HomeMy WebLinkAboutNo Permit Number WORKERS'COMDENSATION DEQARATION I
1 hareby uffirm �hof I hove o certifica�a of conaent �o self 51 �
ins�re,or o coNificate of Workers'Com nwtion Insurance,or
� rensa�o II
o cerlified COpy thereof(Sec.3800,Lab C.) CE80a�qE�1eJ�; qpp«CATiON FOR PERMIT � �
Policy No. Compony �
❑Cerelfied copy is hereby furnished. SEWER - SEWAGE DlSPOSAL-
�Certffled copy is filed wirh rhe counry buiidinq inspecrion COUNTY OF LOS ANGELFS BUIL�ING AND SAFETY
department.
Da�e $6 Applicanr V�Yi Iliest E; Son � � FOR APPLICANT TO FICL7N �� ���' ;�� CO AIECTION DATA
CERT�fICATE OF EXEMPTtON FROM WORKERS' eunoiac �
COMPENSATIDN INSURANCE emRcss 21��2 i�+• �L73�1 �.Utl �T. srnnOr+ oEvtH
(This section need not be completed i(the work involved by the ��iTY Mpnw�aE k�r��
perm�t is for one hundred dollas�S7U0)or less.} ��T TYPF OF CONIVECT r�p��oM i
1 certiiy thut in the perfarmancm of the wark 4or whith this cao55sT. r. CUkE v M.l': P.4 �
parmit is issued.I shall not emp{oy any person in any manoer �
su wz to 6ecome subjea to the Workers'Compensm�on laws. ��R 0 �p i�Np P'�'�' s
MAII TRUIN(PERAtlT NO. ROAD PERMIT NO,
Date Applicant ADDRE55
NOT�CE TO APPUCANT: If, after mok�ng this Certifico�e of ��T� �E`� AFFIDAVIT WAiVER ewsem[nn r�eoRo.mistx.rvo o�r[
E:emption, you should 6ecome su6ject to the Workers'
Compenaotion provisions of the Labor code,you musf forthwi�h ��Ri�vrior� ioT r+o n Hwv,oa sr wioewrrc �
; -omply wilh such provisions ar thi:permit shatl 6e deemed Ax 1b•� I�
< <vokad. - . etocr TRAC7 Yl STATE E OACHME i � E
��&�� PERMIT �
' tICENSED CONTRACT6R5 DfCLARATION s�ZEo�ioT raowor+ior
1 hereby offirm fhat 1 am licensed vnder provisions of Chapter �a
4(commencing wi�h Section 7UOQ�of DWision 3 of ihe Busi- g�iipi� t'�BS• a�acfs S
neu and Professiens Code,and my licenae is i�ful4 force and �
effea. eoraia�nae T�n 7)lESt R $On CONNEC11pN CMARGE F([
tice�se N�m6er �i76a1[�. lic.Ciass� = ? aei,�neu� Nr c �
�Ess 1 9 ?iar,�ier Ave. = y.
Pari ➢lest 4/4/e6 � oare�crno. cu a nuv x vc oer 0
Contrattor Date [ITY ' TEL NO.
BK PF.'� V �
❑I o m e x e m p t�n d e r 5 e c, o f t h e L A.C o. i���. (S'�[� a,i u (�' �� � `�� �
PtumbingCodeand/or5ec. afrhe �� ����T��w�K �E Fw�i � �
ft/BlCSEWER��NECiINGTO o�r� � VAUDATtON v �
B.8 P.Code for tha follawing reosort � W
YPTK TAI�A,SEEPAGE WT OR FINAI �
PI15 AND/OR ORAINFIELD {n
DdiB HpUSE SEWER CONNFCTING TO 6T 7.
PRIV�T IS Y
$i91101Ule COr+NECT AoolipNM glpG pp
N�OR[TO HOUSE SEWER
OWNER-BUIIDER DECIARATION p��,
wcwiow suvno[wr,rnuiNrieio
I here6y affirm thot I am exempf from the ContraUor's License EXTN..CESSPJOI.�RYWELI,MANFKKE �
law far rhe following reason(Seaon 7031.5,Buisness and Pro- a7ea,aevnta oa nenNooN House _' v,
fessians Code): - sewea o0 oiseosu srsrEn+ , :'a
� Q i,ot owner of the property,or my employees with wages as �,� _ , ,��., � ,:
thair sole compenwtion,will do the work and tha srrutt�re
is rrot inMnded or oHered for wla�Ssction 70M,Butiwsa
and Professions Code�. OWPIER'S Permit { � � f� �
❑1,as awner of the property,am ezcluvvely comrocting wi�h AUTHORIZATION TOTAI FEE � � � . ,, - r= �'',
Ii[en5ed C011fIOC�O/3�O CO�S�fu[1 IF1e projeCi(Se[tion 7044, �y�,qyE q7 iH15 DAIE A CONfRACT WITX iHE NEREW NAMED CONTRACIOR i0 �
BuSif1l44 O�ld PIOfe5510M COdB�. CONNfCT TME A60VE OESCRIBE�EXISTING DWEILING TO TME PU6lIC SEWER ��i :__;J �I
CONSTRUCTION LENDING AGENCY ''
I here6y nffirm tho�there is o conslroction lending ogenty SIGNEDTHIS OAroF lv_ � �i
for fhe performance of the work for which this permit is �ER��HT
issued(Set.3097,Civ.C.)- II
Lender's Name �E� �
lender's Addrosa
1 certify that I have read this appiimtion and state that the �
above information is correct.1 agree to comply with all County
ordinunces and State(aws regulating Pl�mbing and Sewers, "
and here6y authorize r prese�tatives of ibis Cwnty to eMer �
upo e obove-men'o ed prOperty for inspeclion p�rposes.
SignaWrg of Per iflee � te SEE pEVEYSE FOM EX�LANA70RY LANGl1A6F �
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