HomeMy WebLinkAbout1765A (10) � WORKERS'COMPENSATION DECLARATION Y�� . � �.. � � , � . �.
I hercby aKirm thot � have a certifimte of consent to self . . � . . - , ,
insure,or a certifimte of Workers'Compensotion Insorooce,or �6�+70 , . . . ,
a�"��'�°°`oPY„".eor es".'e°°,`'b�., "�'�".e,81� APPLICATION FOR PERMIT
Policy No: � Compony �s � �� . � �
� ❑Cenified copy is hereby furnished. � � . � SEWER - SEWAGE DISPOSAL - . ,
e.rified copy is filed with Ihe munty building inapection COUMY Of LOS ANGELES BUILDING AND SAfETY
' department. � ,
oa�� aPPi��a„� FOR APPUCANT TO FILL IN I�t3v• S�CONNECTION DATA
� � CERTIFICATE OF EXEMPTION FROM WORKERS' � � �iia� �
COMPENSAiION INSURANGE � �ooa¢ss i � sut�aa ��-f. ,�� oevrH . , :
, (ihis section need nol be tompleted if the wwk involved by the � MnN�F atfEyEr+CE � � uwFR �
permit is for one hundred dollora(5100)or less.) - ��'��� ' .
rar,rsrsesT rr�a mr+ractwN �rucrN faavi
1 cer�ify�Fot in the perfo.mance�of�be wak for which�hfs caosssT. aC V Y. CURB. P.4 � M.t.rov.i. � .Y -
permil ia issued,1 shall nol employ any person in any manner . n. �
P.C.NO.
� so as to become subject to�he Workers'Compensolion lawa. pwNER 0-:' b O H� ���N'P��� 10s�'�O. G � -
��� / 6 TQUNK PERMIT NO. � ROAD PERMIT NO. �
Dnta � Applicanl - A�u V a `�°o�^ . � ,
NOTICF TO APMICANT: If, oNer making fhls Certificate of ��n, ��� ./ AFFIDAVIT WAIVER EASEMEM RKORD.MSTR.NO. O�TE o �
E�emption, you :hould become subject to the Workers' iFG�i '/ w �
Compensation provisions of�he Labor code,you mast for�hwi�h oFs�aivrida torrio. - Nwv,qtst vno[wai� . - d-
comply wifh suth provisions or fhis permit shall be deemed ` /
feVOkCd. � � . UOCX � " TRRCT � J M STATE Er1CROACNMENT . �
LICENSED CONTRACTORS DECIARATION - !'�°_°F e�°�5. I . �+�T r�o'
vze or�or Q Q r,ow or�wT ( � �
I hereby affirm Ihot I am licensed under provisions of Chopter � �� � ,
9(commencing wilh Section 7000)of Division 3 of the Busi- e�ao�taGS /L ~ Y K oukce5 �
nms ond Professions Code,and my license is in full force and .
eff«t. � ppr.ira�R�q COMNFCTION CMARGf FEE
License Number Lic.Class - Ap�u rsewsuaS�Nr� �
�'OnhO[iof �p18 CIN ti y ' TEL.NO. L � �95 aSiRICTNO. GIIOUP hWP � PRpCESSEDBY �
BK PG
n.� - �,�. �. -3 �Gi�-� �
❑1 am exempt ander Sec. �of ihe L.A.Co. iKEr+st r.p. , R,�ss ' -
Plumbing Code and/or Sac � of Ibe �� " SCRIPfIONOF WORK RE H�� �
� MOUSf SEWER CONNFRING 70 77 UATF G VALI TIbN '
B.8 P.Code for the following reason � ������p �� ' � �D�O� � ,
SERfIC T�NK.SffVAGE PIT OR HNAI
. ' PIiS AND/OR DRAINFIFID � . •
Dote - Mous[scwta cor+nacrn+c ro aY � .
. . - AtIYAIE DI Y . '
S19t1atUf8 ' CONNECTADD1710NALMDG.OR ►� � � �
� OWNER-BUILDER DECLARATION . woxK ro Hovse s�wex - � �
I he�eby oNi�m thoi I om exempt from the Gontractor's ticense � e�iNF�cessvoo��.'E000rvrt�iRiar.�uN�i°q�[ � � �!
law for Ihe foilowing reoson(Sedon 7031.5,e��5�e:s o�d r.o- u�R,�P.,�R�a���,� -- - � - ��1 7 6 5 A
fessions Code�: . s�v+eR oa oiscoiai srSteM . , .
❑I,os owner of ihe prope�fy,or my employees with wages as - �j�'• •-• � � .
iheir sole mmpenmtion,will do Ihe work ond ihe structurE . - � - �
is not intended or offered for sole($ettion 7044,8osiness- - - _ . � • '�7�J�� �
and Professions Code). OWNER�S Pe�mit f
❑I,os owner of the property,am exclusively controcting with � AUTHORIZATION TOTAL FEE � ' ' '2 7��`_'
I�CRIISBCI f0l11lOC�OfS�O COIIS�IUCf�F1@ PfO�ECt(SB[�10l1�OA4� I HAVE AT THIS DA7E A CONiRP.�T WITM iME MERlIN NAMEO CONTRACiOR TO �
BUSin855 011(I PfOfB5510�5 COfIE�. �� CONNECI fHE ABOVE DE�IBED ERISTINC DWELIING TO THE VUELIC SEWER. . � ' O Q O O"�O 2 �
� CONSTRUCTION IENDING AGENCY -� � � ' �
I�hareby aHirm ihat Ihere is a conshu[iion �ending agency SIGNEDTHIS � �A �� - �- � -� ��
for the performance of Ihe work for which this permit is �R� � � �
ISSUBd(SGC.3OV7.CIV.C.J. . OWNERSAGEM^� � . . . _.
� ADCRESS�fJ �^Q A �+C, �p�, � '
Lender's Nama �
�a�a�,•�nad�a�s .
I crtify that I hava read this applkation ond stote tho�ihe � - . � . � � - . - �
" above informolion is mrrect.I ogree to comply wi�h ail County � � - � �: � �
ordinonces and State lows rogulating Plumbinq ond�5ewers, � -� � � � � � . . � � . . � -
and bereby authorize representativas of ihis County to entm � . . . �
n f above•mentioned roperry for InspeUion pvrposes. . ' __ � . � � .
�6r �3
� ignaiure of Permlt�ee Dai� � � � - SEE REVERSE FOR E%►LANAIORY IANGUAGE . ,
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