HomeMy WebLinkAbout0502A (4) WORKERS'COMPENSATION DECLARATION � q �
I here6y�a8i�m thot I have a certificate of conseN lo salf v2-������ • � II
•. 76A6�tD
inauro,or o cerfifimte of Workers'Compensation Insuronce,or . �E� JS
,� PolecyfNo.� PY ihereoc(�Smpan3y�( Y�,'�.�G -� �, � � APPLICATION FOR PERMIT �
� ❑ce,rs�,a�pPY is here6y fornisbed. SEWER - SEWAGE DISPOSAL
(}7 ❑Cer�ified copy is filed with the county bvilding inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
(� dep�a-r.tm��e,nLp . ..` . �.' � .
T pa�e�.1=��pplitant �� . POR APPLICANT TO FILL IN CONNECTION DATA
Q CERTIFIGATE OF EXEMPTION FROM WORKERS' - eunp�rw I � �
� COMPENSATION INSURANCE nooaess � srnnon o[rrH -
�ihis seclion need not be compleled if ihe work involved by the i�117Y ` � �-- µ,,NNaE rs�FEr�r�t� urvtx
permit is for one hundred dollors(E100)or less.) � �
1 certify�hot in the performance of fhe work for which this �qp5557, ^1 , �+ � - TYPEOF�OfJNER�ON , �N�THFROM '
lAY ���-- 1 V. GURB - P.L. ML TO G.L. .
. permit is issued,1 tholi not employ any person in any manner p�Na Q I �
so as to become subiect�o the Workers'Compensarion Lows. owr�e� �'1 ��"' - [o.ima.rvo. �oe rJo. �
' ��� iRUNK PfRMIi NO. � ROI.D VERMI7 Np. '
Dale Applitont - ADDRE�
NOTICE TO APMICANT: I/, aNer makin Ihis Cenificote of AFFIDAVIT wnrvea Ense�Ni RKORD.INS7R.NO. OATE .
9 . CITY TEL NO.
�r �pt�on, you should become subjeci ro the Worken' iE��
J�ensa�ion provizions of the Labor code,you muat fonhwi�h o�xaivriori �ot no. Hvn,pe sT.wio[Nmic
tomply with such provisiona or lhis permit sholl be deemed - `� �^y
fBVOkQA. BLOO( TRACT Q( �-^ SiAiE ENCWACFIMFNT
LICENSED CONTRACTORS DECLARATION - � nq,ov x�c5. �RMit No.
I heroby affirm tho�I am licenaed under proviaions of Chapter 5izeoFior rioworaioT .
9 commentin ivilh Saction 7000 of Diviaion 3 of the Bosi- �� �
( 9 I &IiLD�NGS p1ARG(5
ness and Professions Code,and my license is in full force and '
efflC1. (� �1 � �pN7pq�7pq -� CONNfCTIpN CHARGE FEE .
Licensa Number�+ ��C1 Lic,Clas^s�_ ,qppqEu REIMBURSEMENT FEE n. ,
COM�O[1of�Dole�OI"��`RP � DiSiAiCE NO. GROUv MAP PROCFSSED BY � .
U
utt � i.r+o. -r eic vc Z
❑I am exempt uoder Sec. of the L.A.Co. i1�N��, 6 cuss 1� O
Plumbing Code ond/or5ec, of rhe "a� oFSCaivriOni OF watK xt - F�Nqi V .
FqlISE YWER CONNECTING TO DAiE W
oue��cs�wea ,L_ _ VALIDATION a
B.&P.Code for the following raoson SEpTiC�ANK,SEE�AGf PII 04 FINAI Z
PIfS AN�/OR DqAMf�EID
�--�'���« ' ' MOUSE SFWER CONNFRING TO BY � .
(p{ � PRIVAfE Di5PO5AL SYSTEM
SIOnO�UlB �\/ C_. CUIVNECI AWITtONAt&pG.OR ► �
OWNER-BUILDER DECLARATION � � wowK ro�ausc se+xex � - � �
OVERFLOW SEEVAGE FIT,DRAINFIftD
� I hercby offirm thot I am exempi from the Contmcror"s license exrN. cessrooi,oavweu.N,nNMa¢ �
law for rhe following reoson(Sec�on 7031.5�BVISAB%OOd Pf0- Al$R,ItEP/.IR OR ABANDOfJ HOUSE -�� ... . __ . . �
� nSCOdE�: SEWEROROISR�SALSYSiEM -� �
I ..._._.._.._ .___. . . . . .. . _ - � ,
Ln�,os owner of�he property,or my employees wilh woges os �O 5 O,2 A �
� their sola compensotion,will do the work and the slructu2 �
Ia not intended or offerad for sole(Section 7044,6usiness #• • • • � Q
and Profesaions Code). OWNER'S PBrmi1 E ��
[]�I,os owner of tha propariy,om ezdosively tomroct�ng with AUTHORIZATION TOTAL FEE I • •�7,5 Q
IiGGI1E�d COA1fOC�OrS tD[01151(V[f�IIE PfO�lCI(S2Cf1011�Od4, , I HAVE Af TMIS DATE A CONTRACT WITH THE MEREIN NAME�CON7RAROR TO
BVSIIIESS plld WD{l5510115 COdB�. CONNECT THE ABOVE DE RiBED ExiSTING DWEIUNG 70 THE PUBIIC SEWER. - - • a�2 !,S O V '
CONSTRUCTION LENDING AGENCY � �
I Fereby affirm lhaf fhere is a constrvction lending oqency SIGNE�THIS�O DAYOF� - 19 , ' - Q Q�(j—8 8
for the performance of the work for which this parmil is �`�'NEQOR
�ssoed(Sec.30V7,Civ.C.. owr+�Rs aceNr .. . . . ..
�i�-i�p A�QE55 0l
Lender's Name � .. .
�)c�5 �'tGt��er�.l.•�1, �
Lender':Addrass �rn�� �
_
I tertify thet I have reod�his applicotion and s�ale ihat the . � � -�- - ,
obove iniormolion is torretf.I agree to mmply with oil County
ordinances and Sfafe lows regulating Plum6ing ond Sewers, . � -- � � -- � ' ' � '
and hereby authorize representatives of this CouMy�o enfer • -
upoo the obove-meNioned property for inspettion purposes. _ �- � � -� - - � � i
� �'. �-ao�Rg _
Signoture of Permiflee Dole SEf REVERSE FON EXPLANAiORY LANGUAGE
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