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HomeMy WebLinkAboutNo Permit Number WORKERS'COMP€NSATION DECURAf10N . . . . . .. � . I hereby offirm Ihat 1 hare a ceniEicole of conient to self � }l inwre,or a certificote of Worken'Compensotion Insurance,or � �sne<2o . ... .. .. ._.,.. _ , - , - acerrified copY�hereof(Sec 3800.�ob�., ��a�°E�.,,�� --.AFPLICAf ION F�.R_FERMIT . . -.. ' Policy No. Company , . .. .. ._ . _ .._. .. .._...... . .. -- - .. ❑Certified copy ia here6y fumished. SEWER ' SEWAGE-�DiSP05At- -�� . �Cerr�iied copy is filed wi�h�he counry b�ilding inspec�ion COUNTY OF LOS ANGELES �,.,^��BUILDlNG AND SAFETY depnrtment. pp�e��qppltca�r TJan Tli aa+ P. S�n FOR APPUCANT TO PILL IM � CONNECTION DATA CERTIFICATE OF EXf.MPTIQN FROM WORKERS' � euuoiNc •, � �- � � � �� "������ �� - � � COMPENSATION INSUitANCE- - nnoa[ss 2'�06� G. FLu3.S.1 HUil DT. starroN � oertH - �This section need not be tomple�ed if the work invalved 6y the i���TY � � xwrx�at�erexEr� ` �R permit is for one hundred dollars(f100)or less.) _ ��� . _ _ �����t� _ � �tertify tho�in the performance of the wak fw wh�ch fhis � ��sT. v. aRe 'p.i. M..ro r.i.- - perm�l�s issued,I sholl nor empby ony perwn in uny rtwnner so os to 6«ame su eSt tp ihe WArke�4_Com nspfio�Lavn. ��� a -�..--.------ o�R The ':l on o co.�w_No. �n TRIAJI(p[RAVT Np ipAA PERMiT NO. Dol@ App�iCont AODFE55 AFFIDAYIT WAIVER EASEMEM RECORD INSIR.Np Dn1E NO710E TO APPUCANT: If,.after making this Cartificote of ��Ty r�.np, Exemp�iort, you should become wbjed �o the Workers' �� Compe�sation prorisions af the Labor code,you mus�forthwith oescuiv7wN iotrio. 32 Hwy oR sr wioeNv� �` �ly wifh such provisiona w Ihis permil shofl be deemed :ed. BLOCK iRACt 5��1E E. Nl ' �UCENSEDCONTRAC10R5DECtAkAT1pN'��' °f�O� �M�T sae a�ot raow a.��or f hereby effirm�hat i am licensed onder prodrsione of Chap�er use oF Res. 9(commerxing with SacFion 7000)of Oivision 3 of Me Busi- aunoin�s owc.�s nes�ond Profeuions Code,and my license is in Futl force and effect. wr+Tentro¢ �jc'3I7 �1BSt � �a'OTl CONNECTIONOiARGEffE licenseNumber 3T6e�� LicCiass ��_ ao�u �L�.��. ��c�i�u�'i@T uye. =�= 1� REIMBUR NiFFE y, Connactor n T};�t -Dota �' orv il0£Ci� �i.�q. C�.. �� n o�sTa�cr ra. P � etnv �2 o er U v J ❑i am axampt under Sec. �f�ti��.n.co. �N�,,,o. 376814 �� c 42 � � � NO. DESCRIPTIDNOFWORK FEF � PlumbingCodeand/orSat. oithe E�N+u � � FqU���p CONtBCTiNG TO � � � onre �� VAUDATION t"'j . B.8 P.Code 4or rhe follow�ng reoson � W . s�vnc Tu�ec.s�v,�e�T an o. VITS ANO/OR OQ��Nf IEID i81�AL ,w Data NOUSE SEN'ER CONNECTING TO �• YViVATE�ISPOSFt SYS1E � Sig[W1UI! CONNFCT AWITKiNM&OG OR � . OWNER-BUIlDER DECLARATION WON1[TO HOUSE SEWER QJERFLOW SEFPAGE RT,DRAINFIELO ' I hereby affirm Ihat 1 am exempt trom the CoNrxta's titense EXTN.,CESSPOOL,DRYWELL,MANFKKE law for the following reason(Secton 7031.5,Buianesa end Pro• ui�a.RCPAirt oR nsANooH House fessions Code�: s[weR ok oisrosu wsiEnt .. . n 1,oa pwner of tha property,or my employees with wages os _ •- � + '�� __ ` heir wle compenwfion,will do�he work ond the structure • � ' is not inlended or offered for safe(Setllon 7014,Business pe[miE f ���r0 {�-o • . � �� � and Profeuions Code). OWNER�S j ❑I,as owner of�he property,om exdusively tontrotting with AUTHOR►ZATION TOTAL FEE 27.5� t ' _ +,••� ; licrosed tonhaUors to construce fhe pralect($ection 7044� I HAVE AT TMIS UATE A�pNiiACf WITH TNF HENEIN W1MED CONTRACfOft TD r,= I 8usiness ond Professions Code). ca+r�ca TH[nfiove o[scQ�eeo cxisnra�owEiuwc 7o iN[cueuc sew[a. • ° � f.�J c, CONSiRUCTfON LENDING AGENCY ' ' - 1 bereby oifirm Ihof there is a construdion lending agency S�GNE�THIS DAYOF 19_ � �U.� 5—8 b for the per(ormance of the wwk for which thia permit is p�yS�Ni iswed(Sec.30D7,Civ.C.). � AODRE55 Lender's Name Lendar'a Addrass � I certify Ihal 1 have read this application and stote that the ' above Informotion is mrtect.I aqree to comply wifh pll County , . � ordinances and Smte bws requloting Plum6ing ond Sewers, - ond hereby oulharize represenrotives af Ihis County ro smar � upo e above-mention property for inspection purpoaea. �.Lt +2..� �"�/ SignaWreafParmifea Dale SFEY4VERffiWFX►IANATORYLANGUAGE � � � . � z . • s.� o� ,. . . m = : r, e� q . . 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