HomeMy WebLinkAbout1766A (10) WORKERS'COMPENSATION DECIARATION . ��
1 hereby offirm �hol I hove a te�tificote of to�sent to salf � �� _ . � � . , ��
� insure,or a�certificate of Worke�s'Compenmtion Insurance,or �_ �"6'�D � . � � • � � .
a certified copy tbereof�Sec.3800,�ab�.> . .. . �E��R�,.B,e„ � . -. qpp�ICATION.FOR PERMIT � �
Polity No. Company � Bs � , . .
❑Cenified copy ia heroby furn�shed. -� � SEWER - SEWAGE DISPOSAL �� � � � � �
en�Red copy is filed with�he county building��.P��fior, COUNTY OF LOS ANGELES BUILDING AND SAFETY
deporlmeM. - �
po�e qpprconr FOR APPLICANT TO FILL IN ,��.(J CONNECTION DATA �
' � CERTIfICATE OF EXEMPTION FROM WORKERS' Bunom�. p
COMPENSATION INSURANCE - . ��u D � / ♦N �/ ST�tror� d f�7� o�vrH ..
� (Thia section need not be completed if the work involved by ihe , ���n, AMNNOI[REFERENCE ' /,�j�/� [_ � °PE �
� permit Is for one hundred dollors(SI00)or less.) - - ry R
I certif thot in rhe erformon�e of the work for which ihia �'�ST 1 T�v[a�a+r�c'r� �r�THFaon�'
, Y P CROSS ST. T Y H Y. NRB V. M.L TO V.L �'
� pe�mil ia ixsued,1 aholl not employ ony person in any manne� P�� �s- �
so as fo become subjxt�o the Workers'Compe�sotion Lowa, p�.�ER � � � - �_i��.p � ���,q � Q 0 _
- � ' ��� . � � �1'^'t A ., s Zj �UNK PfRMIt NO. ROAO PERMIT NO. � V
Date Appliconf . .000eEss � - . '" �
. � AFFIOAVIT WAIVER EASEMENT RECORD.INS7It.NO. DA7E O
NOTICE TO APpIICANT: If, oHer moking th�s Cerfifica�e of an. y� i[�.r+o �y 7�- ' � � � V
' Ezemption, you should become sobject to the Workers' C �
Compensa�ion provisions of the Labor code,you mus(forthwith � oeycv�vrioni �orr+0. p - � � wwr,pR sr.w�oewrtJc 0- �
tomply wilh s�ch provisions or ihis parmit shall be deemed �7 y .
- revoked. . eiocx TRACT �� / STAiE ENCROAp11yfM � Z
UCENSED CONTRACTORS DECIARATION � r''°,o��°cs. r�RMir r�o. — �
I hereby affirm thot I om I�censed undar provistoni of Chapter sizeaioT Q�� woworiiot .
�a /
- 9(tommencing with Section 7000)of Pivision 3 of the BUfI• �IIDINGS O �( s, ae�ec�5
ness and Professions Code,and my license is in full force aod . . . �
BHECt.- ' . � �pNTRACfOQ �'�.y� � CONNECTiON CNANGE ffE '.
License Number Lic.Class - �Eu MBURSEMENT fEE '
CorHractor poie - � RKT NO. GRWP . 'NAP P40CESSED 8V
��,� ., ,. � ,E�. . ir � � �� � � �
❑I am exempf under Sec. of the L.A.Co. i��r.�p. � 'anss �� '� ��JL7� �
Vlumbing Code and/or Set. of fhe � �� ����T���WORK r� HNqi � - ,
`ause stwec conir.�cnnc ro oa� Q VALI TION
�B.8 P.Code for fhe following reason � �����R ��—' v.j .
SERIC TlWK.SEEPAGE Mi OR
' � VITS AND/OR DIIAINF��D �A� ' - .
Date . �aus�s�v+[a caar+[criNc ro . eY .�i,.l� (/ -
� PRI AiE DI Y M . � �
$191�O�Vf@ CONNECT Ap0171QNAl&DG.OR , ,
OWNER•6UILDER DECLARATION wo�ro i+ouse sewEc . ,
OVEIIfLOW SEEFAGE%T.DItAINF1�lD .
I hereby oHirm that�am exempt from�he Conuac�or's Licensa � � exrN.,cessrooi.oxrw[u,Mnw+oie .
. Law for the following reason(Sedon 7031.5,Buisness and Vro- xtea,wFvnia at aenNooru House . �-- - - � 7 Q 6 a
fessio�s CodeJ: � s�w�R or�oisvosu 5rsteM . , �.
❑I,ae owner of Ihe property,or my employees with wages as �• • ♦�• � �
their sole compenwrion,will do the work and the slroclore . � � �
� is not intended w offered for wle(Section 7044,Buziness � - � -� �- - '�'. .2 7 r.��o ;
and Professionz CodeJ. OWNER'S Permi� f � ' �
��,os owner of the property,om exclusively cororatting with AUTHORIZATION TOTAL FEE "� • • •z'J,5 Q�
. Iicensed mnlroctors to consiruU the projett(Section 7044� �NAV[AT TMI$DqTE A CON/RI,�T WIM THF NERFIN NAME�CONiNAC10R f0 �
Businau ond vrofeu�ons Code). cow�a Tr�neovE ce�o exisnr�owewNe To rr�weue s�weR. 0�Q O G—O 2
CONSTRUCTION LENDING AGENCY � � �+'� ► �
iereby offirm that there is a construction landing agency SIGNEDTHIS� � OF 'p � ro¢� . ��� - � - � ���
the erformonce of the work for which this ermit is °W"'ERat _ ,
�ed(Sec.3097,Civ.C.)..� P . owr+eas nc,�N� .. A . � . . _., . �
�er's Nome . � � ��Ess��r� �jt� �^' JS�� - �
br's Addrasa � - � � �
iify tlwt I hove road this applica(ion ond stafe thot the . . � � � � - � . . �
e information is mrrect.I agree to comply with all Counry . � . . . ��
ances and State laws reguloting Plombing and Sewers, ; � � � � ' � --
ie�eby authorize represeNatives of�his County to ente� � � � ' �
the above-meMi ed property for inspettion pvrposas. � � �
�,"` ��- %-6- ��
�oture of Perminee Date SEE REVERSE FOR ERPLANATORY LANGUAGE ' , . �
I . PLS� c8 �.
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