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HomeMy WebLinkAbout1818A 2114A WORKERS'COMPENSAT[ONDECLARATION 76A6A2D APPLICATION FOR PERMIT � CE 608(2-801 �� I hereby affirm ihat I have a�certificate of consent to�e�r -. � � � � SEWER-SEWAGE DISPOSAL insure,or a certificate oi Workers'Compensation[nsurence,or • � a certified coo thereoP(sec.7Eoo,Lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No.�mpeny ���R32—A Mi cci nn -� ' � Ip,,�an� FOR APPLICANT TO fILL IN CONNECTION OATA � Certified copy is hereby furnished. - au��o��� 2�2� P&S�O I� '�'2TTd(�O 1�5 STATION oe�rH � Certifiad co Ls filed with the count buildin ms ection� wooesss PY Y 6 P }y� {�.�.,. Uno6R dePBfSme��. LOCALITY Ll�nd 1JGL MANMOL6 R6FEMENC6 �.OWlR Del[ 3/10/g�ppI1C911� � NBAR6lT , TY►E OF CONNQCTION L6NGTM IROM CERTIPICATB OF EREMPTION FROM WORKERS' ceose ar. r. cuwe •.L. M.L.TO P.L. COMPENSATION INSURANCE � �•�•N�• - owncw py�gl Of SOtlth@Iri Cd11fOIYLLd GO.IM�.NO. JOB NO. • """ P.O. Box 2200 �(This section nced�not�6e cQp1 eted if the�work involved •DDNEBf TRVNK►6NMIT NO. ROAC tERMIT NO. a -�6y the permit is�for one hu�red dotlars (S100)or IessJ _7 4 ¢0�50 ,,,,,,,,, ,,,,,,, �„�„a,,,„��,,,,.,,,:r,,,„o. p,rE . p _ ' � " ' TITY Til.NO. V . . — I certify that in the performance of the work for which this �eawt permk is insued,I shatl not empiny any person ie any manner , osscn�vr�oN LOT NO. _ HWv,DR 8T.W�D6nING � � s�as to become subjett to the Workerd Compensatian laws. � � 9LOCK TRACT 41305 sTATH QNCRpACMM6NT Dete AppliCan[ � � no.or e�oce. �Ertw�r No. W , NOT[CE TO APpLICANT:If,after making this Certificate of ��_�or�or now oN�or . � � tixem tion, nu sho�dd become suh'ect to the N'orkera'- �� �se o. - - - - � y � ' BUILDINGS cwwKcss 2 �Compensatlon provisions of the Labor Code,you must forth- ' with com 1 with SUCF1 - � CONNHCTIOn CMAM6!Ffie ,-" p y provisions or this permlt shali be � eowrwweroa - ' deemed revoked. � ' RlIMB11R96M6NT F6E . - LICENSED CONTRACTORS DECLARATION - �nowcas� � I hereby effirm that f am licensed under Drovisions of Chapter sr.ier�o. �.o.�. . .... .6 . ocess�o•r � 9(commencing wilh Section 7000)of Division 3 of the Ausi• c�rr -ra�.r+o. � ness and Prnfessions Code,and-my Iicense is in full torce and •T�TB ^p(� "°• -!O �� : LIC6NSE NO. `pJ��� CLASS�� ' lfYeCi. - � � No, OESCRIPTION OF WORK eEfi '. FINAI. � � �a VALIDATION ' L[cense Num6er 2�27'4 Lic.Clau B�1 °�� ���cn+d ro p owre : s.nc r en Contractor S'�n1P a4 �rs�ptDate ����2 ���� FIHAL � . �m ev � I sm exempt from�the�Iicensing reyuiremenis as I am s licensed architect or a registered profeasional engineer , '� acfing in my.professional capacity(Section 705L,Bus- - � � iness and Profeseions Code). ooi,`o`.:w«�, ou.s . . w�R 01�� Lic.or Reg.No. Date - £ ' 8 _ HOMEOWNER-BUILDERDECLARATION - � # •� �O � I hereby affvm that I am exempt from the Contrector's ��NNER�S Permit f $ St> �'. �85�0 i License Law for the following reeson(Section 7031.5,Busi- AUTHORIZATION TOTAL FEE 7g Sp neSs and Professions Code): .,,r ow:w�c�r w eon- �r• •�]��Q V O1,as nwner of the property.will do tKe work and the +e:`.:�:��i�cw... " o oesc.u• �. � � � structure ia not intended or offered for sale Section � ( st�Heo rN�s oav oc n �� � `8'2 � . 7o4a,Husiness and Professions Code). � — - � CONSTRUCTiON LENDING AG�NCY - o.��s`G� �� � --- " ' 1 hereby affirm that there is a consirucdon Iending agency �22�'���l�A for the performance of the work for whkh this permlt 15 ` issued(Sec.3097,�jv.C... -. .� . . . � ��i�Q � Lender'sName S ity Paeific ��•�.�. - Lender'S Address 890 N. �].Il� $dlltd palld 927�2 . � .�. . .. ... . .. �'�'��7 B.Jr� �I 1 certify that I have read this application and sta[e that the � � � - � � � � � _ � above information is correct.I agree to comply w�ith ell Cour.ty �" '.7�5�� ordinantts and State laws regulaling Plumbing and Sewers, � � � � �� � and h b uthorize reprosentatives of this County W enter .Q�0,7��`8 Z � upo��' �'1t�n p erty for'As�Poses. - . . . _ . y� SF,E REVERSE FOR EXPLANATORY LANGUAGE �fy� 82 Signature of Permittee Da��� mD D�O mD m Dm �C� Z N Z.� CO m z'7nc Zc'� Dm a' �-I rZ 's. t;�. � i---�..- + ;-- - --�' i - -I ;�T �Z•G�7J �- pn pr�i =, . 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