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 .
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