HomeMy WebLinkAbout1499A (8)WORKERS' 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
�sC. )
Policy NWFW ComponY _,7[Ar-E—,i_
❑ Certified copy is hereby furnished.
❑ Certified copy is filed with the county building inspection
department. ,p
Dole.7l/&__Appliconr �• / iPE+l�llN!/•PO
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/IIiP/ 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 L2� �m
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the. Contractor's License
Law for the following reason (Secicn 7031.5, Buisness and Pro-
fessions Code):
❑ 1, as owner of the property, or my emolayees with wages 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 eIiclusively controciing with
licensed contractors to construct the project (Section 7044,
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 regulating Plumbing and Sewers,
and hereby authorize representatives of this County to enter
upon the obove-mentioned property for inspection purposes.
z1
Signo!ure of Permittee Date
rEAnaD
CE STS
?s APPLICATION FOR PERMIT
SEWER - SEWAGE DISPOSAL
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOI APPLICANT TO FILL IN
CONNECTION DATA
RCJ"Lo"oR
STATION
DEPTH
ADDFS$ ze
IOCnUtY
eae
MnN-CLE REFFRFNCE
UPPER
L R
NEAREST / /
IYPEOFCONNFCTION
LENGTH FROM
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CROSS 5T Id iq_
Y. CURR
P L. M1. TO P L.
PC NO.
o—EII V
CO IMP NO
Joe NO
f'L
ADDRESS
TRU-. PERMIT NO
ROAD PERMIT NO.
A" DAVIT 141VIO 111FMFN1 RECORD INSTR NO DATE
[11Y TEL NO
IF.GAL
DFSCR'PT-ON LOT NO
H'NY. OR ST. W'DEN NG
BOCK TRACT
5!A11 FNCROACHAy NT
NO. OF 6![!GS
PERMIT NO
Now ON 101
usE OF
a'„':U NGS .S AJ
CHARGES
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CC's 4:CTION CHARGE FEE
ADDRESS �4t
REIMaU-SEMENT FEE
C'iY TEl � �
C!STRICT NO GROUP
MAP PPOCFSSFU BY
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rxE DESCRIPTION OF WORK HE
tC'J SE $f'WE4 CONNECTING TO
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YP11C TANK, SEEPAGE PIT OR
P:i$ 413/OR DR—HEID
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CC. T T ADDIT L a:OR
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OWNER'S Permit s
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AUTHORIZATION TOTAL FEE
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I HAVE AT TH-5 DATE A CONTRACT W!TM THE HEREIN NAMFD CCN-RACTOa :O
CCN -4,T THE ABOVE DESCR TIED F%'SI NG DWEUININ`G TO THE
PL,31!C SFWYR
VGWD THIS DA`�(jF sl�i�LA 1,w ,
R OR a.� /l
NEG$ ACE"I� f���fl�� -
AD: ESS
SEE REVERSE FOR EXPLANATORY LANGUAGE
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