HomeMy WebLinkAbout9557A (21)WORKERS' COMPENSATION
I, hereby affm that I have a
terrifiV
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R7 ar.7 DP.v 3P
i nsure, (• a cendicate of Workeri Com ns n .
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a cert;h,.!I copy thereof (Sec. 3800, Lavv
Policy %. Co n H.W. F
E]Certified 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 suuSabject 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 emplayeeswith 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
tender's Address
I certify that I have read this application and state that the
above informoHon 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 itree 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_c.r •
5!AiION DEPIM
IOCPLITY TY uO:E RF•EWNCE UIQlq
rA AkFSi TYPF 01 CONNECTION IENGTII FROM
C4OSS Sr .N Y. CURB P t Mt. TOP L.
CA'N[R , CO IMP NO PC NOJOBNO
MA -LADDRFSS R•„'YK PFQH'T NO ROAD PFRM'T NO
Tu. NO 7 86'1 1279
A'F ;;nVll W'A ASEMENT k[COQD INS:k A'O 0-nCfY
IFGAI
M(7110710-4 ICT NO HWY OR Sr. W •JENN
KOCK -CT STAT tNC.V ACHIIN:
NO OF BI DGS PERM•[ NO
S17[ OF IOT NOW ON ICT
16E Or
CON:4AC7rfx[ — r{{/ ,. C ( ..__..___. CO—EC'IICN CHAP -A FFE
ADCRESs MENI IEE
CIlY 1 Z D'SIPICI tq URU> AW> PRd'ESS[D BY
SIMMt•C.
IICT YSE r:O. v {G CLAS$ G Y. O 29
NO DESCR'PTION OF WORK FFT
I':NAL
Si MR CONNECTING TO
F. SEWN? f \ V rA1F
t . S Pnr Aid Al VALIDA ON
SEP::C TANK. REQA(:L PIT OR
IS F ^IA: ANC'(W DRA :W -FID
HOLE Sr WER CCYvHI:c1VG To
BY 2 p 1 O
u
Ow I1A.1C r'ONA[ 9'.t%) CN'
WUQK •O FKIUSF SFWFR
U.!Rr;UA SEFPAGE PI. LIRA YI i:D
FN'N, CFSSF(yJ! jRYV.F;t. HAhnCk.E
RErA•R 0.7 ABA' sN n;I,R
SFAER OR C SYUSAL SYSIM
OWNER'S Permit s
AUTHORIZATION TOTAL FEE
I N''VE AT TI DA'E A CONI41C'1 WITH THE HEkE'N NAMED CCACTcw •O
CCY [CT luE ABOVE NS:4'B[D ["!S"N', CAF:t'!,G TCO n'L PugIIC SE'.L[R
5'(iPIEDTT•.IS DAY OF ^ / 19_
cD
C`A nIFR$ AC4Ni
ADCRESS
SEE REVERSE FOR EXPLANATORY LANGUAGE
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