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���
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