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HomeMy WebLinkAbout0503A WORKERS'COMPEN5.4TION DECLARATION I hereby�offirm Ihat I have a certificote of consent 10 salf 9�"0002DGW7/8] � . �insure,or o cartificate of Workeri�ompensa�ion Insuronce,or �6^beso a ceriified opy th�reof(Sea 3800,{lab C -1 f� `F'�� � -APPLICATION FOR PERMIT � ' o icy No. Compony �l� .����• T l.>. - 0i . �- D Certified copy is hareby fumished. ' � . SEWER - SEWAGE DISPOSAL - � � � � � � ❑Cert�fied mpy is filed wtth t e county building inspecrion COUNTY OF LOS ANGELES BUILDING AND SAfETY � de rt Mp . . . . � oote —�p�Applicant � ' ' FOR APPUCANT TO Flll IN � CONNECTION DATA - � CERT�FICATE OF EREMPTION FROM WORKERS' eunou+c ' � � COMPENSATION MSURANCE - � noou�ss stariori DEPTH kE I (This section need not 6e completed if fhe work involved by ihe �� ��i�tY �-- � naHna¢Re�keNa UP°p '� ' permit is for one hundred dollars(SIOp)or leu.) I certif thot'n ihe rformonce of the work for which this ��EST TYPEOFCONNECiION �r�etHpao� Y Pe CAO55 ST. �r V. .. CUGB . P.L M.4 TO P.L . permit is issaed,I sholf not empfoy any person in any monner -� ' so os to become subject to the Workers'Compensotion laws. ��R �'Q CO:IMP.NO.- - JOB NO. OI � - � ��� � T4UN1(PFRMIT NO. ROAD FfRMtT NO. — Date Applicant � npoRess - � . � NOTICE TO APPLICANT: If, ofler makin Ih15 Certifimte OF l�ti AfFIpAVII WAIVER EASEMENT RFCORD.INSTR.NO. DAIE - 9 CITY iEL.NO. ( �' ' �pption, yo� ahould become subject.�to �he Workeri iFCAi � �/penwtion provisions of the lobor coda,you must fwthwith ��i�i� LOTNO. HKY,p45T.NAOENING compiy with such provisio�s or this permil ahall be deemed � ' �evoked. . siCc[ TPAR �c STATE ENCROACNMENI � .LICENSED CONTRARORS DECIARATION � � rq.a&ocs. . reamii No. , sae or ioT raow ora tor . I hereby offirm that 1 am licansad under pravisioos of Cbapter �� , 9(commendng wi�h Section 7000)of Division 3 of fhe Busi- eunoirac5 � CHARGES � neas and Profeulons Code,ond my.license is in full force ond BNOCf. {{/��{ � � [ONTRACTOR � CONNECTION CHARGE FEE ' LiC�n38 NUTbCI��LI[.CIa55 I ' ,q�E� �+ � REIMBURYMENT ifE ' } , a COMIOC/Of�n"�D01B����� y� _ DiST4ICT NO. GFOUP MAP WlOCESSED BY V ' dTY .NO. BK P("i Z . ❑1 am exempt under$et. of ihe L.A.Co. i1c[rr�sE rp �¢,iss !(� � � �- DESCRIPTION OF WORK ffE () ' Plumbing Code and/or Sec. of the F�NAL NpUSE SFWER CONNECfING TO DATE J yp VALIDAT N W �� B.8 P.Code for�he foilowing reasan ttlB;ic se�R (Z'�Z"0 1 � �' � SFOTIC IANI(.$[EPAGE Pli OR FINPL � Z FIfSAND/ORDYAINFrELD � ' � DO}B � FqVSE SE`NFR CONNKfING f0 6Y . PRIVATE DI At 31'S1EM � S10110�Ul6 .�. ... -. ' CONNECI App1110NAt 8LIX'i.OR ► . OWNER-BUIIDER DECLARATION � `Nomc ro r+ais[s�wea � � OVERFIOW SFEPAGE PIT.DG/.INFIELD . I heroby offirm thot I am exempt from the ComraUor's litense � ¢xrN..cessvoa,wtrweu.ti+nNHote � Law for the following reason(Secton 7031.5,Buisness ond Pro- whR,aeva.ia ou aenNooN House � � � �" �ns Code): � s�wea oa oisaosn�srSreM � . . . . . . .. . . . . . �L�'I,os owner of the proparry,or my emplayeas with wages os �� �(�,5 Q v A thair sole compensolion,will do the work ond the strucfure is nof intended or offered for wle(Sedion 7044,Buziness � � �• • o o � Q and Profecsions Code�. � OWNER�$ P9rmi1 E �(�, . �I,as owner of�ha p�operty,am extlusivaly controcting wi�h . AUTHORIZATION TOTAL FEE � � � � � � • •2 7�5 Q liceni�d Contracfors�o[onsfru[i Ihe project(Section 7044, . I MAVE AT THIS DATE A CONTYACT WITN�HE HERE�N NAMED CONiRnCT04 iD �� � � Business and Professlons Code). ' COr�r+cR rH[neOVE Dc Rlg(D E%ISTING DWEIIING TO TNE PUBII�$EVIER. � • • •2 7,..�i�U � CONSTRUCTION LENDING AGENCY � � I hereby offirm that ihere is a construclion lending agency � SIGNED THIS�� DAY OP � � 19 ► 0&0 4—8 8 for the performonce of the work for which this permit is �� o�u�+Eaoa issued(Sec.3097,Civ.C.. � - owNeas ne�Nr '+ l• n fl . . . ._ . . . . AODRESS 1�� �V� � c%� -��� lender's Name ^� ��1 ��� � � � lender'sAddress Ol� �lf���'('C�_ .►-1. �n�� . . . _. . I certify fhot i have reod this a licalion and sta�e thot the � � , above informmion is correc�.I ogree to comply with all County . � , . , ordinances aod State laws regulaling Plumbing and Sewers, � . � � - � � �� � and hereby authorize representatives of this County to enfer �� upon the above•mantioned property for inspection parposes. � - � �,� . `1-ao-g8_ Signafure o Permillee Dote SEE REVERSE FOR E%PIANATORY IANGUAGE . m � q v8 x'€ �'Y'r �O� °�?, � ..- . , SR D^�O yA � O �� � � rT i o q �l jo� . t� A ",F$L,„ �p � �" ��b �� � .. �- � . . �; � ' d C� O•� Z v p' p OE.. y� F`� � , �.. e�� �,f, O �-� � r . - , . � . , � �' �n9 <F � �`u V+ � ON(!�'ZU N ' .. _ , t� . � N 1 p �� O 0 , e . � . M �` , Z . � � � � � ` � °� � . , � � ., � . . � � o �,, � - . `�,���. �� ��. � � � � � ,. � � � � � � � � � � .-, � � � �_ �, , ;. � , �r� 1. i , ` , , � � , � � \ . ' � - � °�. � ,. . . � � . . N � � 1 . , , . ' i _. _ � 1 ' . p '� � r� . ` - .. , . �` \ ' � . � � �. , . ,,� ' � - ��.r . ' l � .�. 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