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Home My WebLink About0891A (6) , WORKERS'COMPENSATION DECLARATION I hereby affirm ihat I have a certificate of consenr �o self �'��DPW 3/e] � insure,or o certificata af Workars'Compensotion Insurance,or 16A°°Z° a certified copy thereof(Sec.39W,lab C.) `E� APPLICATiON FOR PERl1AtT Policy No. Compony- �s. . . p ❑Cettified copy is here6y furnished. . SEWER - SEWAGE DISPOSAL �Certitied topy is iiled with the monty building inspectian COUNTY OF LOS ANGELES BUILDING AND SAFETY deportmenl. � - - Dote � �"8 Applicant Yr']n D128t & 50A� �riC. ppR APPLICANT TO FILL IN �}�5 CONNECTION OATA CERTIFICAOMPENSATION�ItJSU AN EDRKERS' � �pEu �p7B2 East Ri.m I,au@ srAi�aa �' �� 2�L/� - (This section nead not be completed if the work in�olved by ihe i«Ai�TY ,�a,NHpiE REr�RpryCE � / � permit is for one hundred dol�ars($100)ar less.) � NEAREST TYPE�FCONNERION lENfiTliFROM � I cerrify that in the pedormance of the work for which this Cp0555T. Y. NRB .L M.L.TO P.l. permi�is issued,I shall not employ any person in any manner L d so os�o bacome su6ject b the Workers'Compensation LOWS. pWNER �y p CO�IMP.NO. POB No� f�✓ fJ - - � � � �� iRl1NK PEGMIT NO ROAO PERMIT NO- Dole ApplicaM AODREu NOTICE TO APPIICANT: If, ofter-mokcn �t1iS Ce�Nficate Of AFfIDAV1T WAIYER FASEMENT RECORp.INSTR.Np. DATF �J CITY TEl NO. Exemplion, you should become su6ject to the Workers' �GA� Compenaotion provisions of the Labor cade,you must forthwith DESCR�PTION ioi no.�j2 Hwv.oe sr.wioervir� comply with such provisions or lhis permit shall be deemed revoked. e�ocK TRAR STAiE ENCROACHMENT UCENSED CONTRACTQRS DFCIARATION rio.oc 5toca r�eMir No. I hereb affirm ihot I am licensed under rovisions of Cha ier saeoriol r�owonio� /�� 'J�C Y P P �a �C i �F- 7 9(commencing with Section 7000)of Divisian 3 af fhe Busi- BunDiNGs �s• CHARGES ness and Professions Code,and my license is in fvit force and effect. conrrunoeYlT! 713C8�. & $ori Ix1C. coNNeer�orocNe.x�rce Cicense Numbar�'1Ei81�, Lic Class Qe#2 AODRE55 1494 �er Ave. �� eeiMeuesEnnENr rEE Q - ContractoFan �est Dme $-3�'87 oisTeict nio. caouv awv vuo�sseo er V CNT TEl.NO. � 3 BK PG 2 ❑I am exempt under Sec. of fhe L.A.Co. SUENse NO. 6B� ciASsCi 2 � � � � � NO. DESCRIPTIONOFWORN FEE ~ � Plom6ing Code ond/or Sec. of Ihe wwa U HOUSE SEWEk CONNECTING TO DATE VqLIDATION a - B.8 V.Code for the following raason 1 PUBIIC SEWER j � '�� SEFTIC 7ANK.SEEPAGE PIT OR FtNAL Z � PIiS ANO/OR DVAINFIE:D �012 rypUSE SEWFR CONN(CTING TO BX '�f�. PRIVAfE DISPOS4L SYSTFM S19f101UfC - CANNECf HWITIDNAL BIOG OR � OWNER-BUILDER DECLARATION WORK 7D MOUSE SEWER OVERFIOW SEfPAGE VIT,pRAINilElO I hereby affirm thal I am exempt from the Comrador's License EXTN.,CESSPOOI.�RYWTIL MANMOIE � Law for�he folbwing reaeon(Secron 7031.5,Buisnass and Pro- nirea.pevaiR oa ngnNpora House feA4i0�8 COdeM: SEWER OR�ISPOSAL SYSTEM ❑I,as owrrcr of the property,or my employees with wages as � their sole mmpeneation,will do�ha work ond�he strvctvre - � � es no�intended or oEfered for sale(Sxt�on 7044,Business. � ond Prafeuions Codej. OWN�R'S Pe�mif S �C��O� n � ❑i,as owner of the property,am eadusively conkacGng with AUTHORIZATION TOTAL FEE 2 Q � , lice�5ed[ontraclors io consirucf ihe projeci(Sediort 7044, i MAv�r,r tHis o�*e n coriiawcr wr�r��aeu+warneo cor+Tancroa ro • ' � ° ! C BU51�055 d�d P�o{e551on5 COCJE�. CONNEC7 iME ABOVE�ESCR�BEO E%!STING DWEILING TO THE PUBLIC SEWER � CONSiRUCT10N LENDING AGENCY � • �2 Z'�v i hereby affirm ihat fhere is a consMuction lending agency SIGNEo7H15 DArOF 19_ � � for the perfo�mance of the work for which this permil is p�yyryNER6 AGFNT � � �2 7'`��`. i44uBd $B[.3047.�IV.�.. � �ooREu 1 Q C 5—4 7 Lender�Nome lander's Address. I certify that I hdve read this application and state that ihe � a6ove information is correct.I agree fo comD�Y w��h oll County ardinances and Stote laws regulafing Plum6ing and Sewers, � and hereby authorize representatives of this Counry 1a enter � upon ,p�o6ove-m nFi �ppetty for inspecfion purposes. 1 �..� Signpt�r of armitfee Dale SEE REVERSf FOR EXPLANATOItY LANGUAGE m��; N rK.¢Q W ,p a �+ C. �O 'tl �' ,�cA� ' h• � 61 U � O d'�fi , . . � m p��ih��.Ct � d �.0 s �y w„�n, ? . . y .� b � O1 N O `� � � �`',�' . N r��p t�..�. w�"iS L�.�6 N� 'l3 Q�.C ,v�. ' �'�� 4 Tn�`"'+-�N�� G � �4 �K ¢: 6�i4.�i�= X.�i� . . �ee'+ o <' � .a :��a..Q, .G w'� e „e�:�a� 4..- . �o � �.��.C? � s•. � `' o � .. e •r d 4a �„ C O p^�+ �� .�.e G>� �' .°o.av �: �=�'�;.' -�s � . �. 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