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
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