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HomeMy WebLinkAbout1767A WORKERS'COMPENSATION DECLARATION � , . � � � � � � ,. I hereby offirm thol I have a cerrificote of consent to self � �� , . . � . .. � ' . insure,or a cartificole of Workari Compensalion Insoronte,or � 0°^��� � � � � a�e��,f�ed�oPY«e�aof csa�.3�,�ab�., �E����a,e„ qppLICATION FOR PERMIT Policy No. Compony �i . � ❑Ceriified copy is hereby fornished. � . . ' - SEWER - SEWAGE DISPOSAL . ertified copy is filed with the coumy building inspection ' -. COUNTY OF LOS ANGELES BUILDINCs AND SAFETY � � : deportment. ' . ' ��� appl�co�r FOR APPUCANT TO Fltl IN � �.(� CONNECTION DATA - CERTIFICATE OP E7(EMPiION FROM WORKERS" • ' � COMPENSATION INSURANCE �oo��s�s V srntror+ d�}.E71� � oerTN � � . � (This section need not be completed if the work involved by the i�i�rr . ^�"^���E��E .v6� °�p permit is fw one hundred dollars(5100)or less.) - . � � ° � .. P{AREST TY14 OF CONNECTION IENGTN FRdA. � I ceni(y ihot in rhe performance of�be work for which this . caoss sr. R ��....p Y, ��RB p µ�,7p p,�, T j permit is ias�ed,I aholl not amploy any person in any munner n- � so az to become subject to the Workers'Compenao�ion Laws. p,M,�ER °'���ND� 1}(J - � O � Y O c- a x> co.u�w.rro. �on r�o. L MAIL TRUNKPERMITNO. ROADPERhVTND. . �[ I �ole AppliceM � � ^��u �` '� �+ t � u AFFI�AYIT WAIVER EASEMFNT RECOR�.MSiR.NO. DATE 0 � NOTICE�TO APPLICANT:-If,�ofier making this Certificate of cm tet.rio / — � ' -V Ezemplion, you ahould become subject to the Workea' �� . � � yy I Compoosafion provisions of the Lobor coda,you must iorlhwith oEs[aiaTwu IOTNO.' ' ' " -� HK^/.piST.'MDENING �` camply wifh such previsions or this permit sholl be deemesl ` . N revoked. ' � � �. . etOCc TRACT ,/ � STATE ENCROACHMENT � 4 ' � LICENSED CONTRACTORS DECLARATION � r�o.a xocs. � ocRMir wo. � s�ze a ior �Q rrow au wr I hereby affirm that I om licensed under provisiore of Chaptar �� � � � 9(commencing with Seclion 7000)of Division 9 of the Busi- , eunwracs w rkG aucces ' ness and Profeuions Code,and my lice�ae is i�f�ll force and � effect. . cor+Twaoa V 1n ca�cTiora aatct�c . license N�mbe� Lic.Class ��u 8� �f/, ;� i�neurts[�M�e . � � COf1hOC�Of � DOI@ . C11Y Y�A H- TEL . �Y � s DISiR1CT N0. GROUP AMP PFOCESSED BY ; ❑Iamexemptunde�Sec. �oftheL.A.Co. i�Ns�Np, �.� cuss-C � � �� �r�,�j � 7� ' Plum6ingCodeand/orSec. offhe �� �ESCRiPT10NOFWORK Re � pvnt . Ma,sc sem.c«�,r.�air�c ro p onre „-:ZD�-Sf�J' � B.6 P.Code for the following reason � vu&K 5�'^'rt° _ . VAL��ATIDN � . SEPTIC TMlK.SEEPAGE PIT OR FINAL � PITS ANU/OR DRAINf1Et0 D018 ' IqUSE SEWEY CONNECTfNG TO BY � . . qtIVA 01 5 M �� _ S19�O�u1@ � CONNF(7 AGDRIONM 9lDG.pR . ► ' OWNER-BUItDER DECLARATION � � �K T�NOU�g�R - � . 4�7�7 A.. oveariow sunnc,�r�T,oen�Nr�e�o � 1 hereby affirm that I om exempt from the Contraclor's Licertse [atro.,ces5roa oQrv,ett.Mnw+otE - Lov+)for�he following reason(Secton 7031.5,Boisness nnd Pro- ut[R,aev��a ow�ennipor�House � � . . . . {t��.� �-.� � p - j fessiona CodeJ: - - 56w[R oR oisPov.t srS�M - � � �-�---- - . ❑I,as owner of the proparty,or my employees with wag�s as � . . �.• •2'].5� - their sole compensation,will do tbe work and the strucWre � ' � � is nor inranded or oRmed for wle(Secfion 7044,Business. � _ - � -i and Professions Code). OWNER'S Permit f C .v •2'�,�j Q� AUTHORIZATION ' ❑I,as owner of Ihe properry,om ezclusivaly coniraUing with TOTAL FEE - 0 Q 0 0�—0 2 � i licensed controctors to cons�ruct the proiect(Section 7044, i Hnve aT nns ont¢�caaTawa wrtH t��aew N�Mto ca�Twr�cTat to Busineu and Professions Code). - camea n�e neov¢oexRqED E%ISTING DWELUNG ip TM[PUBLI�SEwER. � � � � � CONSTRUCTION LENDING AGENCY � l'� $3 ' , � hereby affirm that thare is a construttion lending agency � S�GNEDiH�S � DA f t9_ , � � � �'i for the performance of the wo�k for which ihis permit is � ��R� . issaed(Sec.3097.Civ.C.). � owrvceSnGer+r . . . . '. noocess r i Lender's Name . � � � � , Lender's Addrass . � . � . � ' I certify that I�have reod this application and stole thot Ihe � � � � . �. above information is torrect I agree to comply with oll County . � . � � � , ordinances and Stafe laws reguloting Plumbing and Sewers, � � . � � � , - . - - . . � ond here6y authorize representotives of Ihis County to enter. � u obove-me tioned property for inspedion purposes. " � � � � ��. � q-6'- 83 _ Sign9 oture of Permi t e Date ' SEE REVERSE FOR EX►LANATORY IANGUAGE � _ � � � � � z��8 � �� o- �z . ' �, T�• y+�j ➢A �� pa �� � '�'Q � , . �� Z? �,p` p% pg �� �4 o•! �jm Oy Y p 0 � � . � �S� Y� '�io � MM �O p • �^ og �',�, �.� n2 'G . . . . . � O(� mCG� �`� O O� `i r � 4 ' - �7 N Z '�^�O � � N • ,,'{ - • . . , NN�O p F �' . " r •. . . . . R O A Tr � . u Q ' ' ' � c - . � . w �, y " � __- O ➢ " m _ �, . . • — e ' ._ . - � '. 4 ` , �, - ., � , . "' . V . w � ���, N , � . . . ' . 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