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HomeMy WebLinkAbout1769A , WORKERS'COMPENSATION DECLARATION � � . � . � � � . � � � � I hereby affirm thot I hove c certifitole of tonsent to self - , � , _ � insure,or a certificote of Workers'Compensation Insurance,or 7dAA6i�D . � � ' a".,,`��`oP''�''°."o`cs°`.'a°°,�'b�., "��"`°.",8�, APPLICATION FOR PERMIT � .policy No. �� Company � �s . . � ❑c«+,f���oPv is heroby iurnished. SEWER - SEWAGE DISPOSAL ! (�'Certif�ed copy is filed with the coun�y buiiding inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY deparrmeN. � i peie Appiicant FOR APPLfCANT TO FILL IN f,3�-S� CONNECTION DATA j CERTIFICATE OF EXEMPTION FROM WORKERS' � euxa� � � COMPENSATION IMSURANCE �oortEss 8 .� � i� gTATiOr� �- .�°Evr� i (This section need no�ba completed if Ihe work involved by fhe i�i�n, � �,N����� � i � ipermit is for one hundred dollars(f100)or leas.) - I.cer�ify�hot in�ha performance of the work for which this ��ST r rivttKcaun[Cnor+ �r.�cTHrqpm Y. CURe P-t. M.4 TO v.l. } � parmii is iss�ed,I shall no1 employ ony person in cny manner �� � � so os to become subject to the Workers'Compenea�ion Lows. °��•1dO' �� O , owr�rt C G t Q w$' m.vu.r+o. ioe r+o. V � /MIL y S I TRIINN PERMIT ND. - ROI10 PERAAIT NO. Date �Applicant � � ���' � O V`O'�►. 141 . � . AFfIDAY1T WAIVER EFSFMENT RECORU.INSTR.ND. DATE O NOTICE TO APPIICANT: If, nfter moking this Cenificate-of �in p r6t.No / — Q � U � Exemption, you should become aubject to �he Workeri i�Ai �u Compe�sation provisions of the Lobor tode,you most fwthwi�h � p�qi�iq.� ioTrq. H,�,,y.��,y,��N�� �' mmply with such provisions o�Ihis permil sholl be deemed - / � �tn � revoked. - � eiocx ra�[r� �M� .. SrnTe E'+c�eo�cw�n+r � � - LICENSED CONTRACTORS OECLARATION / Pq.pf&DGS. , pEkMfT NO. � �, I hereby offirm fhot I am licensed unde�provisiona of Chapler � ����m o O v/ � �'^'�toT � . , 9(commencing with Seclion 7000)of Division 3 of the Busi- E�UitpwGS ��J� L � Y ./f. ld a,�s � �� . ness and Professions Code,and my license is in fuU force and . j � BHKt. - . . . . CO^1TRI.C�OR �(�. CONNERION CNARGE FEF { � Litenae Nomber Lia Class - - Apppfu b'� �'.-� RFIMBpRghlENt f[E . . Con�mctor Dme - . cin �i, f� ' asraicr No. cawn nar vrzocesseo er � ^ � � i n�TE — � ��C: � -3 ,�/- /� , ❑I am exempf under Set. of the L.A.Co. i��r,�p . n� f � �. PlumbingCodeand/orSec. - ofthe "p. DE RiPf OFWORK � RE � pNAL � w&K s�R cor+rxcrir.�c ro � wre `^ ,�a�y� VALI ATION ; B.8 P.Code far fhe following reason � �ic ir,r�c, v�et�r oa . - � . . . VRS ANp/OR pRAINfIEIU FINAL ' . DOIe ' . 'q�Jc��¢R CONNECTING TO BY . - , - - PRIVATE DISP06AL Sv TFM SignofVre CONNECTl1DDITIONFtBIDG.OR - � . '� � OWNFR-BUItDER DECLARATION - � �K T����'''�Q - ' I hereby affirm that�om ezempt trom the ConModor's License E�NFIOW��R�ORA�I��a�E , . �} 'J�9 A taw for the following rcason(Secton 7031.5,Boisness ond Pro- xnc,rs�vnia oa AerwooN Hous[ - . - � � � - � . FlSSi0l15 CO[JB�: . SfVIER OR DISPp$A�SYSIEM ,.'• • •;� � O � - ❑I,os owner of ihe property,or my employees witb wages as � their sole compensolion,will do the work and the strotWre . � , � � • •2��rJ� � is not intended or offerad for wle(Section 7044,Business - � - -� . � � � � - � Permit s � ZI . . , _ and Profeuions Code). OWNER'S 2'j,;j Q� ❑I,as ownar of the propary,am exdusively tontrncring with AUTHORI2ATION TOtAI fEE r� licensed coMratlors b construcr the project(Secfion 7044� I HAbF AT TNIS U�1TE A CONTR�Cf WITH THE HEREIN N�MFD CON RAQOR TO ' U Q O O�O G Business ond Professions Code�. cowwEcr n+e neoirt cescaieEo EwsTu�owt�un+�To TH[weuc s�rt. - _ . , CONSTRUCTION LENDING AGENCY � � /? � �{ ► . ' I hareby offirm lhot there is o conatrotlion lending ogency � SiGNEDTHIS �o � DnY l9 - ' _ � for Ibe performance of the work for which thia perm❑ is �+EROR � � _ . OWf.IERS A{Ni . �..�aa�s«.aoe�,c�.c.�. �ess j _r�r.- v�l,L i..v � Lender's Name � , � lender's Address � .� � � � ' I cerlify tha�I have rood this application and sta�e fhat�he � � � - � � � - � � � � above informotion is caretl.I aqrea to comply with oll CovMy . � � � � � . . . . . ordinances a�d Sla�e lows regulotinq Plumbing and Sewers, ,� � � � - � � � � . . - and hereby outborize represen�otives of this County to enfer .. - ,. �u the o6ove-mention�ed properry forinspetlioa purposes.- ' � � � � , , . , . , i 6/c��,cr- + ` � — �� � gnatura of Parmittee Dote SEE REVERSE FOR EXPIANATORY LANGUACE � m . �5�c� f o }�� � o� 6a x . y� �� � o��� g y , ' ' ; ���� CR � p➢2�Y � � . � Oy O } \ ����M �Y O y�ptl $ �C� � � , i�'y Z� �p "Z^q A� A �.. � °9 �� �- �> v . . ` ��`�� �4 a °� ` r' N� y � � � � � � �� 'C�u� �� �A � � � , . $�n ; F � .. . . . , . , . , � _ � �1 �� � [ ., . . ' . � . , . ., �. ( ➢ \ ' • ' ' . ' tt �� � ' ' - 1, - ' . . ', � "' � 1 � 1. � . ^� � . i \` . 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