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HomeMy WebLinkAbout1773A (10) � WORKERS'�OMPENSATION DKLARATION � � � � . � � � , I hereby�aHirm ihai I have a cerlificate of conseM to saif , � , . _ � . � insure;or a ceriifimte of Wwkers'Compansolion Insurante,or � �d`^'20 � , a certified copy�hereo((Sea 3800,�ob�, - . �E��°�.B,B�, . APPLICATION FOR PERMIT �� � - .Policy No. Compony , o-li ' . - � . . ❑Certified copy is hereby fu.nished. � - SEWER - SEWAGE DISPOSAL . errified copy is filed wuh rhe county bu�id�n9 ioapecfion COUNTY OF LOS ANGELES BUILDING ANDSAPETY � deporlmeni. _ oate nppl�com FOR APPUCANT TO FILL IN ff �/' CONNECTION DATA " . . ..CERTIFICATE OF EXEMFTION FROM WORKERS' euito�r� • . � � COMPENSATION INSURANCE �oocess p ,� DQ' stnnor+ �� o[vTH . (Thii aettion need not be complefed if the work tnvolved by the , i�iiTY ��wN�ot�¢¢vert�nrc¢ ,'J'� °°E R � � ' pe�mil is for one hundred dollars(f100)or Iess.J � I�cmtii �6at in�he, rformance of�he work for which fhis ���ST . ' TYfEOFGONNKiION ��uGrHfqpv, . Y Pe Ca055 ST. � Y. . CURB P.L. M.l.TO P.L. � , permit is issued,F shall not employ any person in any monner � ' so os Io become sub ect to 1he Workers'Com nsofion Laws. � P'�'�� � � I P� owr�q. a d � i� co.iMv.ra. ,oe no. 9 _ v . . �OOkEu � `�v P 1 6� TWUNK PfRMR NO. RQ4D PERMIT NO. . (L' '; Dote ApPtimni . . AFFIDAVIT WAIVER FASFMENT RECORD.INSTR.NO. DATE Q � �NOTICE TO APPLKANT: If, afier making this Certificate of ' �in.�� � tEi. /'� �.�Q � . V � Exemp�ion, yo��shoold become s�bject to the Worken' �� W , �ompenwtion provisions of the lobor eode,you must forihwith. - oFseaivripa torrio. - „wy.pq 5T.ye�pEwr�l� ' 2 :omply with s�ch provisions w fhis permit sho�l be deemed q � � avoked: �' . . � eioa TQAcr f� SIATEENCRO/CHMEN7 . . _ � � LICENSED CONTRACTORS DECLARATION - ^1O'��� � ���T�� � hereb aff'�rm that I am licensad under roviaions of Cha �er s¢eorim� Q G r�oworrioT Y P P '(commencing wi�h$ettion 7000)of Diviston 3 of fbe Busi- �eu�iio�rxs �h v t+ aue�s. � rss ond Professions Code,ond my licanse is in full force ond . � �9C1. ' . . ' � �pNiRAROR CONNECTION CHARGE FEE . . 9nae Number � L�c.Clau , A�Eu g � � rtei�v�eurtsFx�r+r r[e 1�fOC10! � DOtE CITY. IL Y � 7EL NO. ' I z � DISi41C1 NO. VP �MAP . /VROCESSED 0Y '. I am exempt undet Sec. � of the L.A.Co.� ii���, 5 � a,us C 0�, •.�/ ��1j�3 (�L � . 'lumbing Code and/oi Sac. of the "p� � RiPfiorl OF wORK r�c �qi � '. �&���Rco�+�crn�ro wre Z�:�, VAU ATION t.6 P.Code for the fo�lowing reoson � - SEiTIC TANK.$EEiAGE ili OR FMAI ' � vli5 AND/OR DRA�NF�EID � ' 'Date � ' �5E SEWEp[ONNKTING TO Bv / . - PINYAIE 01 SY M - �nowre coaxcr woirwKu eioc.ors ► r OWNER-BUIIDER DECLARATION ������� � � � ry affirm that I om erempf hom ihe Contradoi s Litenae . E�aF��CE55 vK op IVT+NEt�iAMnN�ibt¢ � � � . •tbe following reoson(Seclon 7031.5,Buisnecs and Pro- uha,a[v��a oa�e.awora House � � � � - � s Code): . SewEc a+o�soosnt svshm � . s owner of the properry,or my employees with wages as . � � r sole com nwtion,will do the work and the s�rocture � � � . �t IMended or oifered for sale(Saction 7044,Bosiness � r . � � q� 7 7'J a . ProfessionsCode). � OWNER�S PCrmi1 S �� (J �.� � �,� 1 0 owner of�he property,arti excluslvely convacting wirh AUTHORIZATION TOTAL FEE S!d[ODifOt�OfS 10 COOSifUt�1M2 P�O�BC}(SBC�IOfI�044, I HAVE AT THIS DATE A CONTRAQ WITH 7M HERFIN NAMED CO wcroa ro � e e 2'j,5� . � ess and Proiessions Code). ConuxCr rNE neovE pFSCR`BED Ex1,5TING DwEILING TO TNE WNIC SFwER. � " �' ' - . , CONSTRUCTION LENDING AGENCY � " - �� e e . offirm ihal rbere is a tonstrutlton Iending ogency ��D THIS ,+a 0.4 19� � � ' -°G�.S�� . 3rformante of the work for which �his permit is o�+ER°R owr+cxs a� ��Q��—Q 2 � t.3097,Civ.C.). � . j . �oowess � eme - dress . . . . � . � d�l hove read this applitotion and state Ihot the . �� � . , . � � � " �- - � � � � � . rrotion is mrrect.I ograe to comply with oll County � . � � � � � ' md$tole laws regulafing Plum6ing ond Sewers, � - - - � ' �oufhorize representatives of�hfs County to entar � . � - � - ! we-menlioned property for inspection purposes. . . . - . t � ' /�.� 9-6—�3 . � � ermitee -Date � . SEEREVERSEFORfXPLANATORYLANGUAGf � . � �� I 2 .- - � ���� � U2 �- � 4 `�� `fn �fi �„` - ' _ . '�wv�v�r 'z.� �C4� ��, z[� c q yn Pp O N➢ � m "�O . . � v� Zp� R,� r O�.+� �� m . � . , a rrin x�(� �q (} p�`� �C'� �` 0 . 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