HomeMy WebLinkAboutNo Permit Number � WORKERS COMPENSATION DECLARATION
1 hereby affirm �hot I hove a certificate of cansem ro self �'��DPW 3'B]
insure,or a certificate ot Workers'Compensolion Insurance,or 76A6"�° �
a cerfified mpy thereof(Sec.3800,Lob G.) `E� APPLICATlON FOR PERMtT
Poliq No. Comppny ��
❑ca���r�aa�oPY�5 ne�eby f��n�shaa. SEWER - SfWAGE DtSPOSAL
�Certified copy�a ftlad wi�h-tha couniy building inspection COUNTY OF l05 ANGELES BUILDING AND SAFETY
deAaN en. . . . ..
Date 7 ST Appliwm_ Yan �e3t dc SOII� IriC• FaR APPL{CANT TO FILL{N f CONNECTION DATA
CERTIFI COMPENSATION�INSU AN EORKERS' � A�REu ZO,rB� P2�8pt R�m L2nQ StAiION �,�, oevr�+ �
(This section need not be complered if ihe work in�olved by the iapim, L],"IOIld 17� � AMNHOLE REF(��[E
permit is for one hundred dollars($100)or less.) �� � UP R
NEAREST 7YPE OF C�NNECTqN
' I certify�hat in ihe performante of�fie work for whicfi this �11ps5 gt, ' IENGTH FPOM ��[`
� permif is issued,1 sholl not employ any person in any manner .,,T,.
Y- CURB .l. M.0 TO Y.t.
� so oa to become subject to the Workers'Compensation Lows. oWnEa �4�+V�n v.c No.
CO.IMv.NO. JOB NO. D
MH�L
Dale Applicont
ADDRE55 TYl1NK PERMIT NJ. ROPD PERMIF Pq.
N�T�� TO APPLICANT: F4, after mok'rng ihis CCrfifiCOfe Of AFFIDAVIi WAIVEN EASEMENT RECORD.INSlR.1� DASE
arv �i,No.
Exemption, you should 6ecome subject to the Workers' LEGAL
Compensotion provisions of�he labor code,yov must fonhwith pESCFIPiION lOT NO. HWY OR Si WIDENING
camply with such provisions or this permlt shcll be deemed
fBYOkBd. BLOCK iRACT S2 � STATE ENCROACHMENf
LICENSED CONTRACTORS DECLARATION -��-- r+o.or eiocs. r�RmiT^m.
: 512E OF lOT NpW pIV LQI �
- f bereby affirm�ha�1 am fimnsed under provisions of Chopter �a 7
! 9�commancing with Section 7000)of Di�ision 3 of�he B�s�- euimir.�s �es� �,�5
� nass and Professions Code,and my license is in fulf force and
effed. mrrtRacroa y� Die t $c oR fONNERION CHARC{FEE
license Number 376ey14 Lic.Closa pC'q 2 AppRE55 1494 �Iamner Ave. � 1� REiMeuRSeMeNT Fee a
V�1 �eS Y � S�] �C• / 1 e7 - DISTRIR NO. GROUP M4P oCOCE55ED BY �
Contractor TTat� V
arv 7F1."p
❑1 am esempt under Sec. of�he L.A.Co. u�ENSE r.p. 68j ctnss � ��� BK � z
�a� �. / O
Plumbing Code and/o�Sec. of ihe NO, DESCRIPTION OF WORK r�e F�� "'� U
HOUSE$EWER CONNECFING IO
PUeIIC SEWER DATE �a VALIDATION W
B.8 P.Code for the foliowing reason s�vnc rnNK,seeaac�PiT orz -�� �U Va1
OpfC GIiS AN�iOR pRGINFiELD FINAL Z
HOUSE SEWE{I CONNECHNG ip sY .
PRNAiE DISPOSAt SVSTE.
$ignoture COt�NFCf ADDtTIONac BLW.Ors � '��
� OWNER•BUILDER DECIARATION woaK ro nous�sev,�x '�.
1 hereb affirm�hot k am exam t from the Contractor's license rn'ERFtow seeaa�vir,oanmriem .
Y P EXTN.,CESSPOIX.�RYWEIt,MANHOIE �
Low for the following reason�52Gton 7O31.S,BUi5I1C55 Di1d Pf0- AL7ER,REP0.1R OR ABANDON HOUSE
- fB5610f15 CoCJeJ: SfWER OR OISVOSAL SYSTEM �
. ❑I,as owner of Ihe properfy,or my employees with wages as
iheir sole compenwtion,will do the work and�he structure j
is nof intended or offered for sole(Section 7044,Business L G�^.��_�'�i, �
and Professions Code). OWNER'S Permit S
, ❑I,as owner of fhe property,om eaclusively ronvatting wifh AUTHORIIATION- �TOTAL�FEE� - - �- �- • �` '�` � ('i
I{[ERSCfI[OI1h'dC1pr5�O COl15hu[f tlle P�0�2C1'$BCtlOfl 7044, I HAVE AT TMIS OATE A CONTRACT WITH THE HEREIN NAMED CONrRACTOR i0 /�
BVSII1B56 Ofld Pf0{BSSIOf14 COdE�. CONNECT THE ABOYE OESCRIBED E%iSTING�WELL�NG TO TNE PUBLIC SEWEW. I • •[ /,5 t.i
CONSTRUCTION LENDING AGENCY
�t � hereby affirm thot there is o construction lending ogency SIGNED THIS oAY OF 19_ � • • •G!,S v a
for the performance of the work for which this permit is �NfROR
i35LLEff�SCC.3U97,,GV.C.�. ' OWNENSAGENT ' U.v v'�•,�
ADDf1E55
Lender's Name
.I Lendei a Addrees
I cartify that I hare reod this applicotion and state that ihe
- above infarmation is wrrect.I agree to comply with all Caunty �
�� ordinontes and State laws regvipting Plumbing ond Sewere, - �
'� and here6y authaize raprasentar'�ec ot this County to enler
kupo�ihe a6ove-me fioned proper for inspeciion purposes.
� 3a �
Signofure of mittee Daf SEE REYERSE fOR EXPLANATORT LANGUAGE
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