HomeMy WebLinkAbout9557AWORKERS' COMPENSATION
I, hereby affim that I have a
terrifiV
c se to (
R7 ar.7 DP.v 3P
i nsure, (• a cendicate of Workeri Com ns n .
cc WAacert;h,.!I copy thereof (Sec. 3800, Lavv
Policy Nb. Co n si F
1:1Certified copy is herek ft
E]%wiffl-
POCIDAP
Certified copy is filed
department.
Date Applicont
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 ($100) or less.)
I certify that in the performance of the work for which this
permit is issued, 1 shall not employ any person in any manner
so as to become subject
abject
to the Workers' Compenscs rrtLfB4T'
DateLApplicnt
NOTICE TO APPLICANT• ter making thi . rtifica'e of
Exemption, you sho become subject t e Workers'
Compensation 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
V (commencing with Sec'ion 7000) of Division 3 of the Busk
ness and Professions Code, and my license is in full force and
effect.
License Number 07AA//L)) Lic. Class C 3 V
Contractor L-t" 6 I I(0%ate
3of rvhe . El am exempt under Sec. A. o.
Plumbing Code and/or Sec. of the
B. 8 P. Code for the following reason
Dose
OWNER.BUIt DER DECLARATION
I hereby affirm that I am exempt from the Conlractor's License
Law for the following reason (Sedan 7031.5, Buisness and Pro-
fessions Code):
I, as owner of The property, or my employees with wages as
their sole compensation, will do the work and the structure
is not intended or offered for sole (Section 7044, Business
and Professions Code).
1, as owner of the property, am exclusively contracting with
licensed contractors to construct the protect (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 that I have read this application and state that the
above informoSon is correct. I agree to comply with all County
ordinances and State laws regulating Plumbing and Sewers,
and hereby authorize represenlariv s of this County to enter
upon the above-mentione erly for inspection purposes.
Signotureof Per ittee DGIe
APPLICATION FOR PERMIT
SEWER - SEWAGE DISPOSAL
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN CONNECTION DATA
ADDRESS T /yFh'LI-mL—"`A •
5!AiION DEPIM
IOCPLITY ' MA' 01 RF•EWNCE UPPF.QLq
rA AkFSi TYPF 01 CONNECTION IENGTIr FROM
C4OSS Sr .N Y. CURB P t Mt. TOP L.
CA'N[R , CO IMP NO PC NOJOBNO
vA-LADDRFSS R•„'YK PFQH'T NO ROAD PFRM'T NO
Tu. NO 7 1279
A'F ;;nVll W'A r•S[MENT k[COQD INS:k A'O 0-nCfY
IFGAI
M(7110710-4 IOT NO HWY OR Sr. W •JEN"Y
KOCK -CT ACI: ;:i N: V
NO OF BI DGS PERM•T NO
S17[ OF IOT NOW ON ICT
16E OrBU:D•NGs CF GAB
CON:4AC7rfx[ — r{{/ ,. ( ( - -- CON" EC'IICN CHAP -A FFE
ADDRESS LL REIMB'RSE MENI IEE
CITY Z D' N", NO [;ROMP AWP PKX_FSS[D BY
STAT[/ t•C.
IICT YSE r:O. v {G CLAS$ G Y O
NO DESCR'PTION OF WORK FFT
I':NAL
I; SE Si MR CONwCT!NG TO/,
B:'C SEWN? f \ V rA1F
t
A, .
S Pnr Aid
VALIDA ON
SEP::C TANK. REQA(:L PIT OR
IS F'IA: AYD'(W DRA :W -FID
HOLE Sr WER CLYvHI:c1 YG TO
BY 2 p - 1 O
1 Tu
i0A1NEC IA.1D r'!yJA[ 9'.t%) CN'
WOQK •O FKJ'JSF SFWFR
U.!Rr;UA SEFPAGE PI. LIRA N1+:D
F N'N, CFSSF(yJ! DRY W[:t. HAhnCk.E
RErA•R OR ABA' sN n;I,S[
SFAER OR C SYUSAL SYSIM
OWNER'S Permit s % i 7. P • i., VAUTHORIZATIONTOTALFEE
I N''VE AT TI DA'E A CONI41C'1 WITH THE HEkE'N NAMED CCACTcw •O
CCY":[CI 1'+E ABOVE NSCR'B[D ["!S"N', CAF:t'!,G TO n'L PugIIC SE'.;[R
S' ,N D T P I S DAY OF ^ / 19_ oilC4
C`.. nIFR$A Ni
ADDRESS
SEE REVERSE FOR EXPLANATORY LANGUAGE
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