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HomeMy WebLinkAbout1362A WORKERS'COMPENSATION DECLAR�710N � � � �-� . � � � � �� �� .� , ., . � - . q ,I hereby affirm 1!�ai I have a certifimte of onsent to�self . � , � � � ��, � . �' . � , II� ..insure,or cerfificate of Workers'Compenaati n Insurance,or . �. �6Ab°� . . .�..� � , , � , ��.� � 1� aceYifie�����e�,.� �. � � �Eeoe,RE�.BB„ ���:APPLICATION��:FOR P�ERMIT � , � Pou� �� c�� "C�Ce�tified�copy is here6y fumished. " SEWER - SEWAGE DISPOSAL � , �, �, � 0 Ce�tified ropy is filed with the county buii ng inspection COUNTY Of LOS ANGELES BUILDING AND'SAFETY � department. � - .�:Dale__ ApplicaN FOR APPLICANT TO FILL IN CONNECTION OATA . , CERTIFICATE OF EXEMPTION FROM WOR�ERS' COMPENSATION INSURANCE . nooe ss 1 � � � 5rnrioN oErTH . � �';(This section need not be completed if ihe work i volved by the � � nnarvHote aeFekeNce uPPeR .. . �,'permit is for one hundred doliars($100)or less:)1 �acnurr � �� IOWER NFARESi � TYPEOFCONNECiION tENGTHFROM � ��'I certify)hat in the performance�of the work�f�r which this ceosssi. . r. cuae P.i. h�i.to7.t. �'!permil is'issued,I sholi not employ any person ir�any manner. . i � eC rvo .-�,jso as to become subiect to the Workers'Compensotion LaWS. � OVlNER r 1Q,�^ �Ct'c CO.IMP No. �oe No 1 '�S AUDRE55 \� ��J� � TRUNK PERMIi NO. ROAO PERMIT NO. � 'Date Applicani ' {/.j� �y� /v, � � '�NOTICE TO APPIICANT: If� dff¢r mpking ihi5 CertlfiCate of ' ' Cli � '�pti�, TELNO. �,�j,�[//V�� AFFIDAVIi WNVER EASEMEM RECORD INSiR.NO. DATE ` �rnption, you �should become subjec7 to the Workers'� �eGa� f pensation provisions of the Labor code,you must forthwi�h � � oe5ceicnoN LOT NO. Hpyy.pg ST.WIDfNING .�r,cimnly with si�ch p nvisions ar this nermit shail 6e deemed� �,...�_„ � . *�revoked..� ' i ,: eiocK TRACT �.�+ STATE ENCROACHMENi LICENSED CONTRACTORS DECLARATION� � � ivo.oF etoca PERMiT No. � i SIZEOFLOT NOWONLOT ' "�I hereby affirm thaf I am licensed uiider provistonseof Chopter - � . ' USeOF � '9(commencing with Secfion 7000)of Division 3 of the Busi- � , BULLOINGS CHAR,ES ��"'ness and Professions Code,ond my license is in full`:force and , ��' effect.� ' � �' �'I CONTRACTOR CONNEtTION CHARGE fEE � ' .LiC@n38 NUmbef���i�,CIO55_ � ; ADDRESS REIMBURSEMENT FEE � � � �COhtlOCtOf��YAN��A..�O�DqtC . DISiRICi NO. GROUP MAP PROCESSED BY � : CITV iEL.NO. BK PG � ;-❑I am exempt under Sec. of the L.A.Co. . � ��ENSE NO. l/� �� ciAss �� � � �� rvo. �ESCRIPTION OF WORK FEE : Plumbing Code and/or Sec. ,of the . Y piNA� �. , ' HOUSi SEWER COYNECTING TO OATE `,' aueucsewee � Q VALIDATION a;, �� B.&P.Code for ihe following reason -y p� � ', SEPTIC TANK,SEEPAGE Pli OR � Date PIiS ANO:OR p2AINFIEL� FINAL Z� , ..� � HOUSF.SEWF.R CONNECTING TO BY � PRIVATE DISPOSAL SYSTEM � Signature WNNECi ADDITIONAL BL�G.OR � �' OWNER-BUILDER DECIARATiON WORK TO HOUSE SWFft 'I hereby affirm that i am ezempt from the Confroctor's�icense � �N��CESSPOOIGDNYWEDLLpIMANHOIE �Law for the following reason(Secton 7037.5,Buisness and Pro- ��? ALTEN,REPAIR OR ABANOON HOUSE ' 'jOf15 COCIB�: -. SEWER OR�ISPOSAL SYSTEM 1 ,.�I,as owner of fhe proper�y,or my employees with wqges as � � � iheir sole compensation,will do the work and the strocture � . 's - � is not intended or off)red for sale(Secfion 7044,Bosiness PermiT � � and Pro4ess�ons Code. OWNER�S � ❑I,as owner of the property,am ezdusively contruding with AUTHORIZATION TOTAL FEE /�f /� licensed coMractors 10 mnsiruct the projed(Seciion 7044, I Mqve ai irus Oq1E a coMRan wlrN rh�E HEREw NqMEo coNiRacraR o �t� J b.�Y1 � .Business and Professions Code). � CONNFCT THE AL'nVE�EXRIBED C%ISTING OWEILING TO THF GUBLIC SEW[R. �,o Y o � y , �. ' CONSTRUC710N LENDING AGENCY � !�.S7-` I hereby affirm ihat there is a construction lending pgenty � SIGNEDTHIS_�_�P Y O P �1., t _I9�� � � �;+�7,tJ� . :for t he per formqnce o f d he wor k for w hic h ihis permit is - � �k owNea oe t � , 955u6t�(SCC.3097,Civ.C.J. g ' /j�� ; OWNF.RS AGFNi r`�J) �1�-- . c , .,.L I,�t, `� �����lJ'M I 61���L�'K A[lDRE55 � 7 � �Y IM C G � �Lender's Name � ��^.��' "�7 . ;Lender's Address � ;I certify thot I have read fhis opplimtion and s�ate that the � �,a6ove information is correct.I agree m mmply with all County �� �,ardinances and State laws regolating PI mbing and Sewers, � rand hereby authorize r prese,a�ives o Ihis County to enter . jupon Ihe above e i ed pr e ty r nspettion por oses ,� � Sign v ermiffee Dale � SEE REVERSE FOR EXPLAttlATORY LANGUAGE � - ... - �. ., ,.y:::. .. .. ,.. ,. . . .... ....._ ., ... .. � ' . , m� DQ F hi D� � � �Q $� �� Z � � � �_ z a�o }�R^( �� oZZ v�� Zm O'O X A� 4]� � D � On2� v'D � �un � m � �c� 8''� zY' �� � 70 ' m D Y'".f1 �� mv n0 0 . 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