HomeMy WebLinkAbout1661A 1662A � WORKERS'COMPENSATtON DF.CLARATION CE 808 2-80) A PP L I CAT 10 N F�J R PE R M IT
I hereby effirm that 1 have a certificate of consent to self SEWER-SEWAGE DISPOSAL �
insure,or a certificate of Wurkers'Compensation Insurance,or
a certified coDY thereof(Sec.3800.Lab.C.) COUNTY OF LOS ANGELES BUI LDING AND SAFETY
Policy No. Company
`� fOR APPLICANT TO FILL IN CONNECTION DATA
, � CeriiCed copy is hereby furnished.
❑ BVILDING l r "-� O STATION D6PTX
Certified cupy is filed with the county building inspection woortess � y�.a+`
IJPPER
department. �ocw�irr MANXOIE REFERENCE LOW6R
Date Applicant NEAREST TYPE OF COryMECTION LENGTH FROM
r CERTIF)CqTE OP EXEMP7iON FROM WORKERS� CRO55 9T. Y. .� CVRB P.L. M.L.TO G.L. P
� -COMPENSATTON(NSURANCE °•�•��•� -
OWNGR Cp,IMV.MO. JOH NO. }
MAIL �
` �T�11S 3CCt1011 need not be completed if the W07�C 111VO�YCQ A�DRESS � � �� TRI)NK PERMIT NO. ROqC PERMIT NO. O
by the permit is far one hundred dollars (5100)or less.) ,,,,,,,,, ,�„E s�,,,E �opo.,,,,,,,.„ o,,,E U
c�rr re�.wo. "Z2
� I certify that in [he performance of the work for which this � n� �
� ermit is issued,I shall not em lo an tiwv.oe sr.w�oeNino
P p y y person in any manner oeae i�r�on LOT HO. O
so as t�become subjeM to the Workers'Cumpensation Laws. V
- � BLOCK TRACT STAT6 ENCRONCHMENT LL�
i Date Applicant NO.OF HtOGS. PCRMIT NO. a
SIZE OF LOT NOW ON LOT �
i NOTICE TO AYPLICANT:If,after making this CertiTicate of � a, Z
Exem tion, � USE OF � �
p you should bemme suh'ect to the Workera' em4oiK�s CNARGE9
Compensation provisions of the Lnbor Code,you must forth- -
i with comply with such provisions or this permii shalt be � conxecrion CNABAE re�
deemedrevoked. conrrswcrow �.LU(K.ar�
Z AEIMBURSEMENT FEE
j L[CFNSED CONTRACTORS DbCLARATION woowess � ^/
caouv «w. rnocessse ar
I hereby aFfi�m thut i am licemed under-pmvisians of Chapter � � /�p(yL N "*"„�" oH ��
9 (commencing with Section'/000)of Divisinn 3 of ihe Busi- cirr TEL.NO. G`�L�Q Q/�
ness and Prnfessions Code,and my license is in full lorce and STATE � ��c. ��S/ j O /N�
£ lfPCCI. LICENSE NO. CLAS9 l> ✓(J
i' No. DESCRIPTION O/ NK PE6
� � � .�[ cTuto ro FINAL ! 3 �� VALIDATION
License Nu � Lic.Class� s ��� ��� � DATE � d
Contractor_� oate�=��3 ��'1 „o�.E sEwE��or..E�.���.o Fanw� z 1 6�1 A
� ow,,,,rE o„oo�,<<.s.E,. eY '#• • • • 10
1 am exempt from the ensing reqvimments as 7 am a �orHEcr woo�.w.+.�aw�,on
licensed architect or a registered professionel enKineer
acting in my professional capacity (Section 7051, 8us- � � �2 2 J�'�
iness and I'rofessions Code). �R o�ow.w:�� ouse =
aoR. �oo,. '•. •2250�
LWEw O lYSTEa~
i Lic,or Reg.No. Uate �SQ R p�,� a p �0 2 2 5�—8 2
e
� HOME OWNER-BUILDER DECGARqT10N C
? I hereby affirm that [ am exempt from the Conttactor's OWNER�S PBfmlt ! ,�' a� .
� Licenee I,aw Por the following reason (Section 7031.5, Busi- AUTHOHIZATION TOTAL FEE �
f ness and Professions Code): wr+ onrn.�r w w r�a� . �
� ,00�.o�«. ,R..; -
� 1, as ownez of the property,wiil do tfie work and the *o*�E��e����sEw D
= structure is not intended or affered for sale (Section s�eneo rnis owr oF �s
t ?044,Business and Yrofessions Code). N6qs,GE
f CONSTRUCT[ON LENUINC AGF.NCY - -
j� I here6y affirm thai Lhere is a construci�on lending agenCy �1.6 Q 2�A
Pur the performance af ihe work for which this permit is .
issued(Sec.3097,Civ.C.). #�;• •'�• •5.4
j Lender's Name .
� LendePs Address
� • •(1Q0�
� I certify Ihal 1 fiave read [his nppliCa�ion an ate ihat the • • •(�,Q.Q�U
s abuve information is wrrect.[agree t �th al]Cour,ty
j ordinan a d State laws regulat' g P mg and Sewers, �2 2 Jr�8 z '
fand her y thorize repmsenta[i es o s Cnunty ta enter •
� upon the ve-mentioned pruper y spectian purposes.
SEE REV ERSE FOR EXPLANATORY LANGIIAGE
ignat ot Permittee Date
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