HomeMy WebLinkAbout0896A WORKFRS'COMPENSATION DECLARATION
I hereby affirm that I have a ceriifimte of consent to se7f �-�Z DPW 3iB] �
insure,or a certificate of Workers'Compensation Insurance,or 76A6a�0
a terlified aopy Ihereoi(Sec.3800,Leb C.) "� APPLICATiQN FOR PERMiT
Policy No. Company �s �
[a Certified copy is here6y furnished. SEWER - SEWAGE DlSPOSAL
$�Cert[f�ed copy is 4iled with the county 6uilding inspection COUNTY OF LOS ANGELES BUILDING AND SAfETY
departmeni. � �
po�6 8-31-87 qpplimnt Van Diest fOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKER$' euuoinq
GOMPENSATION INSl1RANCE P➢�PE55 ZO7L�.G 1'J3Fi'E R]1II L3a@ sTn*iaa �j ocvrw
�Fhis section need not 6e completed if the wark involved 6y the i���TY �wrv�REFERENc� � �
permit�s for o�e hvndred dollors($10p)or-less.j� �NCTH fRan
PFAREST TYPE OF CONNE
i certify that in ihe performance of the woik for which this �RO55 Si. Y. NRB .l� M.L.TO P.L.
permit is issued,I shall not employ any person in any manner ) ��'}
so as�a 6ecome subject ro the Worken'Compensation Laws. pwNea CO.IMP.NO. JOB NO. /O�/
�'�� TRIINK PERMI7 NO ROAD PERMI7 N0.
Dote Applicant � A0°��
NOTICE TO APPUCAN7: If, ofter makin this Certificote of wFFionvir wav[u enSemeNr aecoco.vurv,r�q. m,re
9 CITY TEL.NO.
Eeemption, yar should become subjed to the Workers' iE�i
Ca.mpenwtion provisions cf.fhe ln6or.wda,.you must 4orthwith o�xRi�rro� lOSNO. HWV.ORST.WIOENING
� comply with such previsions or.this permit sholl be deemed r�A
re�oked. . eiocK iRAC7�GY STATEENCROACHMENi
LICENSEO CONTRACTORS OEGLARA710N ivo.or e�ocs. r�pMir�o,
s�ze or ioT raow oN ior C� ����
I here6y affirm thai I am licensed vnder provisions of Chapter �� u
4(commencing with Sacfion 7000�of D�vision 3 of the Busi- ewioincsBeS• CHARGES
nese and Profeas�ons Code,ond my license is in Full force ond
BffOC�. - [pMf7A�TOR ��+��T��„!RGE FEE
!
l�censeN�mbe�7E814 Lit.Cf055 r+d? AbDRE55 1 Hamner Ave, ��. REiM9tIR5EMENi FEE O
ConflGCfw DOtE �ISTR�CT NO. GROUP MqP PROCESSE�BY V
CRY TEI.N
BK PG � Z
� ❑I am exempt onder Sec. of the t.A.Co. i�cENse rio. 68� nn Z J Z A �
PlumbingCodeand/or5ec. ofthe N�� DESCRIPTIONOFWORR �e Hti� //�� U
{ HIXJ$E$EWER CONNECTING TO DAiE � W
� B.8 P.Code for the following reason �ue��c s�v+�R �� � YALIDATION y
SEVTIC iANK,$EEFAC�E PIT OR
%i$ANO�OR ORAINFIELO ftNAt Z
Date rp�s[s[w[R connrrnr�ro sr
. PFIVATE DISPpSA YSi
$ign0lyre CONNKi APDItIONAI BtUG.OR
OWNER-BUIIDER�ECtARATION woaK ro i+o�s�s[w[R
- WERFLOW SEEYAGE Pti,DRAINFlElO
` f here6y affirm tha�f am eaempt fiom�fie Contracror'S license [xrN.,cessrooe,oerweu,nv.NHae
� Law for the fallowing redson(Secton 7031.5,Buisness ond Pro- atea,¢eea�e oa narwmN.Housc
fClSlOfri COdB�: $EWER OR DISPOSAI SYSTEM
❑f,ns owner o4 Ihe property,or my employees with wages as
thair sole compenwtion,wi{I do ihe work and the strucfure
is not inlended or offered for sale(Section 7044,Business '-r�a`".b a`
and ProfessiansCode). OWNER�S Permit S
❑I,as owner of the property,am ezcluai�ely contracting with AUTHORIZATION TOTAL FEE �' ' ' '� C
licensed conkactors to tons�ruct the project�Section 7044, �Have AT THIS onte n mNrRacr wirH THe HeReiN Nn.v�Eo coNtancr R ro � s •�'],G[;
BUSin@55 anfJ Profe55iOn5 Code). CONNECT THE ABO�F DESCQiBED E%IS��NG DWELLING TO TME PUBLIC SEWER.
CONSiRUCT10N LEN�ING AGENCY • a •2�,F��
I hereby affirm that fhere is a construction lending agency SIGNEDTHiS DAYOF 19�
OWNFR OR
for the performonce of �he work for which this permit is OWNERS AGEN7 � �,�.{i—�1
issoed(Sec.3097,Civ.C.). -
A�DRE55
Lender's Name
Lender's Address .
1 cenify that 1 have read this application and state ihat the
above information is correcf.I agree to comply with a�l County
ordinantes dnd State laws regulating Plumbing and Sewers,
and hercby authorize represamatives of this County to enter
�pon e obove-mention ��rope�ry for inspeclion purposes. �
/:�!'� .�.tt�' .}"��f�'�7
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