HomeMy WebLinkAbout0894A (4) �, WORKERS'COMPENSATION DECLARAtION 92 000x prw��e� �
I hereby affirm that f have a certificate of consent to self �apetso
insure,or a certifica�e ot Workers'Campensa�io�Insurance,or ��
a certified copy�hereof(Sec.3800,�ob�., APPLICATION FOR PERMlT
Poliq No. Cornpa�y �s
� ❑Cartified capy is here6y furnished. SEWER • SEWAGE �iSPOSAL
�Cert�tied copy�a filed with ihe county buildin9 inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
�i
department.
Dote 8—�1-87 Applitant Van Ti ag�-, 8cS023 FOR APPLICANT TO Fltl IN yLf 5 CONNECTION DATA
CERTIFICATE OF EXEMPTIOPJ FROM WORKERS' e�iuDit+� �75g �t Rim yane STAiION � b �PTH
COMPFNSATfON INSURANCE � eooa[ss
(This section need no�be comple�ed if the work involved 6y the i��iTy . . nwrmwie eEFeaer�c[ � i�R
permit is for one hundred dollors(510�)or Iess.) NEAREST ivv�oFcoraNecrior+ _ �N�TH FROM ��
1 certify that in�he performance of 1he work for which ffiis GVOSSST. Y. CURB �.i M.i iOv.l.
permit is iuued,!shall not empluy any person in ony monner p�,NO. ^
so as to become subject to the Workers'Compensat�on�OWS. OWNER� �o����'iO� 1O6NO� �
M11��� TRUNKPERMITNp. ROA�PERhVFNp.
Dote Applicant _ aoorzE55 -. ..
AFFIOFYIT WAiVEP EASEMENI RECARD.M57R.NO. DATE
NOTICE FO APPtICANT: If, oHer making this Certificme of pT� r[t.r.q.
Exemptio�, you should become subject �o �he Workers' i�Ai
Compenmliort proviciona of the Lobvr code,yov most farthwith oescqivriqa l0T NO. HWK OR ST.WIOENING
camply with such provisions or lhis parmit shall be deemed ^Ao�jA
re�oked. siocK TAACT Y'fVL`� Stn1EENCWOA.CHMENi
LICENSED CONTRACTORS DECLARATION nio.or e�ocs PeaMir nq.
s�ze a ior riow orr co7 ,! �
I hereby affirm iha�I om�icensed onder provisions of Chapter ��� Y
9(commencing with Section 7000)of Divis�on 3 of the 8usi- ewioi�s �BS• a+nac�s
ness and Professions Code,and my license is in fu�l force and
ersa«. ��T�R�Yan Di St de SOII IriC coNNecran cnnx,�Fee
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LicenseNv�3768i4 Lic.CVass C4� ,woaFss..� Hauaier Ave. 11� a[iMeua�M�rvtFeE �
C0t11fOC10� Y� Diest �01C����� DISTRI�NO. GROII� fNi PROCkS5ED9 („)
CI7Y TEL.NO. � J� BK PG r Z
STAiE �� O
❑I om exempf under Sec. of the LA.Co. �i�N��.�p. (S� aass (,' Q -./ �
� NO. DESCRIDTIONOF WORN FEE U
Plumbing Code and/or Sec. o�the F:N� ut
�+ous�s�weu cor�NEcriv�ro onre r �y p+'7 VAUDATION y
B.&P.Code for the fo��owing reason vusuc s�vreR / Y•! �p '
SEP71C TATlK.SEEVAGE PIT OR FINAL ?
PITS AND'OR OkAINF'EL� BY
DOfB FqUSF SE WER CONNECi�N(i 10
P2IVATE DISPOSA SYSTEM
$I9nOfYfB CONNECr AOOITION4L BLOG.OR �
OWNER-BllILDER DECIARATION woac To Na�S�s[wea
OVERFIOW SFFiAGF Gli,�PA�NFIEI�
1 hereby affirm�at 1 am e.emp�from ihe Comractoi s License exrN_c'�ssaooi,ourweu.nna.NHoie ',
Law for the following reason(SECtOn 7D$1.5,BUISnC55 dnd Pr0- kTEF,RE�AIR OR AtlAN00N HpUSE
fE55ions COdGJ: SEWER OR�I51'OSAL SYSTEM I
❑!,as owner of the p�operty,or my employees with wages as
their sale compensation,wifl do the work and the strudure =C,v��F:
is not in�ended o�oHered for sole(Section 7044,Business
and Profess�ons Code). OWNER'S Permit E �� � � � � �
❑I,as owner of the property,om exdusively controcring with AUTHORIZATION TOTAL FEE �
licansed coNmcrors ro construct the projen(Sect�on 7044, t HAVE Ai TNR DA7E A CONTRACt WITN THE NEIiE'R1 NAMED CONTRACTOR i0 ( ' ���•��
805111CS5 OOd PfOF855i0�5 CO[IC�. CONNEtl 7HE ABOK DESCRIBED E%15TING DWEIIING TO TNF vUBLIC 5�'.'ER. . •
CON5TRUCiION�ENDING AGENCY � �< <�5` �
1 hereby afFlrm 1koF fhere is a consiruelion lending agency StGNEDTHIS DAVOF 19_
for the performance of the work for which this ermi� ia owhea oR ��C�—�7
P OWNE45 AGENT �
iuued(Sec.3097,Gv.C.).
ADDRE55
Lender's Name
� Lender's Address
i certify that#have read this application and state that�he �
� o6ove information is correct.1 agree to comply with all Counfy
ordi�antea pnd 51a1e laws regulating Plumbing and Sewers,
� ond hereby authorize represenfatives of this Counly lo enter
' upon e abova-meMioned property for inspection purposes.
. �¢ /�2�=- �-�,..�
Si lura of Permitiee Date SEE NEVEYSE FOR EXPLANAfORY IANGUAGE
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