HomeMy WebLinkAbout1181A (5) WORKERS'COMPENSATION DECLA4ATION n
'I hereby offirm rhat I have a ce�iificnie of consent to self II
insurp,.ar o�eniiica�e of Workers'Compensotion Insurance,or '6"'%� Z�
a cY�tlifwdl�py thereof(Set.3800,Lob C.) �E���°��.B.°�, APPLICATION FOR PERMIT
, Policy No. Company is
❑Ceriified copy����e6Y��������. SEWER - SEWAGE DISPOSAL
❑Cenilied coPy is filed wiih the couniy buiiding incpecron COUNTY OF l05 ANGELES BWLDING AND SAFETY
daponmeni.
Da�e Aavuco�r FOR APPLICANT TO Flll IN CONNECTION DAiA
� CfRTIFICAiE OF fXEMVTION FROM WORKERS' y�i;o,Y� (�, }��
COMPENSATION INSURANCE wocess EJ Si"n�v /"f—�7 v °f°rH
(Tiria seclio�need nol be comple�ed i!the work involved by�he f � msN„�E c�r�qE,xf f Q.f ]r� Uc#R
permit is for one hundred dollws(5�00)or le�i.) �«AIIfY �y
1 cemf thai in the 4amance of the work fw which thls ���5' T�'���"``�F�1O"' / IENG�H FROM
Y P0� CK15b 51 V. CI:QB C L{/ M L.lO P l.
permil is iasued,I shp�l rol employ any person in ony manr,er P��
sa as10 come subjen to 1 e Workers'Com n ' lows. ��q 7u!L, � cp.u.v.r.o ion No.
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Dal! App�iCan1
NOTIC 70 APPLICANi: H, aFier moking �his Ceri�(icare of �r� ,Ei� R�F��avn .v>:.�;a k/.�lMFVt c[cc+��v:�u r:o. enn
E� 7p��on, you ahould become subjec� to ehe Ww4eri tFGal
}ensa��on provi:ions of the Labor code,you must forthwiih orsrv.m�r,v terr+o H'JJY,[V Sf.`h"�ti'NG
t�.,�ply wi�h such pro��s�o�s or ihis�mi�sholl be daemed
re�oked. aaK fG6[} SiS!E tNCRC4CYM[h:
LICENSEO CONTRACTORS DECLAtiATION n,o c��uxs �rau�r nn
I hereby afiirm that I am I:cansed under provicions o(Ch�p'er 5�7ec%�cr N�'NC4lC1
9 rommenci h Section 70001 0!Division 3 of�he B�si- ��
� !iq WII I BU::.^.:�Ki$ CY49;�f5
ness and Rofess�ons Code,ond my license is in full fo•ce and � .
CC�'tiF.'fiCN p+AP;�F�E
elfRCf. ^ � C(YJ`RAC: �
License Numbe L7c.Closs — ��u / 4F'N3VYYMFNi FEE � .
�On�rOG� DO�6 . CS:4'�i NO GR(i'.'� YaP GPJClSSID 9r V
Clf �[l.f,Y�. �
❑I om e.ampt under Sec. cF the L.A.Co. ii�F�g Np cidss � �v � � � '
�'O. pES�RIPTI pF WpRK RE
�
Plumb�nq Code and/or Sec. of+tie i��ni �V
�rvsc sweR ca+�atrve�o � G,� ^ere ( >� VALIDATION y
�L�6:�C SFAFa
B.8 P.Cod�fcr ttiw icllowing rensnn J �•-�✓"�"— N
s[�;.i>vr..svv�ot r:i cr �vei 2
�::�s Fw��a+oW.:r.��:o '
Do'O �+(`l;s[y�yEP CC`NNFC'AM'a iJ Bv
PA�v4fE'.YSPOS4L 5�57 'l.i
Signo�u�e [(�NKR i�D�i�7.ln!&�Yv(Ht ,
OWHER-BUILDER DECLARATION °'�°K���'"'F s�rrof' .
cwrxow •cE .. xa+sce.o
I hereby offirm Ihat I om exnripl Frem�he Con!mctor's license rx'v,ce%0.�p,oarin!i,wr+�C�E
Law fpi the followinq roason(Sacton 7031.5,Ruis�Pss o�A P•o- n;!Fu,vErn R O4 nu':J^:�uJ�x
I '�fnSCOdC�: VNkQ.'i`C'SMYJl5Y5'FM
r
I � �as ownr.r o1 ihe p�operty,o�my employees wi!h waqes as '.� � `� '�
the�r sole cer�pensorion.will do rhe work and�he srruc!ure
is no�iniended or offered ior sole(Sec!icn 7044,Businass . � ° � � C
I andProiessionsCode). OWNER�S PB�Tif S � „
❑I,os owr.er ot;tie prcperty,am e.clus��ely contracting w�ih AUTHORIZATION TOTAL FEE S
1 � -t:1.;;0
licensed controctors m constroct the projxct(Seciion 70a4, i ua�2<T fll'S D>'E A CONTGKf W1f4 TV(IiFQF�N NPMFD(.�'G�CiOR fp , u '.
� Business ond Profess�ons Code). CCvhECi fuE a&?vf b[SCc�2ED ExiSi:a(',DwEUi�+G ip riaE vu&�C SF'HEk !�` ,'`���"
CONSTRUCTION LENDING AGENCY � �;i���—�J
I I hereby affirm +hal thare is a cans!ruclion lending aqency SIGME�71115 DAYO� IG_ ��
' �or rhe perfo•mance of t�,e wcrk for which rhis permit is °A�'�Q�
pwryfa5 Af.Eni
issued(Sec.3047,Civ.C.J.
nooxess
lander's Name
Lender i Address
I cerli(y rhai I hove read th�s opplication ond s�aie rhot the
above informalion is corract.I agree lo comply wirh a�l Coumy �
. ordinontes nnd S�o�e laws reg�lai�ng Plumb�ng and Sewera, '
and hereby o�thorize represemo�ives ot ihls County io enter
n�be obo�R-r�nt' e p�opery for inspeU�en purposes.
��� ,� �s-�
. Signol e of Permiltae Dolr, fEE REVERSE FOR E%PLANIITORY LANGUAGE
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