HomeMy WebLinkAbout0948A (5) 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 (� (�,�n / �� T9JNK PFYM:i Np RpAp iEPM'T YO Da �� �Applicon�%//� i/fl_X_,2.C�7/ •owrcu NO�ICE TO APPL�CANT: I(, oire�� 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 �-'1__ -�t� ' �\• � . r�'',�,��,��\� •,i�`•.,`� \ i � . . •� ,�� +�'�'• `��ti�' ,�,i . ' , :tr, 4'. 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