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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 . , i - � ; ' � ' o� >� �� f� z9 =s ? ; _ a� �o �A S v� oZ F .� J0 �; °-. 7'^ O . o � . � .. ' . ' ' � : ' ' =�, g m o 9 o z G�`-� � D . e - . � . , ; � �o O� v�D � �o,c po � ,fl . ' . i n mc �i"DnN TT o� � . ' i. - . , . i . �!Zc ^�7 K,mp 0 OF nz � O � � � ; � . � yO A ti i� Z . .. ... CJO p°� �A � `^ , D . N � N T . � � . � � � � � � � � I j N � O . . � � � A _ _. ..__ , ; : tn � - 2 , � � o O � ' t � a � m . . . , , t ; . - . N . � - Z , , n � . . . . ' . '_ . ' p. . . . � . � ; ' . . - - . 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