HomeMy WebLinkAbout1499AWORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance, or
a certified copy thereof (Sec. 3800, Lab C.) G'
Policy NWFW ComponY _,r-E—,-sr��
❑ Certified copy is hereby furnished.
❑ Certified copy is filed with the county building inspection
department. ,p
Dote.7l/&__Appliconr �• / iPE+l�llNlliP/
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the work involved by the
permit is for one hundred dollars (SIOO) or less.)
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers' Compensation Laws.
Dare Applicant
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers'
Compensotion provisions of the Labor code, you must forthwith
comply with such provisions or this permit shall be deemed
revoked.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter
9 (commencing with Section 7(M) of Division 3 of the Busi-
ness and Professions Code, and my license is in full force and
effect.
License Number�s3o-/APo Lic. Class C—#2_
Contractor /EIV/AI/U.P/ Date
❑ I am exempt under Sec. f e L.A. Co.
Plumbing Code and/or Sec. of the
B. B P. Code for the following reason
Date
Signature J M
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the. Contractor's License
Law for the following reason (Sec7cn 7031.5, Buisness and Pro.
fessions Code):
❑ 1, as owner of the property, or my ernoiayees with wagms as
-heir sole compensation, will do the work and the structure
is not intended or offered for sale (Section 7044, Business
and Professions Code).
❑ I, as owner of the property, om exclusively controciing with
licensed contractors to construct the project (Section 7040,
Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is
issued (Sec. 3097, Civ. C.).
Lender's Name
Lender's Address
I certify ?hot I have read this application and state that the
above information is correct. I agree to comply with all County
ordinances and State lows regvloting Plumbing and Sewers,
and hereby authorize representatives of this County to enter
upon the obove-mentioned property for inspection purposes.
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Signature of Permittee Date
rEAn.PD
CE STS
?s APPLICATION FOR PERMIT
SEWER - SEWAGE DISPOSAL
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOI APPLICANT TO FILL IN
CONNECTION DATA
BCJ"Lo""R
STATION
DEPTH
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OWNER'S Permit s
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AUTHORIZATION I TOTAL FEE
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I HAVE AT TH-5 DATE A CONTRACT W!TM IHE HEREIN NAMFD CCN-RACTOa :O
CCN -4,T THE ABOVE D(5CR iRD Fx'St NG DWEUING TO THE
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SEE REVERSE FOR EXPLANATORY LANGUAGE
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