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HomeMy WebLinkAbout1772A (10) ---�_-_--��„�.__._:f_._.,.._,..__....._�--- f _ . . ,��,,--__--_._ � WORKERS'COMPENSATION DECIARATION. � . .- - � � '�-�._��:.'�-^—.�, I hereby aFfirm tha� I have a certificate of conseM to self � '�� . , , , . � �«^i inwre,or a cenifimle of Workers'Compenwtion Insurance,or �anb'� � . - � a certified copy ihereof(Sec.3800,�eb�., .i �E��R�.8,8�, - qppLICATION FOR PERMIT - � - �� � - Volicy No. Compony . Os � _ � ❑Ceriified topy is hemby furnished. . �� � SEWER - SEWAGE DISPOSAL ��� ertified mpy is filed with the county boilding inspaction COUNTY OF LOS ANGELES BUILDING AND SAFETY - deporlment. . � � Dare Applicom FOR APPLICANT TO FILL IN �9y� /��' CONNECTION DATA . � CERTIFICATE OF EXEMPTION PROM WORKERS' � �iioi� � . COMPENSATtON INSURANCE nooacu 6. rw o `, sT�noni . ��G ceerH. - � (This settion naed not be completed if the work Involved 6y�he i�iin, M4NNqE REFERENCE , i,S � ' � permit is for one hundred dollors(SI00)or lesa,) � I�certif thnl Pn the r(orma�ce of the work for which�his ^�'°�sT . � n'Ptoctow+[tnoa� ��THFy�r, ., Y PB CRO55 ST. � Y. . CURB .L. M.L.TO P.l. .� permit is issued,I shall not empfoy any person in any manner o ' so as lo become subjetl to iha Workari Compeasation Laws. �N,�R j. ' - P.C.NO, , . S� �p.IMP.Np. JOB NO. � v . - ��� / TRVNKifRMiTNp. 0.0ADPFRMITNO. - a Dote Applicont � � ^�u 1�w LALAV y AFFtOpVli WA�'ER EASEMEN7 RECORD.MSIR.NO. DA1E Q ' � N0T10E TO APPUCANT: If, oftar mokinq �his Certificate of crcv iEi.t�o. �'; f Q � _ � U � Exemption, you should become subjeU to the Workers' 2 Compensotion provisiom of the Lobor code,you must forihwith cescRianori toT rao. .Z- J � ' Hwr.dt sr.wioeNi� � �- mmply with such provisions oi Ihis permif sfiall be daemtd � fBVOlted. ' ' • &OCK �TRACf STATE FNCROACHMEM ? � � LtCENSED CONTRACTORS DECLARATION Q /� ri°.°F�°cs. c�rs�n r�o. . . � SRE Of lOT (J OO V �'�'OM lOT � I Ffereby offirm that I am licensad under provisions of Chapter �� � � ' , 9(commencing with Seclion'7000)of Division�3 ot 16e Busi- eu�mwGS K .a P 1..�`L cHaaces � � � ness and Professions Code,ond my licenae is in full force and � . effact. �. . eaaic�etae eoruJeaior+wnvc,��e . . ! t Licenu Number LiC.CIOSS A�E� � � rteu�nwastr�Nr rce Comractor Date wsraKi r.a. r r,n�v wocesseo er . cm • � _ ,�//� BK PC ❑I am eaempt under Sec, of�he L.A.Co. i�Ny rip. .SS� �c nss � - '�` `� ���Jr�j � ' PlombingCodeond/or5ec � � ofthe �� � RiPfIIXJOFWORK rEe N�i . . wuse sewec cor+Htcrir+o ro � onre �j y VALI ATION W&IC iEWFR �`��r O✓ B.8 P.Code for the following reoson gp{��7�py(��pq�p�T pq FINAI l ' PIiS ANp/OR pqAINF1EL� � . DOfE 1qU5E SEWER[ONNECTiNG i0 6Y ' . . . WtIVAIE DISYOSM SYSIEM � � , Signolure � CONNECT Md7iONnl&W.OR ► OWNER-BU�tDER DECLARATION � w°°K i°�wus�s�w�R ' ' ' OJERFLOW SEEPAGE PIT.DRAINFIELO � � L� 7 7.Z R I hereby affitm thot I om eaempt from the ConlroctOr's Lftense E%TN..CESSVOOL.�RYWELL,IMNNq,E - ' Law for fhe following raoson(Secton 7031.5,Buisness and Pro- u7Ek,REVA�c qt nenNOON HpuSE �. • • • � � fl8510�15 COd@�: SEWEG OR D�SPOS^d SYSIEM � � ' ❑I,os owner of fhe property,or my employees with woges as � � . ' - � a,•2 7.5� � ihair sole companwiion;.will do the work and the slruduro � � . , is not intdnded or offered for sale(Sedion 7044,8�sineu � � � - � - � � _ ond Protessions Code). OWNER�S Permit- s Q �fJ • • 'L 7...�v ❑I,as owner of the property,am exdusively cootratting with AUTHORIZATION TOTAL FEE c1 r(J �' 0 Q�Q—�2 �ICBnSed COl1fla[1o�2�o COnSiIUCi 1ElE PlO�ECi($9tfiOn 7�4d, � �HAVE AT iH15 DATE A CONTRAC7 WITH THE HEREIN NMhFD COMRIKTOR TO � Business and Professions Code). � '� ca+r�cr n+e naovc o[�o Ex�srrt+�owewr�To rN[vueuc sEw[e. � - - . � � � , CONSiRUCiION LENDING AGENCY ► � . I hareby offirm that Ihe�e is a construction lending agpncy� ' SIGNE�THIS- DAV�p 19� " - - . . ; for �he performonce of the work for which �hia parmit is ��RO� . OWNERS AGENT - issued(Sec 3097.Civ.C.). � ADW+E55 '' . .. . , lender'z Nome � � � • �' � . Lender's Address � . . ' , . . • I cerlify tFwt I have read this applicalion ond stme Ihot the . �� . . � - . - - - � � ' � above informotion is mrrecf.I oqree to comply with all County' -� . � . � � . . ordinonces ond State laws regolating Plombing ond Sewers, � - . - � � � � � and hereby authorize represemalives of this Counry to eMer � � , � . upy�above•menI ioned pr erty for inspedion purposes: �� , , _ ._ . . .� - ' - �"/�--�/rs,.�- q 'G—�� Signalureof ermittee Date � � . SEEREVERSEFOIIEXPtIINATORYLANGUAGE � �� � • � � . . I � . ' ' � 1 � i f .- • 1 ; : . � . ' ' , ; a� �D� �� � g� �e � C - ... - , , . 1 ' � y� ZO Dn � �� 07 . � � ! � SZ om � A➢ �� gN ~ N d =-1 ND �J�� pU T � ❑ D' 1 ' _ � ' . � . ' �(l OS 8s� Z9 SO Yn� '� . 1 � ' + . � � . . "_' m D G1 DK' �. 00 � .�! T _ � • ' ZN, N� �Z p O . _ ' . ' , �"N mZ NA � ov D . .._. . ,' , . .. " . . 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