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HomeMy WebLinkAbout1758A (10) WORKERS'�OMPENSATION DECLARATION - � I hereby offirm that I hove o cerfificofe of consenl lo self _ - }1 insure,or a tertilica�e of Workers'Compenwtion Insumnce,or �6"b�m � _ . , u a«��;f� y IllfEO{ SE[.3BOO �ObC.) CEBOBIREV.1/831 qpp��CATION FOR PERMIT PolicyN ompany � r�" ��'1�,���U��,� � . � ❑Cenified copy ia hereby iurnish . . � SEWER - SEWAGE DISPOSAL- � . . ❑Certlffed co y is filed wi�h th nry buildin impeu�on ' COUNTY OF l05 ANGELES BUILOING AND SAFETY �dapa men � � � Date Applicam FOR AP LICANT TO FILL IN CONNECTION DATA � . CE IFICATE OF EXEMPTIO FROM WORKERS' �iipu.� � COMPENSATION INSURANCE noox[ss _{ STATION oeviH (This section need not be mmpleted if�he work involved by the IA4NNqE RfiEYENCE u°°ER permit is for one h�ndred doliors(SI00)or less.) 1OG°��n � R . I cerfify ihat�tn ehe performd�ce of�he work(or which rh�s �u55T. 1YPE����T'� tENCTMFYOM � Y. Ct1R6 7.L. M.L TO C.t. permit is issued,I shall noYemplay ony parson in any manner � � r v�.rao. w as to bemme subject�o the Wo�keri Companwtion tows. owr�x !f� �7L'�L, � �O.IMP.Np. JOB NO. ��� �'+� TRUNK V[RMIi N0. � QOAD VFRMIT N�. � O'a' ' Date� .. . APPlicant � -- �Du�55C.�C.LJ d NOTICE TO APPLICANT: If, ofier making this Ce�tifimte of � AfFlD�vn WAIy[R fnSEniFr+t FECORD.MSTR.NO. DATE Exemption, .you should betome subject to the Workers' ��TM ����� . � Com ensatlon rovisions of fhe lobor tode, ou mual forthwi�b - tee�t P P Y DESCRiPf10N lOTNO. HWy.pq57.wiDFMNG comp!y�witfi sv[h provisio�s or•�his�rmil shell be deemed revoked.� � � � � eioCK 1RA�T $teTE ENCRO�CHMENT � LICENSED CONTRACiORS DECIARATION Np,pF&OGS. YfRMIT Np. I bereb affirm thal I om licensed under siz¢orior rqwqaior _ y provisions of Chop�er �� _ V(mmme�cing wtrh Sed�on 7000)of Division 3 of fhe Busi• eu�mir+�s � a�cc.�s ness ond Professions Code,and my I(cense is in full fwce ond effett. 1 f � �Tppnpq � � CONNECT�ON CNhRGE ffE �iClnSB NV I ( ✓� �j[,��OSS' [��� A�yE �� -REIMBU45EMENT i(E COMlOCiOr�/I�.YIw•—DO�! W' � U�' OISfkICT NO. GROUP MAi iWWOCF55FD BY � . OTY^ TFLNO.- (,. 1 � L � � v $TA LIC. I� /��— +� � ❑I am e:empt under Sec. of tha LA.Co. i��E��,p �iAu �jv �� 3 � NO. pESCRIVTIpN WpRK fEE �Q Plvmb�ngCodeand/orSec. ofthe f'NA� VAUDATION ~ HOUSE SEwER�pNNECTING TO DATE 9 4 G_["" u. B.8 P.Code for the fallowing reason �. �&�c��R ✓ p J w . . . . ... . . SF�TIC T�NK.5[EPA�E PIT pt 6 PRS AMp/OR pR�INfIE1D HNAI . N �IQ n0u5E gwER CO�+NFCTIrJ(',TO BY Z � - PRiVATE 01 SYSiEM "� SI(�l101UfQ .. .� .�. � CONMC7 11DOIiIptJAI BIOG.OR ► OWNER-BUILDER DECLARATION �+K io'rous[s[w[a OYERfIOW SEEiPGE%1.p1tA1NiIFlD - 1 hereby affirm thot I am exempt from the Controtlor's License F%TN.,CE55R')Ol.DRYV+ELL M,1NHp1.E �4W{Of�h!�O��Owln(3 fBO5011(5fC10t1 703�.$,BUISIfOEE 011d Pf0- ALTER.RE7AIR OR P9ANDON IKKISE $�r��p n fession5 COdEJ: 3EwER D�SDOSAlSYSTEM . r o r� ❑I,os owner of the property,or my employees with wages os � #�•�• �'�rj(� their sole compensafion,will do the work and the structure ' � is not intended or offered for sale(Sacrlon 7044,Business '� • � 5 d�� ond Professions Code). OWNER'S Pe�mit S , ❑1,as ownar of the property,am exclosivaly commUing with AUTHORIZATION TOTAL FEE - •' � $4��v licensed contraclors to construtl the�project(Section 7041� I MI.VE AT iH15 W11E A�ONTA��T WIiH TN[NfREIN N4MED C0�1W ox 10 ' BUSIIIl55 Ofid PfOfB55iOnS COd@�. CONNECT THE ABOVE�ESCRIBED F%ISTING DWFILING TO TNE W&IC SFWFR. O Z 2 9 j 8 5 CONSTRUCTION IENDING AGENCY • � - , I hereby offirm that rhere is a cons�roctlon lending ogenq S�GNEDTH�S onvOF t9_ � for fhe performance of �he work for whith Ihis parmit is ��Q� � - OwNfRS AGEM iSSUBd($! 09�.Civ.C.�. . . . ADDRESS � lender' Name � - len r's Addreu - - I c rtify thol I ve reod this opplicotion ond stote tha�the � � � ' � o ve tnforma' n is corrocL I ogroe fo tomply wieh oll CouMy � �. or Inances d Stoie lows reguloting Plumbing o�d ers, . - - � � a her outhorize repreunfolives of ihis C unty t en�er . u e ve- ' ed properry for InspeN' n pur sys� .� G Signoloro o}Permifiee Dole � , SEE REVERSE fOR EIIHANATORY MNGUAGE .. ' � ' � y�, C� � . , ' V ��„f :i�i` Oq O 1 S . . _ • , � .� �.� yn p�. �. nD C�` O' _� . , . .. . � '? n, Z 1 b�w, r 3cZ py s' 'S1 � .. ' , ��.� � :� �� a� 'o ��f". .' o � � �� � � ��� N" ` G . ,' ', � T : �� � �. ,�2 _ • • � �V � � . ; �.n�n ?� i� oa. �Y' � �' . 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