Loading...
HomeMy WebLinkAbout1770A WORKERS'COMPENSATION DECLARATION . _ . � � I hereby offirm rhor I Fwve o cerlificale of consent-to self _ . , . � . �- inaure,or o certificote of Workers'Compensotion Insurance,or ��`61�0 � . ' � . � a cerlified topy theroof(Set.3800,�ab�, �E���.e,B,> . � APPLICATION� FOR PERMIT - � �� � � Policy No. Company ' �� . - . � ��Certified copy is hereby fomished. SEWER - SEWAGE DISPOSAL � � L�1 Certified copy i:filed with�he munty buflding inspec�ian COUNTY OF LOS ANGELES BUILDING AND SAFETY deparlmenl. oo�e nvPirmnr POR APPUCANT TO flll IN � ��j(�•.S OCONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' • euuoirvc. ' COMPENSATION INSURANCE �wort�ss � Ll � �I STATior+ � �mN (Tbis settion need not be completed if the work fnvolved by the i��t� ��0 Y. M4NHOLE REFERFNCE �R permit ia for one hundred doliors(E100)or Iass.J : T�v�octor+r�tTiar.� I certify ihot in rhe performonce of the work for which rhis c�ao�ssssr. 1� r� d r. . cues vl.� M.i�ioP.� � � permit is issved,I shall not employ any person in any manner � � P.�,NO. O so os�o become subject lo the Workers'Compensotion Laws. p�Ep � rQG � � � �p,�µp,pp, �pg Np, u _ ��� F TRUNK iEkMIT NO. ROAD PERMIT NO. x . Dote Applicam - � . Aooa[u b 'Pr �� k , NOTICE TO APVIICANi: If, oNer making this Certifitate of ��TY � �i� ` '� ''7 Q -MFFIDAVIT WAIVER EASEh1ENT RECORD.INSTR.NO. DAfE Q E.amption,, you should become subjetl.to the Workers' r w . LEGAL Compensotion provisions of the Lobor code,you must forthwi�h DEKRiPfION LOTNO. � � HWY.ORST.WIDENING _ ' � . mmply with such provisions or this permit shall be deemed -- ^ � revoked. � � � � . BtocK TRACT /C .�� STAiEENCiOACHMEM � LICENSED CONTRACTORS DECLARATION � � � "'°.a&°�5. �w.�ii r�o. � . I hareby aifirm that I am licensed under provisions of Chopter ����T Q Q �ow o�.�ioT � � 9(commencing with Section 700D)of Division 3 of ihe Busi- Wuwr�GS tJ h � � t7a¢c�s nns ond Professions Code,and my license is in full force and . � ' � effect. � � - � � � tOwiWiCTOR �.� CONNFCiiON CN�RC"#FEE � , litense Num6ar Lia Clau � p��ss �'� REIMBURSFMEM HE � COnt(OC10( ��� CITY '+t� d(�,. �. .��� . DISTRICE NO. MAP PROCESSEO BY ❑I om ezempt under Sec. - of�he L.A.Co. i��r.p,� n,yu — .� � �`�� �� � C� Plumbing Code and/or Sat. of the NO� SCRiPTION OF WORK r� FiNAi � . � ����R coNr.�crinc ro n DATE �Z�r�� VALID ION B.8 P.Code for ihe following reason �� � SEPTiC TANK.SEEPAGE PI7 OR . � - � P�75 AND/OR ORAINf1ElD FMAL _ � �IB - WUSE SEwER COMIFRING TO . BY .j� �. . ,. - ' PRIYA7 D1 SvSTEM � Signofure . � Cav�cr noomaut e�oc.oa � � OWNER-BUIIDERDECIARATION � woRK*o�ou5e5ewEe . - OVERFIOW SFEPACaE Fl7,ORAINFIEL� ' ' � I hereby affirm that I om eaempt hom the Cont.otlor's licenae emN..cessc�a.ocrwEtt.�w�a[ . � , law for fhe following reoson(Secton 7031.5,Buisness and Pro- xhc.2ev�ia oc�ennioor+Hous� � � fessions Code�: � � - - s�vrta at oisrosai svshM . _ . ❑1,os owner of the properry,or my employees with wages as � �'4� �7'�A their sole tompenwtion,will do the work and ihe strutture � � . #• • • • � p � i:not intended or offerad for sale(Section 7044,Bosiness � � and Professions Code). OWNER'S Permit L �J U � •'�2 7 5� ❑1,os owner o(the propery,am exclusively contracting with AUTHORIZATION TOTAL fEE 0 . IICBI15Bd CO�IfOC10f5 f0 COf15�NC1 tI1B PfO�BCI(S2C110f1 7044, ' I HA�F A�iH15 DATE A CONTRACT WITH THE MEREIN NAN£D CONTRACfOR TO . .��a �2�7.5 0 s Busineas and Professions Cade). co�tr T�neove cescaieeo ezisnn�owFxun�To rNc vua�ic s�+rtc. � � CONSTRUCTION LENDING AGENCY � - �',P 19C2 , " �O�Q O O—O Z ' I heraby offirm fhof fhere is a construUion lending agency ' SIGNEDTHIS AYOF � U � ' . for fhe performance of the work for which this permit is �ERs�r,�r�n � issVed(SeC.3097.CiV.C.). A��� . , . . . Lender's Name � - . � . . lender's Address - - � � � - ' ��, I cerlify Ihot I hove reod fhis opplitation and stote lhot 1he. � � - , � - � � � . � - � � � � 1 above informalion is correct I agree ro comply wirh all Counry ' � � - . � � . � ordinonces and Stote laws regulating Plumbing and Sewers, _ � � - - � � - � �� ond he�eby outhorize representofives of this Counly to antar . - . � '� ' u �he obove•mentfon d properry for inspection porposes. � � . . � . ' . . . - - �r��..�... 9—�-5 3 � : '--SignafureofPermiltee Date � . SEEREVERSEFO�EXPIANAiORYLANGUAGE z 9Y�G� � _ O �� ��^ �?n .�� SO 9 . �p �a g 0-` G� '9 ' ��n Y� Y_ PY � 1 .d'�+��Z Oq D y��ir$� �� O � . , � ,t, I'��� _� Z o p Z � � � O� �N x➢ � a M c 9`� a °=' � r' . : , . �y� N y '�<A �° ,1 �' \ ` . ` �' . o N�v �o � - 8a'° ; ` . ' ,, p � o . � � �, � , , m � _ . , . , � • _ � i `� , , � , s y o , � � N � � ' 1t� - . . �� '_ • . N . �\. � ` i ,1 � , � , . • _, � \ , . - .. . , � � , . G . N � � � � , ` N ' � ' � . . . � , ; . �\ ' . . . . � . � - . . , � - • . � ' ... . . . . Y �, . 3�` , • . ., . ' • ' � r/ � � . ,, . , ' , `� � ;� : � � ',. . ��' � � � ` . . � ' -t�'� ' , . ' . �� 1F . v � �i . . , •/ ! •'� 'J,. i ,.��• L . :1 , �. �' , . ., / � � � � '' A ' . , - . . , � ' . � ' , Y � � � , J Om . , � ' f `.f. � , n . . ��. �t ' �� '� • . . , . ' .. '• _. � �'.'✓y. �' . . ,�/��r,� J., =/ �� " . • . , �y.f: i: ' � �Y � .. � , �, � � ;_n ... �'. N 7 . . , U t �.�o o i ° " c,c�„ Q . � � :. � = � 7. � o;, N.� �s..� ' � � r,.� . . y.y cnnQo�,'»�,;N e, o N K �w �yy � ,�,�. � � o�; � o� ^.��xFpO � 7.^.,'}" � N� Y:{� ,,,..• ,�,,� • � ' �. -�C.H.. o � o �G �, � o ^ p � ��` . � N.,�0 '� � . � . � � . �,� '�,� . ..O� .� -a �`�+t' c+.Q° »'�, �"M a o ^ � _ ' '.`� -a^� O �t ,,L .�,.r "�ca [n;3 �. -+� `,, .. ��' Y v.d G'+ V �,�� »W 7.^� r�$ � n �''.� ^•,�a+b=c �'-� N n..'' C� . � � O � � C � � G N•S O� p �.lN"`,O M�� p �L .�1 ' �� � � y c � � � N �� ' ry i�,. .. .. s�.� �� � 7 :: � T••,;� o' "c�n^ , .. p � - ��,, �'f* '�d ,. Q..--�] � �. � g. o '^ ..o...='».p y�, = :n�'.� � . . . . � . f: , � � c, �o"3 c..�v L' 'u^�.�j���� ��"�'�" ° �n ^-n y °c..d'' �� M . . . . . . � .. h . . �, ✓� '�� „ 7 w-. O � 4 f � O t' .�.n y (�,..1�..N p�C. � +..n� .� . ,. . � . . O r, o �: � p =� + w� '� „� O�„Q,-.. o � �. � x. c: .r' � . . , � y u,� ��� :�U ��a�" "-=s;" =-v�=s ���A�o � � _ C -. � � � k � � - � ��� - . . " � �• ty�}�j 3� �..c.� o�° ;."� 7''t �'� °�..N G.� o=�„e? " � � - - , M '" . ^ ��w O�»u�... e, O`t ","�'s� ^.�� 'e7�eo ~ Q-...�..f ry (C (J� G'`�4 O �~��^ -�".'ACT � n 4 ��0.«C p� 7 � �°� p. p 7'� , /1 , . . � � . � 9� () ' ,�. i�. ia� f� � C ^ x �T,.�;� � '• ' p „ O , . , . . . . . fp ;l ��,,,� P �, -a�j N 4,d �-,s. � O � :+:N y.--� '..�,. . 7 �=�:,=''� o C�...o � ` � ° .x(�� �'� h o� O r. O ��..."� .�O • ' . , . � . , . Z G"1�'`w E':S O Q N y� �'O Yn�.W 4 `�.P 0�LS-N O ' � . ' • ' .�.P 4 4 . .pi � p�0 f+�'�^b O " + � `� V�v. . . . � . - � .. �.. ' ' � i°,x O"o P.�'..I ro O ��r''�' A�--.� e' � �o k ' o � F o'�� e�a. .Y �-� 93 E'wo r. .. . ,. C C'�'r� ���.� - +.� ��'V � . . . , � n � � n p ',� � � � ^� � . . . : � .�y�� '.�� n . . . . . . _. � G Y ,Y �p 0�3 .. . . .. . . ', � . , � . - �0.��+.B��,' m , r. ta � . - ' �,r ' ' . . ', ' ., " . . . `':.`, ' _ . A