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Home My WebLink About1613A � � � WORKERS'COMPENSATION DEQARATION � � 1 here6y a{#irm ttwt I have a certificate o4 consent to seif � I insure,or o certificate of Workers'Compensation Insurance,or J6A�o •a certified copy thereof(Sec.3800,�ae�., CE BOB(REV.9/BI� APPLiCATION FOR PERMIT � Policy No. Company ��s ' ❑Cerfified copy;_�e«by f��5h�a. SEWER - SEWAGE DISPOSAL � ❑Certitied copy is filed wifh fhe counly 6uilding inspection COUNTY OF LOS ANGElES BUILDING ANDSAFETY deportmenr. � � . Dme Applicant_ __ FOR APPLICANT TO FILI IN CONNEC710N DATA ' �- CERTIFICATE Of EXEMPTION FROM WORKERS' ��a^� 2S� G�T �'�I � � COMPENSATION INSURANCE �wna[u stnTww oevrH � �ihis section need erot be completed if the woek'rnvolved by Ihe d� � uvaea MANHOLE REfERENCE permit is for one hurtdrad dallars(S1UQy or less.} 1O��TY �� j�J IOWER I�FARES, T�7E OF CONNECf�«J IENGTH FROM � � t ceriify ihat In the performance of rhe work iOr which�his �qp555T. V. C�RB P. M.I.TOP.I. permN is issuad !ahull no�employ any person i y manner PC.NO. �l�',I so.as fo 6 o su6jen fo rhe Workers'Compe wY n Laws. oW�R CD.IMP.Np. JpB NO. T�I rM.0 Date Applicant ADDRESS TRUNK PERMIT NO. nOno FENMIT ND. �T� T APPUCANT: If, a B� aking �hi3 CBfllfif�fE of AfFIDAVIT WAIVER EASEMENT RECORO INSTR.NO. �ATE Eaemptio , yo� should�become subject ia the Workers' arv Te�.rq. Com ensolion rorisions of the Labor code, ou must forthwith �E�� P P Y DESCYIPtION LOTNO, HWY OqST.WIDENING compfy with cuch provisions or rhia permi�shall be deemad *eroked. e�acx TRPCT STpTEENCROACHMEN7 LICENSED CONTRARORS DECLARATION nq.o�e�s. �°'�'�T No. srze or ior wow orr�or i hereby offirm thm I am lirensed under provisions of Chopfer �� . 4(commeacing with Section 7000)of Divisivn 3 of�he BVSi- BWIDiNGS an�s ness ond Professions Code,and my license is in full forte dnd - � effect. ` �qNi�oR �pNNECTION CHARGE ffE � � license Num6e v� Lic.Class � � �R�- 3 R[imeures�rneNr F�e O �ISTRICENO. GRWP (�pP GOlIf�OCtOt CRY ��D gY z STAT UC. BK PG � ❑1 am axempt under Set. pt�he L A.Co. i�� i� t� Q Pfum6ing Code and/or Sec. of the �� SCRIPTfON OF WORK ffe FNA` V R 1qu5E 5[wER CONNKTING TO � B.8 P.Code for the fol4owing reason I �8��SEWER � �A�E �a�E . VALIDAi{ON y SEPTIC TANK.SEEPFGE VIT OR FINAI Z Da�e P�TS ANO/OR ONAINFIELD BY � HOUSE SEVvER CONNECTING TO 7RNATE DISPOSAL SYSTE $i9nafUfE �R ADDF710NAt&D6.OR � OWNER-BUILDER�ECLARATION woaK ro r+ouse sewea 1 hereb affirm thar 1 am e�em t from the Contractor's License ��EPAGE RT,�RAINFIELO � Y P E%iN„CESSPOOL,W2YWElL MANHOIE law for the following reawn(SEC100 7CI3I.S,BUi51tB55 Of1CI P�O- AIiER,REPAIR OR ABqNDpN Llpp$( fessions Code): sEv+�re ae oisrosai svsrzm F ❑I,as ownar of the propeny,or my employees wifh wagea as 2 1 ��."�. I Iheir sole compensation,will do ihe work ond ihe struciure � ia nof intended or offered for sale(Section 7Q44,Business �� .� � C � ond Professions Codey. OWNER'S Permit S CQ S`� ❑I,as owner of the properry,am exclusively contracting wirh AUTFfORIZATION TOTAL fEE I p•�'],�j Q licansed coniracmrs to mnstruct the project(Secfion 7044� �NAVE AT TH�S DATE A CONTRACT W1TH THE HERFIN NAMFD CONTRAROR TO BUSirtBS4 0�1fI Pro{E5510115 COdB�. CONNEQ THE ABpVE DESCRIBED E%ISiING�WFLLING TO THE PUOI�C SEWER •a o 2�.v�� 1 CONSTRUCTION LENDING AGENCY i I hareby affirm thal there is a constrodion landing agency S�Ea at 15 DAv� 19— � . �rY,�j 4"8 f'i � for the perfarmance of Ihe work for which this permit is issoed(Sec.3097,Civ.C.). owrveas nGeNr � ADDRE53 Lender's Nome . � Lender's Addresa I certify that 1 have read ihis application and state thot the obove information is wrrect.1 agre o omply with all Coumy � ordinances and State laws regul ing lumbing and Sewen, and hereby author�e represent ive of this Counry to ter �pon 1 ova- tivn pro erf or inspec�ion pur e C�--1 d� � � i nurore of Permi ee Dale SEE REVERSE FOR iXPIANATORY LANGUAGE �� ,�, � • . � �� `��"'��. � � a y � � �� * � � �� .,s,�c�'" ��"�� Q� s��M��,� ��$ ��'�� ... � •�§. '' � ~ � MY� �� ~�� . �' �� S 3�.�� ' .�� ':'��,�, N F' v�.,c'� � . � � � . �� . �� _ � �� . � �� A �"' F� � 0/ � � q'� � 4'? �,.� �..,� � s$� � � � $ �' A �,�,�, �,. ..^��;,,�,,� ��; �� j v v � g�� $ ��Qr��°�� -�;� � a � � � � —� u� � � � e � aS Ca p ��« .a �,�`� $�'� ,.�g."� a,�• � W �� M �� R.�� a g M � � �� p� �� b^� �*Y�O�� '�'� T� 9L�^� � �� Q �� O� �� ;�� N ��r ��' �� v.� ..�..b'?Q M�' ' . �� `�L'�• ��,::, ,.. d ,�, Q�A O �� . �� . � r j�� O ' Z � O � 1 ' ' � � Z N �c4 � � � �� g _` �o •s. � � `~ ~ � � � �o o � °p� � �� t� � ,� .s � � � r � � '/�'''` '��C �`� � �'d��0 's� 70 � ��o � �� , ��