HomeMy WebLinkAbout0893A (6) :- WORKERS'COMPENSATION DECIARATION
I hereby affirm that 1 have a certificote of consent fo self 92�aoo2 ovw sra� �
insure,or a certificate of Workers'Compensaiion Insurance,or �6A6�°
a certified mpy thereof(Sec.3800,Lab C.) CE80B� APPLICATION FOR PERMIT
Policy No. Company 0s
❑Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
�fertified topy is filed with the county bu�ld�ng inspectian COUNTY OF LOS ANGELES BUILDING AND$AFbTY
deparrment. �
.. .. . .�—�-..
Date 8-31-87 Applicant Fan �1388$ dc $Ori FpR APPIICANT TO HlL►N �j CONNECTIpN DATA
CERTIFICA7E OF EXEMPTION FROM WORKERS' � euiwirvc�
GOMPENSATION tNSURANCE nooaess 2Q ( j-i;a,�apt $yTp �3ne srnlioN �. oevrH
(This sectian need not 6e completed if�he wo.k�molved by the iaAUT� ��IRQn� YAI.' �' µANHOLE fiEfERENW ��/ �WER)
permit is for one hundred dcllars($100)or less.�
I cer�ify tha�in the performance of the work for which this ��SSST. TVPEOFCONNECTION �rv�rnreom �
permil is iuued,I shall not employ any penon in any manner y� cuRs .t. M.t.To v.t.
P.C.NO.
so as�o come w ject to ihe Workers'Compensation Laws. owNER, C0.�MP.hp. �pg Mp. �
�u TRUNK PERMIT NO. RpAp PERM1VT NO.
�ate Applimnt ^�Fu �
NOTICE TO AFPUCANT: !f, after makfng ih15 Cerrificoie Of - AFFIDAVI7 WAIVER EASEMENi RECORD.tNSiR.NO. DA7E
UiY TEL.NO.
Exemption, you sho�ld becoma subject to ihe Wakers' ��A�
Compenwtion proaisions of Ihe labor code,you must forthwith OESERIPTION lOT NO. Mwv.OR 5T.WI�ENING
comply with such provis�ons or�his permit sholl be deemed
revoked. eioCK iRACT 2 STATE Eti�RpACMMENi
UCENSED CONTRACTORS QECLARATION no.oF�ocs. �Rmit r,p
SIZE OF l0T rypyy pry�p7
I here6y offirm that 1 am licensed under provisions of Chapter �E� • �. 3 r- . Lc
9(commencing with Section 7000)of Divisian 3 of the Busi- euno�mcs a�ec�s
neu and Prafessions Code,and my licease is in foll force and
CNCtt. CONlRAROR . CONNECTIpN CHApC{f{E
ticense IJumber 7jT68�A �IC.C�a55 1�A7 Jl REIMBURSEMFNT FEE 6
Y ,••r �� nooRess
DISTRICT NO. GROIIP MAP PROQ$$EO BY 6
Comractor Date crtr �OTCO �i.i,�p.7�`r�'2 � e� � C)
�ran uc.
2
1 am e:empt under Sac. of the t.A.Co. ii�N�r.�p. cuss �-�-3 �_ O
NO. D SCRIPfI OF WORK FEE f' �
PlumhingCodeand/or5ec. ofthe F�ne,; U �
HOUSE$FWER CONNC{TING i0 OAiE VqLIDATION W �
B.&P.Code for ihe foliowing reason vueuCsewek � y �,
5€GiIC TANK,SEEPAGE PIS OR Z ��
Date VIiS Ah�:OR DRAINF�EID F�NA� �'
HOVSE SEWER CONNER�NG 10 BY ,
PRIVATE DISVO,Ut SYSS€M '�,
. Signature CONNECT AppIT10NAL BLpG.OR � ���
OWNER-BUIl,pER DECIARATION wortK�to rwus[sevrta ',
OYERFIOW SFEPAGE PIT,�RAINFIELp ' i
1 Fereby affirm fha�i am eaemp�from the Contractor's License [xm.,c.�s,uopi,oarwEu.�+arw+oie
L¢W�Of t}12 SOIIOWitI(�lCOfiOO[SCCtOft�O3I.S,BUISp9S5�fld Pf0- MiER,REPAIR pR ABANOOPi FKK15E �
fBl3ion5 COdB�: SEWER OR D�SPOSAL SYSiEM ,
❑1,os owner af the property,ar my employees with wages as �
thair sole compemation,will do the work and the structure ���1�"•�h �
is not intended or offared for sale(Section 7044,Business
and Professions Cade�. OWNER�S Permit ; �� 50 �• • • • � Q
❑I,as owner of the properry,am e:dusively canrracring with AUTHCRIZATION TOTAL FEE f • •G!�C
licensed coNraetors to mnstruct�he project(Secfion 7044, I HAVE 0.T iH15 OATE A CONiRAR WITH THE HF7E[M W.ry�pO.CANT&Q 70
Bu5i1t235 ond PfoPessions C�C�eJ. � - CONNECf iHE ABOYE�ESC218E0 E%ISTING�WELLING TO1HE GUBIIC SEWER. • • •2^.Jc J� �
CONS7RUCT�ON IENDING AGENCY � �
I hereby affirm lhot tfiere is a constroclion lending agency SiGNEo rni5 D,av oF Iv._ � . � Q,C v—�!
fw the performonte of the work for which �his permit is °'N�R oR �
OWMECS AGEfJT
ISSl1C�,5@C..�7.CIY.C.;. .
A��RE55
Lender's Nama �
Lender's Addreu
I certify that I have read this application and state thot Ihe
abova infwmation is correct.I ogree fo comply wi�h a�i Co�nry
ordinances and Sta1e�lows reg�luting Plumbing and Sewe�s,
and here6y authorize representatives of fhis County ta enier
upon t above-m Mion property for inspection pvrposes �
���.:,�--�--�i�
Signat oF Permittea Date SEE REYERSE FOR EXYLANATORY LANGUAGE I
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