HomeMy WebLinkAbout0361A (4)WORKERS' COMPENSATION DECLARATION
I hereby offirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance, or
a cyrtified copy thereof (Sec. 3800, Lob C.1
Policy No. Company R k S 7'/.4 Goo [2Z e
XCerlifief opy 1s ere furnished.
❑ Certified copy is filed with the county buildin:;g in/cr;A
department. Q� o
pdrq&_�: pplicantQ
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the work involved by the
permit is for one hundred dollars (EI00) or less.)
I Certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers' Compensation Laws.
Dote Applicant
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor code, you must forthwith
comply with such provisions or this permit shall be deemed
revoked.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter
9 lcommenc ing with Section 7000) of Division 3 of the Busi-
ness and Professions Code, and my license is in full force and
effect.
License Number ?A AatLic. Clnss_ /A� J({�
ConlroctorQ„�gr�$Dote �y r� at
❑ I am exempt under Sec. of the L.A. Co.
Plumbing Code and/or Sec. of the
S. R P. Code for the following reason
^— Date
Signature
-B :LDER D CLARATION
I hereby offi— thnt I am exempt frcm the Cr•.nsroctor's License
Law for the following reason (Seclon 7031.5, Buisness and Pro.
fstsions Code):
❑ I, as owner of the properly, or my employees with wages ns
their sole compensation, will do the work and the sl—lure
is not intended or offered for sole (Section 704A, Business
and Professions Code).
❑ I, as owner of Ike property, am exclusively contracting with
licensed contractors to construct the project (Section 70,14,
Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency
for the pe•formar.ce of the wcrk for which this permit is
issued (Sec. 3097, Civ. C.).
lender's Name
Lender's Address
I certify that I have read this application and state that the
above information is correct. I agree to comply with all County
ordinances and Stale laws regulating Plumbing and Sewers,
and hereby authorize representatives of this County to enter
upon the above-mentioned property flA inspection purposes.
7tAs<n
"'°"11/111)APPLICATION FOR PERMIT
PRtc�s SEWER • SEWAGE DISPOSAL
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN
CONNECTION DATA
Bun DINC y
STATION / I/
DFP•4
ADDRESS O/ S
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LOCALITY Z
MAN -CIE REFERENCE
3L, RE'_T
TYPE OF CCRWFCTION
LENGTH FROM
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Y. CURB P L
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O'WNFR R.A ' L �R
Co IMP No
MtiO
''%'I'TRUNK
ADFIRE$S
PERMIT NO
ROAD PFRM.1 NO
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All DAVIT *1IvFR EA$FMENI
RECORD 1145T' NO CA7E
CITY 4Z
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[Y$CR1P•'(YJ lC•N^ Ol
HWY. CR ST. W:Df N.No
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SIAIE ENCRCAC.IMENr ,
NO. OF B1o"S
PERMIT NC
S1: E CF LOT NOW ON LCT
USE (Y
BUILDoNGS r /� Cie t
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CO—ECT-CN C -;ECA FEE
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REIMBURSEMENT HE
DIVR'CT NO. GPO(.+ MqP
PR(XE$$[I1 BY
CITY TEL NO
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"LO DESCR:FILLII()F WORK HE
TATE
pi� si st MERCUNNLCt:W To
OD
DATE � f D
/
VALIDATION
SLP^C TAW. SF.FRA„r PT. CR
. nS AND'OP DRA!W4{ D
hNAL
MO'J5F SEWER CONNECTING 70
+R.VATE DIBP(MAl 5r TEM
BY t r
I F. ( Lf Ck,(� 0,�/
C'Ot`NFC7 4N.�i.ONAI &DG OR
wCAK TD —,-J SE St MFQ
0 VERRIOw saltAilif lixt, DRAxsLELD
,
[x:N.CEO( DAYxxtiu. vxi •oil
YFR'J
ATTER. WIDAW OR ABANDON I.OUSE
Sf'wER GR C SAl7.SAL 5•S1kM
J
OWNER'S Permit s
80361 A
AUTHORIZATION TOTAL FEE
-e
HAVE Al TH:$ DA'E A CON'RACT WIN TME HEREIN NAMED CONTRACTOR r0
CONNECT T11F If DESCR:BID Fx-STPJG DWEII ING TO IK PU&IC SEWER
SIGNED THIS DAY Or 19_
C ,14 Uv
OWNERS ACE17
ADDRESS
J so -
lure of Permittee Dole EEE REVERSE FOR EXPLANATORY LANGUAGE
A••••lU
I •'i 27.50
i•i27.50�
/ 1 1.30-83
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