HomeMy WebLinkAbout0997A (5) " WONKERS'COMPF.NSATIONUIiCLARATION 76A642� APPLICATION FOR PERMIT
, CE 808(2-80) � 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. '
SEE REVF.NSE POR EXPLANAT�AY LANGUAGF' - i
/.9-- / eP,[_ �
�gnature of Yermitiee- Date
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