HomeMy WebLinkAbout0504A (6) WORKERS'COMPENSATION DECIARATION
I hereby�uffirm thal � have a cartificate of consent to self 9z-oomocwaie� q
�insure,or a cartificofe of Workars'Compensation Insuronce,or �6A°��° � � 11
°"`""�`°Y'h°"°`�S°`.3�° ` b /� "� APPLICATION FOR PERMIT �
Policy No. Company �-���� l7 �� . !
❑ce.,�f��a�oPY�s ne�ebY r�.��:nea. SEWER - SEWAGE DISPOSAL
❑Certified copy ia f�ied with rhe c000ty bwlding inspettion COUNTY OF LOS ANGElES BUILDING AND SAFETY
I . de�°rt�j�'�j nt(�q� . . . `
aore..ZJ�1Applimnt��� FOR APPUCANT TO FILL IN CONNECTION DATA
_ CERTIFICATE OF EXEMPTION FROM WORKERS' � - avuninic - �
� COMPENSAiION INSURANCE nooa�ss p1 ' p sranoN otwrH � �
� (This tettion need not be completed if rhe work i�volved by the i�iin .�l � NANHIXE REFERENCE °P°R j
� permit is for one hundred dollars(5100)or less.) �
I cert�fy flat in rhe performance of the work for wh�ch rhis �pp�A` � � TYVEOFCONNEQION �r.�cTHFaav,. .
Y. . . - . CUR& P.L. Ml.TO P.L.
permit ia issued,I shall not employ ony person in ony manner P�� _
so os ro become subject to Ihe Workeri Compenwtion Laws. owriea b`� �- - CO.IMP.NO. JOB NO. �/
' _ AM1nll TRl1NKPERMITNO. ROA�PERMITNO.
Date Applicont � aooaess P —
NOTiCE TO APPtICANT: If, aher moking this Cerlificote OF �tty - 1 i[L.NO. � � �C AFFIDAVIi WAIVER EASEMENI RECORD.INSiR.NO. DAIE .
�ption, you should become eubjxt to the.Workers' tEcnt
ensa�ion provi�ions of the Labor wde,you must torthwith pescaivriora lOTNO. HWY.OR$T.WIpENINC
camply wi�h such p�ovisions or this permit shall be deemed �'}
ravoked. - � - e�oCK TRAR :!� STA�E ENCROACHMENT -
LICENSED CONTRACTORS DECLARATION � ''b.o�Biocs.- . �°MiT N°.
"- SRE OF(OT r�OW ON LOT
I here6y af4irm Ihol 1 am licansed under provisions of Chopler ��� .
9(commencing wi�h Seaton 7000)of Division 3 of the BU41- BU�LDiNGS ( aARc�s
ness and Professions Code,o�d my license is in full force ond
lflECl. [pNTqAC70R � � CONn1EGTION CNARGE FEE �
' ',� r
L�cense Numbe�� 1�1�c.Closs � , A�WIE55 � REIMBlIRSEMfNT fEE �
Coniracror��010\�–�1�� ��TY n � DiSTRICI NO. GROV4 MAP PROCESSED BY (�� �
' L 1 L.NO. 1 � BK PC
Z
❑I am e:empt under Sec. of the L.A.Co. iKENy i,p. �anss �� � �
N0. DESCRIPiIONOFWORK- rfE ~
Plumbing Code ond/or Sec, of the � � � ciNn� U -
FVBIC��WER��NNERINGiO ��/� DAIE VAIIDATION a ,
B.8 P.Coda for the following reaean � L��-� ��–I L' y
SEP11C 7ANK.SEEPAGE PIT OR . fINAI z '
- PIT$ANp/OR pRA1NFIELD '
_D012 1pV5E SEWFR CONNECTING TO . . BY
PRIVAiE DISPOSAI SYStEM
Sianature I�. ('ANNfCi ADpIttONRI BLOG.OR ► .
� OWNER-BUILDER CLARATION � � '. woaK ra Novu scweR
' OVERf�OW SEEPAC#ili,D4A�NFiELD
I heroby affirm thot I am exempt from the Contmctar's ticense ExiN.,ces5root,oavw[u.maNHaE
LOW{Of fI1G FOIIOWIli9 lB�SpI1,$BC�OII 7O3I.S,BUISf1QS5 dll(�Pf0- AIIER,RE�AIROR ABANDON HOL)SE � � � �� � -
�5�O�e�: SEWER OR DISPOSAL SYSTEM
? �05Q[tA
� I,oa owner of the property,or my employees with wages ds
their sole companwtion,will do the work and the structure #• i • • � C
is nol intanded or offered for mle(Sedion 7044,Busineis �- � - ��
and Profassions Code). , OWNER'S Pe�mit E I y •�7,rJ C
�I,as owner of iha property,am axclusively mntracting with AUTHORIZATION TOTAL FEE � � � � � - �'
licensed comractors to construct the projed(Sectlon 7044� �HAVE AT THIS DATE A CONTRn�7 WIiH iHE HERE�N NPMFD CONiRACfOR TO � ����•�O U �
Business and Professions Code). coN�cr rwe neove FIB[D EXISTING OWEIIING 70 THE Pl1BlIC SEWER.
CONSTRUCTION IENDING AGENCY � � Q�O�—H a �
I hereby oHhm that fhere is a conshudion lending ogency��, SIGNEDTHiS DAYOF�I , � - � �- �- � �
for the performonce of the work for which this permit is Ov+NeaOa �
iuued(Sac 3097,Civ.C.). f w+ru�as . . . . ..
lender's Nome �ITti l A�pEss 1 �
Lender's Address �� �b 1 _ �, �
I certify that i have reod Ihis op lication and state that th . �. � - � �
above informotion is corract.I agree to comply with all Coum __ _
ordinances and State laws�e8uloting Plum6ing ond Sewers - � -� �
and her by aathorize representafives of ihis County to ente
up n t o -mentioned propeny fo�inspection purposea. � - � - �� �-- -- - - � - � - -� - -
,�. --�.- -. 8 -
Signoture Of Permiltee Da1e SEE REYERSE FOR E%PLANATORY LANGUAGE �'
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