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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. � �Q���'";/�,� Si u of Pnmiflee Opte SEE REVEIiSE FOR E]IPLANAtONY tANGUAGE ",-��a y � � O��"« �'� �„4„x•�s A�a vm ° � � �,^°� �, d o'mz' �� d� or d ,y,+ .°ic�� �S�i o, °' - •�� �,n*� �..' e �t� g�; ��P' ��s Q"�� G � . ��~r, �„C" .c e"� c E c+ n e+ a a � k ��':_. , ,� �a a� �.� «x� � d�'~�°. 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