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HomeMy WebLinkAbout1756A (10) � WORKERS'COMPENSATION DECLARATION ` � ?� I hereby oFiirm ihot I hove a cen�fica�e of conseni to seli � ins�ra,or a certificore of Wor4ers'Compensarion Insuronce,or ��"��� � S a ce�Nfied copy thereo((Sec.3800,Lab C.) c¢�.�e;�[v.eiei� APPLICATION FOR PERMIT Volicy No. Company ?s ❑Cen�f�ed copy is hereby furnished. SEWER - SEWAGE DISPOSAL [�CertH�ed copy is iiled wirh�!ee coumy bu�ld��g��spection COUNTY OF LOS ANGELES BUILDING AND SAFETY depar!ment. ome Appliconl POR APPLICANT TO FILL IN /.1. �. �/ CONNECTION OATA , CERTIFICATE OF E%EMPTION FROM WORKERS' gi,�:�p.n� J COMPENSATION INSURANCE �nnvEss ,Z O �U , �(rC 4�1 ,. 57°���Y a y+ 2 �°�� (Tfi�s section need no�be complered if�he work invol�ed by the i�A�ii� � ! MAW��It RE�EREYCE ,L�� p�rmil is for one h�ndred dollars�5100)or less.) nEnxFsl rrRa co�.r¢tnOr+ ��,rH pqpp I cen�fy ihoi in the performonce of rhe work fo�wh�ch ih�s cnosssr. �( v. CURB Pl`�� M�.TpPI. 1' pe�mil is issued,I shall nol employ any person in any monner �+ p�� �, �(n IL � eo as lo become subject lo ihe Workari Compensa�ion Lows. a�q r- � b J 0�.. [O w.'o.nip �oe No y{' � .w�� ` '.q;1NKPEYM'7 'h0. RpGDYFPMITWp pote Appli[On1 A���u (� '� Iw / O J. SV � (�Y\ o AFf�AVII WAn'f4 FMSENEvi RE.•.ORD!N$TR NO D4TF �/ IvOTiCE TO APPIICANT: Ii, ofiar moking ihis Ceriifico�e of aiv� 1!l rFi rx7 �y �6 7 U EKempiion, yo� should becomr subject io ihe Workert � Compensar�on p�ovisions ot�he labor code,you musl forthwi�h �Ka'oi;cya ierno. � "� comply w�rh such p.o��s�ons or�his pe�mil sholl bP denmed IJ ` �] HK~�5•µ�Y�A' �L n revo�. &OCK i4nCT /^ J / 51��E'YCWACHMFM •r LICENSED CONiRACTORS DECIARATION r.�p pr g;pp5 RQMII ly7 "' I herob aNirm�hot I am I�censed under siz¢c�toi Q Q 0 r+owwior � � y provisions of Chapier �,�� r 9(commencing wlrh Sechon 7000)of D��Ision 3 oF the Busi- �ii�,�s {4 C�a.(' S � �wq�,�g neaa ord Proieasiona Code,and my license ia i�full force and B1{e(1. C0�1!R6'iOlt C'I+n'..T'bJ CMeP^„F fEE LiePnse Number L�e.Class appQEs,e g Y RENM:.RSEMENi i�E Contrador Date � . _ ��SmCTHo crc V.Pv wocesseu?r CIIY � ��� IFl.NO I� . ❑I am exemPl under$ec. of the LA.Co. i;Ews[nwi ,! ciass C— '� �{-���� ��/L'�� . P!um6ingCodeand/orSec. ofthe � DESCRIGTIONOFW'ORK rcc �,�i I '`� � 11C1.'SE SEWE4 CONNECi:NG TO DnTE VAU TION B.8 P.Code for�he following reason �uw:c stwtc � r-- r� ' Y."T\Yk.SEEPt�:;i'7 L4 f:hn: ��e V•5 AVD'OV'JRa•^1��EL'J Bv ML`:/5[SEVIFR CONNECI NG!O �J . W�Vnif DISPOSN SrS�EM S�qnowre mr:rxc�noara�w�:oc.ou , /� OWNER-BUILD[R DECLARATION �•+�t ro����Y vwsa ONFFi.tTN SFPK'1 PT.DR�.NFV.D I he�e6y offhm iha�I ori e•er�p+frorn the Controuor's l�cense e�in.cf55WC1,carwH� v�.�+�[ low For the iollowina reoson(Sectan 7031.5.Buisness ond Pro• ��*f.c.4v��w a.wwoN NCust j less�ons Code): se�+r[c oa wsrosni srsnv f • r l ❑I,as owner of Ihe properly,or my employees wilh wages as .�� i:]C;rl 6 �heir sole tompensn!ion,will do IF.e wcrk and Ihe slructure � ' is nol iniended or off�red icr solr.(Seclicn 7044,Business "• • • • � n �l and Rofessions Code). OWNER'S Permit t F'' � ❑I,es owner of ihe pro�erty,am xxclusively contracting wiih AUTHORIZATION TOTAL FEE � � ' ' �=�•�� � IiceMed contracbrs lo cons+ruct Ihe project(Seclfon 7011, i�.nvE ar nn5 n41f 4 CON'RKf WIfY il1E ME4F�N N6Mf9 COW �[iox to � o _ Busineas and Proieuions Code�. co^�^�c�7'�E A6�1r(DFSCQ�QfD Ex•Sin�p�y(�l'NG f0 THE W&':SF.NRP •� � .)U<: CONSTRUC710N LENDING AGENCY ••t� I hereby aSiirm rho� �here �s a constr�<�ion lend�np ogency S�GniFDiH�S Dnv •SYO�w�� ► C Q C�—�� p fer the performance of the work for which this permit is o�ti 4s�nc,�ui I' issued(Set.3097,C�v.C.). � A709E55 Lender's Nome Le�der's Address I cerlify thai I ho�e reod�h�s oop�aaGon ond sro'e ihai the �bove info�mation is correc�.I og.ee�o comply wirh all Co�niy . crd�nonces ond Stoie Inws reguln�inq Plur�b�ng ond Sewera, � ard hereby ourhorize representotives of this Coumy�a enter ' . ��p"'��n Ihe n^bore-me/.n�lionnd�roperly lor inspxcfion purposes. 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