HomeMy WebLinkAbout0497A S WORKERS'COMPENSATION DECLARATION qZ.pppz DPw 3iel q I
� 1 heraby�offirm that I hove a certifimte of consen� to self �aneeso � � II `
� 'insure,or a certificate of Workeri Compansation Insur ce,or �E�B � JS
. °"""'°d`°PY,he.B°`'S°`.'e°°, b�. APPLICATION FOR PERMIT j
¢y o. Compony �� . .
�S ❑Cettified Copy is hereby furNsbed. SEWER - SEWAGE DISPOSAI
� ❑�eriified copy is filed wi�h�he counry 6ujldinq inspenion � �� COUNTY OF LOS ANGELES BWLDING AND SAFETY �
Q deportmen� �.,M R� , _ � . . .
� Dotq�� Applicant �1� FOR APPLICANT TO PILI IN CONNECTION DATA �
CERTIFICATE Of EXEMPTION FROM WORKERS' eunoiN�
COMPENSATION INSURANCE aooaess STATION cevtx
(This section need not be completed if the work involved 6y the �«A`�TM hWNNOIE REFEFENGE � UPiER
permit is for one hundred doilara(f100)or less.� - - � R
I certify thaf in�he performance of the work for which fhis �pouE55T .. rva[oFcoraNecTror+ t�r�TMfqp�,�
V... ... . NR8 P.l. ' M.l.TO P.L. .
permit is issued,1 shall no1 empioy any person in ony monner v.c.No. /Q�p
so a:fo betome subjecl to the Workers'Compensmion�Ows. Q�,�R CO.�MP.NO. J09 Np. / p
��� � iRUNI(P[qMIT Np. ROAD PERMIT NO. - �
Da�e Applicant ���� - �
Alf10AVIT WAIVFR EASEMENI RECORD.INSiR.Np. DAfE -
NOTICE TO APPLICANT: If, oher making this Cerrificate of cin, . i.r,p.
��'�ption, you should become subject ro the Worke�s' iE�Ai '
� �ensotion provisiona of the Lobor code,you must forthwiih DESCRIViION lOTNO. NWy,pR ST.WIDENING
comply with such provisions or4his permil sholl be deemed ^
fBVOItld. BLOCK TRACT _S�K.. SiATE ENCROACHMENI
LICENSED CONiRACTORS DECIARATION - - rq.or eiocs � c�RMiT No.
�hereby affirm tMot 1 om licensed under provisions of Chapter 5izeoriOT , NowoNioT
9(commencing with Sedion 7000)of Division 3 of the Bosi• � g fip�5- � � crna�5
ness o�d Professions Code,and my license is in full forca and
!fflCt. /� /�/+ �pp�TpqRpq - � CONNECiION CHnFGE FEE
License Numbe,����/�,,/)���I�,C�Qys REIMBURSEMEM FFE 6
'�x-�-�+-� � ADDRE55 Q .
/�+��� ��Q���, ��������-��� �^��J ( p DISTRiCT NO. GFWP MAP . VROCESSED BY �
ConiraCfar���Date �L����/ GS-O PtY /����.rao. �� BK x, Z
❑I am exempt under S . of ihB L.A.Co. S�NSE NO. �LnSS I� 0
PlumbingCodeond/or5ec. oHhe �� SCRIPTIONOFWORK �fE ' FINAI U
� NOUSE SEWER CONNECfING TD DATE W
B.&P.Code for fhe following�eoson � P�&���'+�R � bD VALlD ��N �
SfViIC fANK,$EEPAGE Plt OR FiNAI Z
OOIC PIiS AND/OR DpAiNfiElD 8Y �
1qU5E SEWER CONNECfING TO
' PRIVATE DIS++OSAI SVSTEM
$ionalure �y� �47Kd _ CONNECT ADpITIONAlBLOG.OR ►
OWNER-BUlLDER DECLARATION � woac to Novs[s�wea - � -
OVENFLOW SFEPAGE PIT,DRAiNFIELD
I hereby affirm thal I om eaempf from tfie Confroctor's Lirense ENTN.,('p55POOL,D4YVJElL M?NFKKE
Low for the following reoson(Setton 7031.5,Buisness ond Pro- at�a,a¢aniR ou nenNoon wous� � . . - .
f �ns Code): s�weR oa msrov.i srsrem �G 4 9.7 A
��I_,-,as owner of ihe property,or my empioyees with wages as , �• • • � .� O
�hair sole compensotion,will do the work ond ihe strutlure _
. iz not intanded or offared for sole(Section 704<,Business � � o G!�rJ Q
o�d rrorB::�or,:code). OWNER'S Parmit. s �
�I,as owner of the prope�ty,om exclosively conlroding with AUTHORIZAtION TOTAL FEE � ,. e �2 7 Jr Q x
litensed conlrocfors to tonstr�tf the project(Section�044, I HAVE AT TMIS DATE A CONiRq�i WITM iHE MfPEIN NAN.Ep C NTRACIOR i0 L �
BUSIneSE OI1CI Pf0{23510r15 CotllJ. CONNECT TNE A90VE DESC_'I D E%ISiING OWEILING Lp TM P�B����,�R. � � o a o 4—a a
CONSTRUCTION LENDING AGENCY , '
I hereby offirm fhat thare is a construction lending ogenty SIGNEDiH15 D YOF 19� '� � ' -�� � �
for Ihe performance of the work for which this permit is O`�'NERoa ,
IRUB(��Sl.`[.3097� 'V/C.�. OWNERS AGFM .. . . . .. . . _. ' _" ... . . ,
ADDRESS
Lender's Name . .
lender's Address �
I cerfify that I have read t applicmion ond siate that the � � � � � �
above information is correct ogree to mmply wiih all Counly , _ ,. � ,
ordinancas ond Stafe laws regulating Plumbing ond$ewers, - - � � -
���hereby authorize represenrotives of this Counly fo enter '
•the oboyv�e-menlioned properfy for inspeclion purposes. - �
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