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HomeMy WebLinkAbout1364A � WORKERS'COMPENSATION DECLARATION � � � � . � �. -� . ' � � � I�hereby �ffirm li'iat I hove a cerfificote of conseni to self��. ' �� . �,, � Insure,or,o certifi<a�e of Workers'Comp��e n��n�rante,or.._ lanaszo . . . . , . . . Pol crfified co y e t�pan800, C.) � .. ..�Eeoe�aE�,8,g�� . ::.�`APPL�ICATION: FOR���.:�.PERMIT ._ . . - �p.��_c tL{c„ � �� y . : -��� couNr SEWER - SEWAGE DISPOSAL ' � ❑Certified copy is hereby fumished. . � � ���� 0 Ce�rfied copy is filed with�he coonty building inspection Y OF LOS ANGELES BUILDING AND SAFETY • departme�i. � -• -Date Applicant_ FOR APPLICANT TO FILL IN CONNECTION DATA CERTIPICATE OF EXEMPTION PROM WORKERS' e�uoiN� � � i sanoN oEPTH COMPENSATION INSURANCE .. � aooaess I 11 I 1 � �V� � . UPPER � �'��his section need not be completed if ihe work involved by the � � �, vaniti0ie rze�uFNce �owek � �ocnutt -'� permit is for�one hundred dollars($100)or less.) NEAaEsi ivaeoFcoNNecnorv �Ncni Faonn '1 certify�hat in ihe performance of tfie work for which this ck055 SL � ' Y���� v. cUae P.i. no.:,TO P.�. permit is issued,I shall noi employ any person in nny manner . P.c.uo. . - '�sb as to become su6ject to the�Workers'Compensation tows. OwnEk (�l 1�� � �� CO.IMv,NO. JOB NO � - MAIL � � L r TRUNK PERMIT ND. ROAD PERMIT NO. , �Da�e A IiCatlt ADDi1ES5 PP �-y-� AFFIDAVIT WAIVER EASEMENi RECORD.INSiR.NO. DAT[ -' NOTICE TO APPLICANT: If, after making this Certificate of �iTy -,-� t.No. �p v r�� ��mption, you should become subject .to the Workers' � �EGat �ipensdtion provisions of ihe�Labor wde,you must farthwith �� � oescaiviiON tot No. nwy.oe sr.wio¢NwG . `-; 'comply with sach provisions or ihis permit shall be deemed (/ c'[�,, . �'�-���'"'l9vOkE4�. . , BLCCi: iRACT iJ $1ATE ENGROACHMENT ,,;���, . NO.OF BlDGS. FERMIi NO. LICENSED CONTRACTORS DECLARATION ; SizeOF�pi r+ow on�or _ _ ''��i 1 hereby affirm that I om licensed under provisions of Chapter ._ _� �E eP . - '.'.-9(commencing wilh Section 7000)of Division 3 of�he Busi- euuoiN�s cHneGES � � 'r ness and Professions Code,and my ficense is in full farce and . ' ' CONNECiION CHARGE FEE � } �•�"effect. T� - CONTRACTOR � +j REIMBURSEMENT FEE u , �� License Number � �`� Lic.Class__ � , � nooRess �ISTRICi NO. GROUP MAF GROCESSE�BY ��• COn1�4CiOfg cz���/'��P�O � CIiY iEL.NO. BK PG (� Z , STATE �: LIC. �\� O . � ❑I am exempt under Se<. of the L.A.Co. . ' uceNse No. � 7l «�S �:� �A�.- .�� � , Plumb�ng Code and/or Sec. of fhe . No. D CRIPTION OF WORK FEe Hous�sEweR mNNecriN�ro f �V �aTe `y f 5,�/�� VAIIDATION � � B.&P:Code for�he following reason Noeucsev�ra /! / SEPiIC iANK,SEEPAGE PIT OR HNAL ' � - PITS AN�J'OR�RPINFIEI� aY i � . � DOie _ , � FipVSE SEWCR CONNECi1NG i0 �.p� � � PRIV�iE DISPOSAL SYSTEM ' $19natUfe . CONN.�i nDDI?IONAL Bl'JG.OR � � � 01NNER-BUILDER DECLARATION woRK To nous[seweR . OVERFtOW SEEPAG[PIT,DRAINFIEID �, I hereby uffirm that I am exemp�from�he Contractor's License ezrN. cessvoc�oPvweu,MnNnoie � ��Law for the following reason(Secton 7031.5,Buisness and Pra SEW[R OR o15Po9ntBs 5�e��oUse ons Code)� � �- �� ��I,as owner of ihe oroperty.or my employees with wn�Pc n� �� �heir sole compensation,will do the work and the sirucfure is not intended or offered for sale(Sec}ion 7044,Business , OWNER�S Permit $ ('} ,;,`A I . ��4,!- i ' ' and Protessions Code). ` � ALITHORIZATION 7' ' � t' �,�I,as owner of the property,am ezdusively contracting with � OTAL FEE . �� � 2'].5 C licensed controciors to tons�rucl ihe project(Section 7�4d, � �HAVE AT iM15�ATE A GONTRACT WIiH THE HEREIN NAMFD CONTRAClOR�O . ���ut BUSiness and PrOfeS5iOn5 COCIBJ. CONNER THE ABOVE OESCRBED EXISTING DWfI'I�i0 THE PUBLIC SEWER. '' " `"== �•�+•. t ' CONSTRUCTION LENDING AGENCY �y�—/i�, �ii�r,(�Ll—�� >,�I hereby affirm fhat ihere is a consirucfion lending agency SIGNEOiH15�__DAY OF��� • 19;I ? OWNER OR ` i ��'.for.the performance of the work for which this permit is - owrveas ncFNT_.�{'�e'^�G t'�'"' �•'" ("i�` ;��-issue d Sec.3 0 9 7,CI�.C . G� � /' � � y���,y noozEss ?i! �a Jw t4� v c. 9,1 ��l 1. ������tender's Name ���)�lj l�� �Q!v�«v� � �����Lender's Address_ �� �f-� . � •' � � �>��.I certify that I have read �hls appllcatien ond slate that ihe ? � �.��above iniormation is rorrect.i agrea to comply with all County . ? `�.�ordinances and Stafe laws regulating Plumbing and Sewers, � < . ",�,and hereby authorize epr entatives of lhis County to enter 1 �:'upon the abov -me�ti ned r rty for inspe tion urposes. � : � � ' Signature o Permiitee Dafe SEEREVERSEFOREXPLANATORYIANGUAGE i � 7 ... .. ,. . .. : q C - .. �� ��,�A � o�z� � _ . :�� xo �- � �; �,� � � . .. � �� pjm Q� r OX F � � ( �p . ... 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