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HomeMy WebLinkAbout1755A (10) WORKER$'COMPENSATION DECIARATI � I hereby o�f�rm �hai I hove o cerrifico�e oi co ent io seif LS insure,or a cerrifica�e of Worke�s'Compensaticn I urance,a �b4M1a�� o cer�iii�d copy ihereof(Sec.3800,lob C.) C=B0.a;ffY.B'B1) APPLICATION FOR PERMIT � Po�li�cy No. Compony �'` SEWER - SEWAGE DISPOSAt �pice fied copy is hereby fu�nished. i Ceri�fied copy is f�led with ihe covn�y building� pec��on COUNTY OF LOS ANGELES BUILOING AND SAFETY { depnrtmenl. Do�e Applicanr FOR APPLICANT TO FILL IN ��j�s" .f1 CONNECTION DATA CERTiFiCATE OF E%EMPTION fROM WORKERS'� a.��ic n�.; �7 p ' st•'iov � o[cT�+ " COMffNSATION INSURANCE �000¢ss ,L O O O LYS h J 17�=�j. (This senion need nor be comple�ed if rhe work involved y ihe �A�i�r ' � ,�y�KHp;E 4EiFiFI.wE ��,�1� q perm�t is for one hundrad dollars(f100�or leca.� IFYGiHFNQV. I cerl�Fy thar in rhe performonce o(rhe work [or whic this �ss�sr �Y�����T�� � L 1 e�. . ��Ra a� M�.:o o�. } permil is iss�ed,I sFoll no�e�nploy o�y person in a�y m ner a�� � 'a- so as io 6ecome s�bjecr to the W��knrs'Co�npensor�on Ia �s. p�,.r„o� p e f r SO r co iMo r✓�. �;�,n r:o. �p�� l'/ V . 'w'� .�J7 IQUNK P[QM�!Np ROM�PEQMIi NO � Daie ADPlitonf �"":EY+ Cs f�J`. / �<a. ✓ i•� O .vr�osv�r w.�vFa tase+Ncvi utco�.v:ras:n rm D�R O NOTICE TO APFIICANT: If, af�er mak�ng �his Cenli�cote�of �iTr •F�nq � Eaemp��on, you ahould become subjxt to the Wor4eey Compenwlion povisions of Ihe Lobo�coda,Yau musl fonhwi$i prt��ini:ya lCT r�o Hwy.pq Sr,u'ain•:G � comply wi�h such pravisions o��h�s permi�:holl lx desmetl ']/ <� revo4ed. � �Gb(N T4PCT � / M Si�Tf EYC�NCN�.+fhl � LICENSED CONTRACTORS DFCLARATION ' ' "p a`e��`'S �QM:T vo — � I hereby off�rm ihof I om I�censed under prov�a�ons oF Chc,pier� s�accic� O O C7 r:ow oy ioi V(commencin wirh Seciinn 70D0 0(Division 3 of the Busi• a � 9 ) BY��7 VG5 V h[ ' [NeNG[5 � nex�ond Vrofessions Code,ond my license is in full force ond � 1 effect. Cpnf4n[•�a ' C01M1�rQ•pY C!4FGE i([ 1 license Number Lic.Class ,r�oxess p �'"�Rsw��r�tf Contmcw pa�e • � - r� asr�a no r � +.no owx[.sco xr C:�Y ►'� iEL. 7 ❑I am exem �under$ac. of fhe L.A.Co. �°�f �•c. � B�/ � � i/-� P ucrNs�r�o. �S aass C— 3�� �� ;� �!'�f 1r�7 � �:G r�.� Pl��mb�nqCodeondinrSwc. ofiha ^0 DEsc:k;v!��OFwc:WK r�[ pN,i rr.:ls�sv.t�car.�ci vc io rJ w�c 7 VAl! TION � • 8.B P.Code ior rhe following reason °'��y�R �1 ~ `� . SEnK TUR.YFo�()[R�px s�Ml I o..5 VYC'OV UiA:fFIE:7 . �O'a �s�wce caw�acn�.c�o ev olllVAfE G V Signnlurc C7MIE[7 ADGt'YUI 91[1G.(M � OWNER-6UIl�ER DFCLARATION w�'�"�'�u�'�v , , ;7���`:�.• . � dF.RFu.hN SEEPAGE PR.DR�:NFIfi'J • • 1 hereby aFf�rm rhoi I om exempt from�he Con!roc+ols Licenee [x'Y,(':SV�Jp',pFTNI:t.Mi4��.,;F Low for�M(ollewinq reown(Secton 7031.5,Buisness and Ro- �e�Fo aEp�m Oa Abaw'+G+�.C��R �, a � � . �� fessions Codel. :r.:ta:.a c�,ac:�5=:srs•�v. • . ❑I,os ownxr ol Ilie prope��y,or my employees wilh woges as I • •C' l.'V rhe�r sole campenwt�on.w�il do rhe wak and rhe siructure ' �— is no�i.+�r.n:lod cr vHered fo!wle(Snciion 7044,Busineas ��� ��7•��'`' ond Professions Code). OWNER'S Permit t y 5 J ❑I,os ownar oi�he properry,am exclusively contracting wiih AVTH�RIZATION T�TAL FEE ��'•'�`r'�_�'� licensed conlroctors 10 cons�rutl 1he projecl�Se[�i0n 70d4, i Ms•:��i i45^�.•E A COMianCT J.i1N fMF lf4ENJ h4M!'J CLMII4I�[ipq ro Business and Professions Code). ce•:vccT rwt<bo•:[as..-x.�o[.:sriw owe:i�r�c io tH[v���c:twFc CONSTRUCTION LEND!NG AGENCY .t� 1 • I haeby affirm fhal thpre is a cnns!ruclion lending ogency S�GVEDTH!S D Off SPV 7 19�� , � , for the partormance of !he work for which Niis permil is ��R� � O'h'tiF�S n:.Fuf issued�Sec.JOG7,Civ.C.). p�x,a!ss / � Lender's Nome Lenda's Address I cerNfy ihor I have road rhis oppl�ca��on ond sio�e rho�ihe obove informo�ion is cerrect.I ogree�o comply with oll County crdinances a�d S�aie lows rwgulating Plumbing nnd Sewers, ond hereby au�ho�i:e represenlolivxs of this County�o en�er u 7he above-menlioned p�operly for inspxtlion purpos�s. ,� �—G-83 Signatu�eofPermii�ee . 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