HomeMy WebLinkAbout0694A • WORKERS'COMPENSATION DECLARATION �s
I`hereby affirm that I hove o certifico�e of tonsent lo self 92�o°°z ovw aiei � ,
insure,or a cartificate of Workers'Compenwtion Insuiance,or 7°fi6°2°
a cenified mpy thereof(Sac.3800,����.,F. �G �E� APPliCAT10N FOR PERMIT �
Poli y No. � ompany e_ t �s
❑c��;yO�,p,,� �e„by r„�,,;,,,�d. SEWER - SEWAGE DISPOSAL
❑�r��"efapy iz�k�d���coun�building inspecsion o �- OUNiY OF�OS ANGELES BUILDING AND SAFETY
Dore Applimnt�� FOR AP ICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' euna�c
COMPENSATION INSl1RANCE aooaess srnnoN oevTx
(This section naed not be mmpleted if the wwk involved by�he ����n, ,tanHo�E REFERENCE uaffa
permit is for ona hundred dollars(SI00)or less.) ioy�y
I cerfif tFwt in the rformanca-of the work fo�which Ihis �pR�T TYPEOFCpNNECTION �r.�rHFRpro
Y Pe caoss sr. �
permil is issued,I shall oot employ any person in ony monner ��� aae v.t. M.�.rov,i.
so as ro become su6ject to ihe Workers'Campensation laws. ('� r.c.No. /D
OWNEN �\ CO.IMP.NO. J08 NO. G 17
��� �� C' O lRUhA(PERMIT NO. ROAU PFRMIi NO.
Dote Appliconi AooaEu
NOTICE TO APPLICANT: If, after moking �his Certificate OF �� .4FF�DAYIT WAIVER EASEMENT 4ECORO.INSTR.NO. DAiE
UTY�� . TEl.�..
F-�mption, you should become subject to the Workers' ��� —
E �pensafion provisions of ihe Labor COde,yov must farthwitb pcsCRii'iOP; �O'�. � �.,��,N��N�� �- �
...nply wilb such provisions or tfifs permif aFwll be deemed � — �
f2YOkBd. BIOCX TRACI SiATE ENCROACHMEM
UCENSED CONTRACTORS DECIARATVpN No.oc stoos �ERMIi NO.
SIZE OF lOi NOw ON LOT
I haraby offirm that 1 am licensed under provisions of Chapter ��
9(commencing with Sedion 7000)oE Divisior�3 of the$ust- auiEonvcs aAa�Es
ness and Professions Code,and my license is in full force and
BffBC�. f� �pNiRAROR� CONNECTION CHARGE FEE
Li[Cnie NumbC���iG.C�ass }`�. Ap�p�cc REIMBURSEMENi FFE p_ .
/ � DISTFICT NO. GROUP Mqp ppp�[$$Ep gy �
CoMractor (7 FnG_ Date ' pTr - re�.NO. , V
3 STATE lIG �O � �' O
- ❑I om exempt u❑der Sec. oTthe L.A.Co. �i�E�� - cuss
PlumbingCodeand/orSec. o£Ihe � �ESCRIPTIONOFWORK iFE F�NA� V
HOUSE$EWER C�NNECTING Tp .� /���_�J�y.
weuc s�v�R o^rE YALIDATION W
B.8 P.Code for tha follow�ng reason � gvri�7Awc SEEPaGE P�i IXt �� y
�ITS ANO/OR DRAINFIEID g�� ���� Z
POte � � HOUSE SEWER CCNNECTING 7O
YRIVAIE DISGOSAL 51'SiEM
Signafure � .. CONNECT AD�Ii1IXJAL&DG.OR �
OWNER•BUILDER�ECLARATION WORR 70 HOUSE SEWER
I hereby aftirm that I am exempt from the Contractm's License XTNF���POpI,OqYWFLtA'MANMae
Law for the following reason(Setlon 7031.5�BUIS0055 dpd PIO- N7ER,REPAIB pR P$ANDON MOt15E
; '�lOns Code): SEwEa pR D�SPOSAL S�STEM, ,..
� . �. .. . .. . . ._.. ._ . . . . . .. ._ -_._:.�_.'__ ._.._ . - _ .. . .. ,
. 1,as ownar ef Me property,or my employees with wages as � � §(?�V Q�`,
their sole compensaiion,wili do the work and the strunure -
is not intended or offered for sale(Section 7044,Business �;s • . . � ;`; i
and Profassions Code). OWPlER�S Permit y
�1,a;owner of the proparry,om exclusively controtting with AUTHORIZATION TOTAL PEE (j � • '��•�i�+
Iicensed contractors to consiruct the project(Seciion 7044, �W{yE At THLS LwiE A-CONSRAfi WRM THE HFFEIN NAME�J CONiRAROR i0 -
Business nnd Professions Code�. CpNNECT THE ABpVE qESCRIBEP E%ISTING�WELIING TO iHE%1BLIC SEWER. '� � �'C ....�,�-�
CONSTRUCTtON LENDING-AGENCY- � �
{ hereby affirm ihat there is a constructian fendinq agency SiGNEDiHiS �_,.�_Dnv OF � t� , ��:.i'�—��
for ihe performance of the work for which �his permif is ��R� �
iss�ed{Sec.3097,Civ. � + OWNEfiSA
lender'sName . �l�"l fXi� �� ��. .�.... ������, .
Lender's Addreas�� S��IQ��'IO�i_ J7���Q�C,q �
I carlify ihat I hove read this appiica ion ond state thal�he C�OD��
obove informalio�is correct.I agree ro wmply with a!1 County .
ordinances and State lows regulating Plum6ing and Sewers,
and hereby authorize representa�ives of�his County�o enter
upon the a6ove-mentianed proparry 4or inspection purposes. � -�
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