HomeMy WebLinkAbout0948A WORKERS'COM�ENSATION DECIARATION W �"'�^�"^�
1 hereby alfirm �hot 1 have o ceriiiico�e o1 consenr lo self ��
�nsure,or a ceri�f�ca�e of Workeri Compensoiion Insuronce,o� "�°"�� �
o�a„�;ed copy�hereo((Sec.3800,Lob C.) �E°��°:�.,°,. APPLICATION FOR PERMIT �`" z�. im3o
Policy No. Compony C
❑Ceriifled copy is he�eby f�rnished. SEWGR - SEWAGE DISPOSAL
❑Cenil�ed copy is filed w��h�he couniy bu�ld�ng i�spection COUNTV OF LOS ANGELES BUILDING AND SAFETY
deparlment.
oo,� Applfcon� FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF E7(EMVTION FROM WORKERS' eunov�c 5rnr�pN ptv�H
COMPENSATION INSURANCE +coatss �S G�r tiGi
(This secr�on need noi he completed�f the wo�k in�o��ed by�he i«pi�rY ���{�� �� 1�4ti���E REFE4EN(f i q
pe�mil is for one hundred doilars�5�00)or lesc.)
I certiiy rFal in�he parformnnce oF rhe wo�4 for which this �ap555sr /� ���0`���� �`'K'THf°�"'' /
perm��is issued,I shail not employ any person in ony monne. , � r� c�ae r i ,� M i*o v i.
so os io ome ubjwc�ta ihe Wo.keri CompE�tion Lows. � o c.no e�iL
cwvr¢ ,y .Y�wL co�Mo rao. ioe r+o T
(� / �� T9JNK PFYM:i Np RpAp iEPM'T YO
Do� �� �Applicont�1�13XiJ.C�t/ •owrcss
NO�ICE TO APPL�CANT: I(, oire� moking Ihis CerfiFica�e oF AF{iDAVIf w�i�a F45F41FN� aFCpRp ia5iv.ryp WrE
EKemp�ion, you should bacome subjeti �o the Workeri ���Y �F���
Com sotion �fr'�'�
psn prov�sions of the lobor code,yo�musr fonhwi+h trxa�vnor.i iorwo 1nW pqST Wq�NiNG
comply wi�h such provisions or�h�s permil sholl be deemed
re�oked. e�ocR fOq�7 51A'E ENCRWCNNiYI
IICENSED CONTRACTORS DECIARATION ����s °F°'"""'�
I hereby alfirm thoi I�m licenced under provitionc o�Choplar `-�zEOilOr '.q,Hpr.��p�
9 commencin �h Section 7000 of Division 3 0(the Busi- ��
( 9�'� 1 �mo:ar,s n cw•K,�s
nef7 a�d ProFessiona Codr,ond my license is in iull iac!ond
effe��. !� ��o„�!r�l CORY[Ci'ON�HnRG[FEF
l�ce.��e N��.,be� Lcc.Class C`7 � r AppRf55 C � �.y QE�MBU95FMENT f{E �
eonr.oao ^-4D`G7L�"rL�e 6 �l cn� .tt r+o c o�sro�r wo. c,�ouv µnv rtoass[o e+ O
❑I om eaempi under Sec. of the L.A.Co. �'�� �Cl gR �
���F,.�� 9 <i.0 ` 2 �� �
� Plu�+b��gCodea�d/e.5ec. oftha "� DEx4���iqJO�WORK �E � ""°� ,�� S $ VALIDATION t'j
� �+DUSE SE'.vfY CpYVECi�'K.TO D�tE
B.8 P.Code(o•�tie!ol�ow�ng reoson P1°"�y"'EQ � �y W
Y : �N[. Fw�GE s.T OR � .
154ND�ORDRI1�NFd:D e nl I^^
Dal! y����Q C�S+STEM �� \�1`���"� ?
$i9nOlura WONNFCT'AODiipNpt�',w pq ,
OWNER�BUILDER DECLARATION �RK lQH«J$[5E'hEo
(7r1YF:()Mr yEFPW[NT.OQ�W��1'J
I hereby affirm that I om e.empi from ihe Con'rac�or's Utencs Fzfr�.[ESSPDIX.OYrvfFLl MAw.qE
law for rhe Follow��g repspn(Secr�n 7031.5,Buisness and Pr�• atf4 arn��x at na�r�aa�x±;�5t �
�elfiOnS�Odl�: SF'NFP Oi D:W.SeI$Yc�f N
❑I,as owner oi�he properly,or my employees wiih woqes os ��C�(,�1i
Iheir sole companwrion,will do the work ond�he struc�urr.
is not iniended or offered for sole(SeNion 70a4,Bus�ness j!• • • • � n
ond Professions Code). OWNER�S Permit S �O ,S`Z7 �
❑I,as owner of�he property,om n.clusively tontracting wilh AUTHORIZATION TOTAL FEE � � ��'J�
licenfed conhac�ars b conshutl the prolet�(Setiion IOU, 1 u4�F Pi iH�S�4TE F C0�1rY�P W�T�iHE MRF'N NnMi�CONRaROR fD • • •�7�J�?
Business and Profnssions Code�. co�:aeci�wt neovt ttsccrefo t.�sr�r:�ovrt;uue ro rwe auet�c s�v.�w �
CONSTRUCTION LENDING AGEN[Y , � S'�
1 hereby off�rm �hat there is o construc!ion lending agency SiGraEDTH:
5 DAYOF I9_ �'�'z���J
�or �he performonce of the wo�k for wh�ch �his permi� is �'''F'C4
i�sued(Sec.3097,Civ.C.). owracsncc�:r
A;H1aF55
Lendei s Name
Lender's Address
I cerHfy thot I hove reod ihis applicaiion and s�ote thot�he
obove informoiion is corretr.I agree comply wi+h all County
ordinonces ond Sro�e lows reguio n Plumbing and Sewers,
and here6y au�hor'ye re sen�at/ves of�his Co�nry io en�er . ,
upon�he above� eNio propE�ty r inspetlion purpos S
'� lf�i�/'� �J �l S� .
o�u�e of Prminee Daie SFE REV[RSE FOR E%KANAiORY IANGUAGE
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