HomeMy WebLinkAbout0895A (4) � WORKERS'COMPENSATION DECLRRATION -
I hereby offirm that I have a cenificme of consent to self 9zaooz oPw�ie� , �
insure,or a certificnte of Workers'Compensation Insurance,or �dA697D
o cenified copy thereof(Sec_3800,Lab C.) `E� APPLICATION F�R PERMIT
Policy No. Company �i �
❑Cenif'�ed copy is hereby fomished. --� _ . SEWER - SEWAGE DtSPOSA!
�Ce�Nfied copy is filed wilh ihe couMy building�nspect�on COUNTY OF LOS ANGELES BWLDING AND SAPETY
deppHment.
Date�31-87 APPlimnr V� �@St - FOR APPLICANT TO FILL IN �I5 CONNECTION DATA
� CERTIFICATE OF EXEMPTION FROM WORKERS' emiPn,�c
� � tOMPENSATION INSURANCE � � noouess �7 Z �,38't �1.1a T�3Tl@ srnnora ���. oerrH
(Thia section need not be completad if the wwk invalved by the � nwr+i-iae aereeeNc[ �7 �/
permit is for one hundred dollars($100)or�ess.) ����tt
. PkAREST TYPE pF CONNECTION �ry�iH F�1
I certify that in the performance of the work far which this ceo5ssr- v: cuxs .�. /a.l.foP.t- �J�
permit is issued,I sholl not employ any person in any monner l
so as ta become subjed�o the Workars'Compensmion Laws. pwNEa �p.iMP.r.ip. P���o.!�
�'U'�� TRIINK PERMIT NO. GOAO PERMIT NO.
Date Applican� ADDRE55
AFFIOAVIT WAIVFP EASEMENT RECO(i�.INSTG.NO. OATE
NOTICE TO APPLICANT: If, afrer making this Certificate of atv TEl NO.
Ezemption, yoo shouid become su4jett ro rhe Workeri ��q�
Compenwtion provts�ons o(the Labor mde,you must forthwith pe5ceivTroN toi r�o. 'O Hwv atsr.wio¢wr�
comply with such provisions or ihis permit sFwll be deemed .�A ,}
fEVOI[@fI. BLOCK 7FAR YYB�`f ST/+iE ENCROACHMENT
LICENSE�CONTRACTORS DECLARATION r+o.ov eiocs. ��"T�'�O�
SIZE OF l0T NQW ON l0f ,' � 7�` �
I hereby offirm�ha�!am licensed under pravisions of Chapter ��� p .?.-� / �
9(commencin9 with Secfion 70p0}af Division 3 of the BU5i- , BUIlOINGY1CBa CHARGES
� ness and Professions Code,and my license is in full force and
effed. corvtancrat coNr�cran cHnuc,�FEe
�
, licensa Number�i..�?�j/,� Lic Class ('�' noouess 1 Hamner Ave. �� REi"^B�Rs�^"FNr FEE a
(ryZ �} 0
�� COnfrUC1OI� �eSb Date�J��1 OISiRICTNO. GROU� MAP PGOCESSEDBV V
CIFY TEt.NO.
.. STATE f ^ � 8K �('i • ! 1
❑I om e:empl under 5ac. of the L.A.Co. uCENSe nt0. p$ aass �— � O
No. - DESCRiPnONOFWORK rEE ~
Plumbing Code and/o�Sec. of the �+Nni V
'ause srweR cor�Nernr�c ro onre l VALIDATION W
B.&P-Code for the follawing reason °������� � a
sevrlc tnrx.�vnc�wr oa y
P115 ANO!OR bRA1NfIELS FINAL ?
��f@ HOIISE SEWER CONNfRIFAi T� Bt
�fll ATE CIS SYSi
Signafure CANNKT qDDITIONAI&OG.04 _
-OWNER-BUILDER DECLARATION '�RK FO HOUSE SEWE9
. OVERfLOW SeEPAGE Pli.ORpINilElp
1 hareby affirm thof i am exemp�from the Coniroctor's License cxTN..cesswa,oavweu,raarrHo� �rj�,'��'F,
Law for the foflowing reason'SBL}Oft�Q3).S,BUtSl1E55 Ofl(I Pf0- AITER,NEPFIR OR ABANDON FKKISE
FelSlOfl!COCIB�: SFWER OR p15Fp511 SYSiEM �� � � � 1 O
I
❑1,as owner of the property,or my employees wifh wages as
� � their sola compensation,will do the work and the structure � • •C�•J i:'
is not intended or offered for sale(Sec�ion 7Q44,Business
ond Professions Code). OWNER'S Permit s • • •2 7,S 0�
❑I,as owner of the property,om ezcl�sively connacting with AUTHORIZATION TOTAL FEE C p
licensed contractors to mnstruct the projecf(Settion 7�44� ��{qyE qT iHiS OATE A COMRAC7 WI7X THE HEREiN NAMED COMTR Ci R TO 'O'O`�_V �
. B�SInB55 Qn(1 Professions Code). CONhIECT 7F1E A60vE DESCRiBED ExiST�NG OwEuiNG TO iME PUBLK SFW'F4,
CONSTRUCTION LENDING AGENCY �
I hereby ofFirm thaf fhere is a construction lending agency SIGNEDTHIS DpVOF 19_
for the performance vf the work for which this permit is pWNERS�AGENT
iuved�Sec.3097,Civ.C.}.
aooaEss
Lender's Name �
� Lender's Addrass
I certify 1Fw1 1 huve reod this opplication and state ihnt the �
obove informotion is correct.I agree to comply with all County
ordinances and S�ote laws regula�ing Vlumbing and Sewars,
. and hereby autho�ize representatives of this County to enrer
upo above-mentioned propeny for inspection purposes.
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Si u of Pnmiflee Opte SEE REVEIiSE FOR E]IPLANAtONY tANGUAGE
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