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Home My WebLink About0997A " WONKERS'COMPF.NSATIONUIiCLARATION CE808(o2-80) APPLICATION FOR PERMIT I � � I hereby affi[m [ha[ I have a certificate of consent tu se�r . SEWER-SEWAGE DISPOSAL insure,or a certificate of Worken'C�mpensutiun Insurence,or � a certitied opv the o/E(Sec.3800.Lah.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY � Policy��"CompanY��S��X��-� �� FOR APPLICANT TO FILL IN CONNECTION DATA ! � Certified copy is heceAy Purnished. 6llILDING i STATION 'O.�' v Z DEPTM �� aCettiffed cupy is fiied with the county building inc cY m a�ORE55�� f ,rj �� I a2P8l�fllEtl�. I,OCALITV � � - 2 MqNHOLE NEFERENCE O� �`� UPPER . � 0 J LO � D'dltl�App3ic�nt NEAREST TYPE OF CONNECT LENGTM FROM / � Ck:RT[F'1CATl OF EXEMPT[ON FROM WORKERS' �Rass sr. � Y. CYRB �j.L. M.L.TO P�. ,�',z � COMPENSATION INSURANCE v.c.rvo. ��G/ f ' OWNEF /C CO.fMP.NO. JOB NO. } ` MA{L a � ��it5 SCC�i011 need not be compieted 1P��IC WOI�( involred AOGRESS M(j 1 N � T�xuNK PEw�f�T n0. Rowo PERM�T rv0. O by the permit is for one hundred dollaze (S10(})or tess.) .q �� Fp�p�„� ,�,6 ME �oRp.�„srR.,, ,.,E U ClT`K//A/1J EL.NO. '� �.�.$ l � � 1 certity that in th�performance of the work tor which this LEGAL a � perrti!is issued,I shall not employ any person in any manner � osscw�vr�on �or rvo. O � XWY.OR 9T.WIUfiNFNG so as to bacome subject to the K'orkers'ComPensation Laws. J'I V ' BLOCK i1iACT tJ (/I{� STATE ENCROACMMENT (L Date Appkicant NO.OP BLpGB. PERMiT rvo. A � SIZE OF LOT NOW ON LOT y NOTICF TO qPPL[CANT:IL,after making this Certificate uf Z F,xemption, you should become subject to the Workers' use oF CXARGES — 3 BUtLD�N65 � Compensetion prnvicions uf the Labor Code,you must forth- WI(�i camply Wlttl SllCh piUVIS10f15 O� �}IIS permit shall 6e COHTRACTOR CONIVECTION CNARGE FEE � - deemed revoked. ��'�� - L[CENSN:I)C'UNTEtAC70kS t]E(;LARATION AOOR654 REIMBURSEMEN4 FEE � .2 r X/. N�V [hereby affirm that F am licensed under provisions of Chapter �J yy �_*Ho. �wouP K M�P PRo�EssEo er f C�TY Jr /� TEL.NQ.S/ � CT� siw e S 9 (commencing with Seccion 7000)of Division 3 oT the Busi- ! ness and Protessinns Code,and my 4icense is in full torce and L;ATE ue. �� 1 L � GENSE NO.� CLA53 �� 9� . - [PfeCt. H0. DESfRIPTiON OF WORK FEE ��366f C—Y�. FINAL / � VALIDATION � License Number•+ Lia Ciass - E o��E��To d� OATE / / �,/ ' Contractoaf/_� Date /�Jy �� oion o hE�,��oo �j � FfnAL �/� [ � ��srs.c G'oF sr. (tia��,�1/� � I am ezempt from the licensing requitements as I am a licensed architect or a registered professionai engineer o� �l � acting in my profeseiona( capacity (SecCion 7051, Bus- F�o..sV iness and Professions Code). a�sE Lic.nr Fteg.No. llate . j �(�f/rp 1 l�'i[�#� � tiOME OWNER-BUILDER DECLARATION OWNER'S Permit s �Q � 1 hereby aftirm that I am exempt from the Contractor's — 1 � License Law for the Following reason(Section 7031.5, Busi- AUTHORIZAFION TOTAL FEE ,j��/ 1j nrss and Professionx Code): ..Eo con- �Q 4 9�'�A f � e xs ru:6Mc sewcw.•wa weov�nsece�eeo cxisnno oweiuwo ; I, as owner of the property,will do ttie work anJ the structure es nut intended or affer)d for snle (Section 516NED TfIS�o�v oF '��s� #�•�� 7044,Business and Prafessions Code. ownew o.. // xEws�� .��,l�r ( • •2250 � CONSTRUCT[ON LENDING AGF.NCY I hereby affirm that thete is n construcfion lending ugency �� 2 Z JC 0� fnr the pecfurmunce nf the work for which this permit is � , � issued Sec.3�97,Civ.C.. ` � LenJer's Nxme ) �2� 4'�8�� LendePs Address � � 1 cer[ify Ihut I hnve read this applica[ion and state that the �buve information is correct.1 agree Co comply with a�l Cour•ty � � qrdinnnces and State laws regulating Plumhing and Sewers, � and hereby authorize representatives of this County to enter � upon the abuve-mentioned pmperty for inspecti�n purposes. 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