HomeMy WebLinkAbout1767A (10) 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 � _ �
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