r ' IIC. f BK VG � Z ❑I am exempt under Sec. of the l.A.Co. � u[eNs[r+o. �-{ nass - /� � . PlumbingCodeond/or5e[. ofthe ''b� - �ESCRIPTIONOFwORK rfE FiNA� V � - HOVSE SEWER CONNFCTING TO � DATE VALIDATION � � B.8 P.Gode for the following reoson PU&K SEVrER . r��t�� . � SFP11C iANK.SEEPAGE PII OR fINAL Z FTS AND/OR DF4tNF1ELD ��g HOU5E SEWER GONNFCLING i0 gr , GRIVAiE ISPOSAL S1'STEM $ianotufe �� . . .. CONNECT AOOIiIONnI BIDG.OR ► � OWNER-BUIIDER DECLARATION . wo�K to nouse s�v.Fa � � � - O'JERFLOW SEFPAGE PIT.DFAINiIELD . . I he�eby oHirm ihol I am e.empt from fha CoMraclor's License EXTN.,CESSPOOL.DR1'WEIt.MaNHOIE Low for the following reoson($ecton 7031.5,Buisness and Pro- uhc,xF�nic oa nenr+ooa Nws� - � � - �E COCIB�: SF�4ER OR OISPOSAI SYSiEM . `l�5!1 b A ± V lA -� I,as owner of�he properry,or my employeee with wages os - ihair sole compenwtion,will do the work and the structure . , #• • • • � � � is not fn�anded or offered for sale�Section 7044,6usiness PgfRlit S � • •2�,5 Q and Mofessions CodeJ. OWNER'S �O 5 �I,os owner of the property,am exclusively contratting wiih AUTHORIZATION TOTAL FEE D �� �2�S��z litensed controtlors to tonsfruct the projecl(SetNon 70d4� _ I HAVE AT THIS DATF A CON@FCT WITM TME MEREIN NAMED CONTRACTOR 10 . . . . . _ . BVSil1p54 Otld Pf0{955I0115 COdE�. CONNECT THE ABOVE DFjCRiBED Ex15iiNG DWELLING TO T�+f�UBUC SEwER. ��O��II o . � CONSTRUCTION LENDWG AGENCY �ii Q , . �� . I hereby oHirm tfwl ihere Is a Conslrvcfion lending agenty SIGNEDTHIS � QDAYOF �9Q for ihe performance of the work for which Ihis permit i5 , �IFE SOAGEN7 1.�� _. .. .. . . issuad(Sec.3097,Civ.C.J. � c ' . . - e��icr.sP ��E55 tb`� ��f��iY,�� �,�,��� lender's Npme - � � �- Lender's Addrau�as �1Q112S—('�C)._L ����Q�� I certify thot I hove reod this ap ication ond state Ihat the - - obove information is corroct.I agree to comply with oll Covnty - . ,_ . . _ _ _ . _ _ . ordinances ond State laws regulaling Plombing ond Sewers, - and hereby aothori:e representotives of this County to enter - . u on t above-menfioned property{oi inspedion purposes � � "�� � - �� �� � - � �, �. �7-ao-��'_ _ _ SignoWre of PermiNee Dafe . SEE REVERSE FOR E%PLANATONY LANGUAGE - � o`�a� � �,yQ �pQ 'Gg c� �� �� '�''O Y� � . ���O �� g ��py$ ���O . ' ',��M �y p �'� �=� .. . . . . ' ' i� �5.� 4" �q Q O '° G , � pf,°g���,� a �=�'`� r ,_ � . - . '` ..i mG� y� P N {� /.A a .-. _ � , , \ , ��Q�Q �A � .. ' ' 1`' ' 1 . 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