Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
1758A
WORKFR$'COMPENSATION DECLARATION � I he�eby aifirm ihat I ha�e a certi(ica�e of consent to sel( . insure.or a certificoie of Worke�i CompensaHon Inauronce,or 1M14fA]D S a«�,,f;edcopy�hereol(Sec.3800,LobC.) �E��°�°e�°�� APPLICATION FOR PERMIT Policy No. Compony ' '�s ❑c :r;��oPY�5 ne�e�Y F���,sh�,. SEWER • SEWAGE DISPOSAL Ce�r��ed copy+s f��ed w�rh rhe counry build�ng inspecrio� COUNTY OF LOS ANGELES BUILDING AND SAFETY depanment. ' oeie Appiiconf FOR APPLICANT TO Flll IN ,U�L�[' CONNECTION DATA CERTIFICATE OF E?(EMFTION FROM WORKERS' n l • COMPENSATlON INSURANCE �iss �l �L 4 Y w`p 5 4i��y ��]S OF�TH (This seclion need nol be comple!ed if Ihe work involved 6y Ihe �«�iin, �•'T .WNi�^!C YFFFYFNCF � � permit is for one hurdred dollors(f100)or lets.) I cert�fy ihoi in�he periormance of �he work For which�his CQ�ssssr ivoco�cotir�rtci�o.� IFNGfNFROM ,' Y. CVRB Pl� Ml IOVI. 1' permit is issued,I sholl no1 employ nny persan in nny mnnner � � � .� '� 50 OS 10 FilCCmG SUE;PC��O iti�WOrk!'S Com enu�tlon lows. v c.No ('�� 7 � , P p.A.•:[4 T [� I SC4.f CO Ih'v.N'J J^0 NO J I�J ��� iiUNR oEiM�I NO ROip GEYMii NO � Dote Appli[ont a�cRf55 J a'C � � �` �7 ♦Fi�AVIi M'A:`hW FPyEM(!:1 RECLw7�wS:R NO D4�k J NOTICE TO APPIICANT: If, oher mokinfl ihis Ceriifito�e of �iT� r r,���p / � /6 V Eaemplion. you should become subject �o �he Workers' Compenso•ion provisions of ihe Lobor code,you musl(orrhwi�h pEscaiGr��,^,v �Cr no � MWY,C3 ST WI�41\.^s 'y comply wi�h such provisions o�this permil shall be deemed �� revoked. BiocK +:<Cr � SfI�IFfN�4p4CYMfYf r LICENSFD CONTRACTORS DECLARATION ��&�5 ��f��� 5i7E OF�C. �G 6 .�OW a�0, I hereby affirm ttiai I ar�licensed undar pravisians of Chap:er i�� � 9(commencing wi�h Section 7000)o(D�vision 3 of Ihe Busi- bu�i��•:cs L .P S ( J H o�aacts ness and P�ofessions Code,ond my license is�n iuil force and _ � effecl. ca�:rRatiOa CONn:C7'ON CM4RGE ifE . License Number Lic.Class q.N,�ss rtew�a�:ostv[nr r�t Conrroctor � Do�e orr •;Et.�a � — "sc:'c�+a. coouv .,w= PYOCESSFD BY sare 7 BK/ / � ❑I om e.empi under Sec. of ihe l.A.Co. i,,p�;c;n;� cuss (�� ,� �V �'I/f �J (�!�-��,��/^'� NO (yCCG'GT'ONOFWORK if[ . PlumbingCodranJ/or5ec. ofihe �rvni • IC::��CSFNERCCwNF.i'NG'� � =:.rr VALID TION B.8 P.Code lar ihe foilawing reason p1°°'�'�P � ...J 4P':�I�Yk.$Efo�'.<:�.1 f:u iivn ni.5 nv�•OR Pin rv��Fl� ' Dale �+OUSE SEMN CO�w+EC':NG!O BY ' GN�VA'E G�S�'.^.SAL 5�5'EN $+gra`ure L'J0.VF:l a'ti:'�,7:5L tl:J!;UR , OWNER-BUIIDER�ECLARATION W�»��X SF��YfN , CVE i W SEf1's{�(P.1.�Yia.M�i:;J I hareby oHirm�hot I am e.empt from r!�e Con+rocior's License [�ia,�E55voa..:wrv.s;i wv.wo+r Law(or thc following rsason(Secion 7031.5,Bu�sness and Pro- ..=c Reon.c cs:,�.+�a::r.��;;�,:x lessions Cede): sE sEv ov C�sw„sni Srs[M ❑I,�5 ownnr of ihe Froperly,or my employees wilh woges os � their scle compensation,will do�he work and Il+e stru:lure �= I I �v • . ' �s�or�n'er+dad cr offr.�ed ler wie(Sec:�on 7CJ4,Business and Profess�oos CoJe). OWNER�S Permit S �fJ,�' . • •'• � (i ❑I,os owner of rhe propertY,am xxtlusivcly[on�•acling wi!h AUTHORIZATION TOTAL fEE '' (' � � ��7 r,C licansed contra.iors'o cons'ruU�he prejeU(Sec�ion 7014� ���yy'r qI fHi$OpiE A CON�i.fU N'IW fl�E M4i'N N4YrJ C er ncTcw ro BVS�nE55 O�(I PfOfBS5in�5 COd@�. COM1M1F.i T��E A&:V[DfSiR��D FM•ST!�fl'A(II'r1G T.7 iME PV&'C SF`MFR '� / ,.^-.. • i(_'!..){/U CONSTRUCTION LENDING AGENCY � n I Ferehy nH��m thoi �hrrP i� a cens•ruc��e� In�ding agency SiC,NFDTNiS � AVOF J � Io� for �he parformonce cf the werk for which ihh perma is �'`'�'�RC° , V� issued(Sec.3097,Civ.C.). Ov.':txs n,^,t ��.C�— !.D^+'FSS � v Lender's Nome Lender's Address . I certify thot I havr. reod ihis aapHcaGon ond s�a�e ihai ihe. � obove informa��on is co�rect.I agree 10 comply wl�h all Co�nly ordinonces a�d S�n�e laws�equlo�inp Plumbinq ond Sewnrs, � and hereby a�thorize rep�esenro��ves cf�h�s Coun+y ro entar �°�r1,e abo�e-menl�oned p�operly(or inspecfion purposas. �—�Y7 r`..0�rJt._—. ! `G^ �3 , i— g�nnlureofPermit�ee Do�e SEEREYERSEFONEI(PLANATORYl11NGUAGE � � %:�" ,•� r I � T • c,^, �• it,. +! " � �`,;� . . r,.�`,,r� `? �1 i �'t'; ;`+� .�, +y y� '� j• .:n �:i �`�• � _ c,'i'! �c�`�; O �. u • �; `,(. ,�' �•Y;. OI �`�1�1� :" � y'':�.1:`^'„ } �ll�_ {n ' ��``'��A�-� �i}' '� � . � ' ' �� , • � " I ._--�'; C � , � ry . _-'- � � � � � , . _ ,_�..�,_- . v � ► � � � - � ���� �; �, � �, t/N i,. G` O �a N �'• i � '� . ,' ' , . �'' . ! ; � � � ' � . i .. � � : �, � y� ' � . � � � � I : . I � �� t, i � � � .I I �'� 1� � � i ' � t � i I � 1 �� �. '' ' �` ' � .. ' � � � N •• ' � � i 1 'I 11� � :' ; ' • � '� 1 , I� I � ; � � F � 1 1 ', � ' ; � � ' �, , � 1 � ' �,i �, ��, � I �� � � � �'� � .; , ,, . , � � � I , � � � I� � M . �: : ._ . .. . � � I _ L. .� .. - � __ _ . _ � � _ _ r-'r�-��" - ``- _ ��. •: I. . i', � • .. ��',. ^.. S� - : .. � � '. .. � i� y`~.i S. ' l• Y ,� ~ {.,t f:• ` _''/',•. ' ~� . .. , t O ` �V � -+._ . ��� .. �� � � ��,^:.'. t" ` ' ' �/ �. r f� t �.` �� ^ '_,l'1 f ' . . �r�'. 1� ' �, � � �..' _ �.:�` . J'•"`�~ _%' _ v, . +: _ _ r • y ` ^ ^ ' ' ' s. :: �� �" W`'^. � � ~ ✓ I. �• � ' � ' ' , =� . +^ "'• , �`t `—•r .. — M C.:� .." •L C..^ ...� n I �• `� tw � :- � � '^ _ ^� r �� `�' 4-t.. I: � 'i' ,: � � . � � J ` �T, r,t =�i N yr`^'�� �7 ti_ �c..• "`'r''✓.�� � � ' C (� �^ •('.G � � ^ ,�i "..�_��y � ^ �~^.., 'I, �.�: �: ', t._ F '� . r �,t ,' F �'^ .. * � O ` , � � C• y C7,^C' . y � , �c. � � 1•I^ �1 ,Y. _ ' ^ r '� = c"'� ' �- � _ =. � O 1 , ' ._.-:�t� c" .. F C _ y �.� w �, ^ •= ^ •.,� „ �+' . 1 Y" �V".Y Lr ,.�� �• � _ S C �. — � *" ^ . � C`�..C'�. ~ ~ G :� �, 7• • '�'v~, • V� � • f � � _�'_� _ `1 1_Y _w N`_.�. ✓ ' �__....�'����� � " - x`� _-----�- �__