Loading...
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 �. pI N yn . �Y '�' �r7. �yy �n �m I ' 1 � I � v��� mA v AY �� � � .' � m Q9 r �� a➢ � ' i • .,� ' y � i� z(� p 'D yN �O h� .p , -- � - ' ` , , ��°� � :�. �O N O rv o- � --� � � . .D �N..c�i �f oy n> �' O ' . . - _.. � T S� tA A N _ � ` `�O '°� �A �x u+ � . • � � ' p . v ..- _ r . o N rn . . Q . . .. ... �- ' ' , ' � ., l� Z ' w ' � . . 1� . �' � ' Q � � . .. '" . � , . , � N • N � � '' . . - _�". ' ' " •. � a . m � . � . ` . . i .. , 1 . . ; , ' . ,� �.l�. ' � . • .. . . ' , j ' . . ' r ' � •'' ' ' . , ' �{ ' ' r- . 4 , j ` ,i . , �''� ._ . � . . _ - ✓ ` � � ` � � n � - ` � _ - O '� '� , _ � . ' , �..'. � O iI . ,7 f. � . ` � ; � �. N ,' _ -. . . , �T, i . ._ (-. 1 �' l � • t .�+ , f � F[ ., i y j: • . i i • - ' .f.. - i � '. - ' ! ' � . . {+ "�q `�.--�o o�3 � z y K� � O ,. . ` � �ti �+ r ��o �� n o ^ � �Q�`-o-'T'��� r•�,� o +.,, n f r ' _ i . � . �, . (n • '^ -� H G' - � s `�'� o �' "fi M o o h � ° a� �� r�.e 7 . '1 � , . . � . . �. ., � ". . - . ` � , � W o o�" �c � '' �.�� �i+ a -�.� F, H i. ;� o a�� P �'.. ,Ct1 - . . • . . � Q' m ,r-, »,'"a �v ...�-;, c ?n a`°``o a G��� '�'" . �� N '/� . .. . . ' W .�/.d � O „ � .. :t .*r�n N n G.C�.tv'Q.�' w i� ^' '^ 'S1� L'+ �' , . - ' .. � . : � � �r�y tr''� � �'Q t7 `�'� ti !;��V p � '�".-.p a b •^• „��•n» F� Q j ^ �� . , _ ' . , .�i ' � f{:] ��^, M��,0.� x o '�"._o�„ �{ °�.:�q N�S� A ;.� � � 'r' . �. . . ' � , � R �" .. Y � � � M ~1 H in fa .R p� .'S � �� r;J� .\/ . . a �o . a-a o o�:. •�` .a„-��o_-'o'� Y ' � M�..{ � � �� �„ � ..."^ ~ �t �n e�..� :. O • . . . � •1 • O � t. Ct V�` `�.i�.. 7 n �� q ^ � f: `/" 1 ��i: ,-. � a� � °.o �.c.. 7 � o s, o n ',�, r c�c� •x ,I , . �� �� � - � � � �� »�r ti o A'G,"y b^ �^'+ ('�V� '"`�..^. � C,,V� rt .�„/. N rn` � �t fiy�p i,�. r' . C u� q p a'.-.� C n .. . , . . � . . M Mi . ^ �r. o 'II a.�O ' �;r. ° ��T-�^.� o M •`• �� � . � ' ' ' �' Vj � �� �..���-w m�,f y � �.�...-• �n N � -F .T.O � ["�. .. ,'�,j � � . , . . � . a H O 4 � ^ "� � o � ' .. � . . . ' � n � '+. o ��p'^ n � �y ^�+�tv ��-h A.C'o•..�.i.. '� � 9r.� . . . . . . . . � . '•� � A.�,�a'N �'�V � � � �t�.,0.�_C7�4� � .. ,n, o n ~ � . . , . . . . . Q �^,�� �0,�' r tC y p •� C �a� .+ .F '*�. . . . . . . � . ' - . ' `1 �e: � �� OQ ��'q.L..,rn.:� � � � �� �O � . �••� p �� .. Q .� � N 11 , . . _ � _ � �.y'�'. w o'v -. h� � ' � , � _. � .b� C, o � �.-s 3.'^ W�'^ o � � .n p w Z 1 - o F'� �" "2 o c o � e'`r o W^ . a �e o H ^+ 'o r. -� �,,, � iC'aP+ � CC ��..� E�'. � � A�.`.�'��'J`"ea � q� C.7t �. .- . . . . , �, ��� � � a;:O- .N Q � 3'j��eR�i n ti 4 H N . i � �� C ` . � . . . . .,F.� �.� N O s G+ _ ' . . - ' .� � ��`W N �w� � . !` . . ' . .. . .