Loading...
HomeMy WebLinkAbout1075A (5) _ _ _. _ _ WORKERS'COMPENSATION DECLARATION � � �� � I hereby affirm that I have a cartifimte of consent io self 92-000s ovw sis� � � � .� � � insure,or a cerfifimte of Workers'Compensafion Ins�rance,or �6A699D � .� a cer�ified copy�hereof,(Sec.3800,L,�j�, �y/� ���°�B � - �� � � .APPLICATfON FOR PERMIT � � � - PolicyN W 7D�i'rS��ny_ ��7e�3G7/�`f.i�1.Q /IT✓� ..�s . . .� �. � :.., . ❑Certified copy is hereby fur�;5ned. . .. SEWER - SEWAGE DISPOSAL . � � �- - � �.Certified copy Is filed with the coumy b ilding inspection ..��COUNTY OP LOS ANGELES BUILDING AND SAFETY: � ' ' "" depart �, �� � ����y-� Da�e � �f i��"�4pplicam FOR APPLICANT TO FI L IN CONNECTION DATA CER�FICATE OF EXEMPTION fROM WORKERS' COMPENSATION INSURANCE �DfDRE55 (j'.�f,(q/'� sranoN �EPTH (This section need noi be completed if the work involved by the / MaNHo�E REFERENCE ucaee ' peimit is far one hundred dollars�$700)or less.) �ocnutr �` �,Ssr(/ G-- tOWER ' I certif th0� in the erformance Of ihe WOfk f0�whlCh fh15 NEARESi TVPEOFCONNECTION LENGTHFROM � Y P CRO55 ST. (f J Y. CURB v.L. M.l.TO P.L. � permii is issued,I shall not employ any person in any monner ec No. so as to become sobject to ihe Workers'Compensation Lows. . , pwNPR ���� - / ca innP n10, �os No Q(;1 f DaiB Applicont A�DRE55 ✓���JQ��/ .�3,� TRUNKPFRMITNO. ROA�PEHMIiNO_ q'Zb%,�+'� . NOTICE TO APPUCANT: If, ofter makln ihi5 Certificate Of� t,(� -� "l'1G,_� (3 AFFIDAVII 'JJANER EASEMENi NECORD.INSTR.NO. DAiE ' 9 GIiY �.Y TEL.NO ��Z) ✓.�� Exemption, you should become subject fo the Workers'� tE�Ai � Compensation provisions of the Lobor code,you most forthwi�h. oescaiarioN ioirvo. Hwv.oesT.wioeNiN� � comply with such provisions or Ihis perrqit shall be deemed � .o„�bo�l � o�n.� .�.�, LICENSED CONTRACTORS DECIARATION V v rdo oF e�ocs. e�RMn�No.V��.�,������ . SRE OF LOT NOW ON LOT � I hereby affirm that I am licensed under provisions of Chapter� . use or '�_.__ .__ _ -�-�9(commencing wilkSection 7000)of DiJision 3 of the B�si-; ouimiNcs �HARGE$ ' � ness and Professions Code,and my license is in ful�force and�. L'Ff2[�. . �f� _ ('pNTRACTOR �'t'%' ��� � GONNEGTION CHARGE FLE Y . //' � License Num�b/er' C CIa55 ADDRE55 � REIMBURSEMENT fEE a Coniractor�f�' �+�� � � �ci NO GRoua M.4F PROCESSEo ev p � f� i I ' ��� r �� � QTY �� /LC.S� iEL.NO. � � 'i('"�� AK PG ) �' . LJ I am exempt under Sec. of t e LA.Ca. ucETnEise No. anss (,� �r�1S�� V O Plum6ing Code and/or Sec. of ihe N� DESCRIPTION OF WORK Yee riNat � U HOUSE SEWFR CONNECTING TO UA(E W � B.&P.Code for the following reason PUBLiC SEWER VALIDATION . � �PTIC TANk,SEEPAGE PIT OR � � 7175AND/ORDRAINFIFLp b+AL .;�' � ......... "_"_._ .. - HOlISF SEWER GONNECTING 70 / PRIVATE�ISPOSAL SVSiEM ' $IOIIOIUfe �/� , � �•' CONNECi AD�IiIONAt BLDG-OR , ' , OWNER- UILDER DEC�ARATION woaK ro House sewre .I herz6y affirm that I am exempi from the Contracior's License EO%RFLC�'SSPWLGURYWF.LRAMANI OLC Law for ihe following reason(Secton 7D31.5,Buisness and Pro- atiER,R6PAiR oa nenNooN HousE � feSSlOnS COfIe�: SEWER OR p15POSAI gSYS�i/EM�� , �i,as owner of the propertv,or my employees with waaes as �YNZt�-C� , �� their sola compensation,will do the work and ihe sfructure . is nat infended or offered for sole(Section 7044,Business r� �l%,,F,�'•, � ' and Professions Code). OWNER'$ PCrmit g -� � � �. I,as owner of the properry,am exdusively mmrocting with AUTHORIZATION TOTAL FEE ;� v'7j '�° " " '�° licensed coniractors to construct fhe project(Section 7�44, I HqyE AT iN15 DAiE A CONIRACi WITH THE HEREIN NAMCD C NTRACTOR i0 f h .I v 1��`\ � . BI/SInC55 a�CI PfOfE5510f15 COCIe�. � CONNECT iHE ABOVE UESCRI9EU EXISTING�WFLIING TO THE PU6LIC SEWER. x� � CONSTRUCTION LENDING AGENCY I hereby affirm that there is a tonstruction'lending agency SIGNED THIS �AY OF 19_ , °V "' � v��,t;ti� for the performance of �he work for which this permit is ��'`'NE°oR issaed(Sec 3097�ClV,C.�. OWNENSAGENI U��(�_,��� FlDDRCSS Lender's Name Lender's Address ' I certify�that I have read ihis applica�ion and state that the above informafion is correct.I agree to comply with all Coonty , �ordinances ond$tate laws regulafing Plum6ing and Sewers, and hereby authorize representatives of this Coumy ta en�er , � upon the qbo -mentioned roperiy for inspection pos q. . ' ,�����- ����-- SignalU e o Permiitee Dof SEE REVERSE FOR EXPLANATORV LANGUAGE :.. ,. .. .. ; s��y A� `� � os oS � ' . ., . . .. 9�{OZ mm � '�D nl-�i o � Zm Ov UZ p➢ m � `` 4 v ° � c�iJO � T`�p� 5 � k � V Qn OC r� m? n� � � � � . r�. Z mD vim O o� RY � � I $o�Ao mR � N �, ; a � � � 4 N : b � � m ' ,u ;r � � � i' Q � I m � � ` � � I� � w t � �� � � � '� � � , . ' . . ' . . . ... � � ,, , E . � I1 � �1, � � I I� ? � ► P'yI S � � ap I ' � � � � { � � , %� ��. � ` � � . � I . ' .I� � ' � h � S i � �. � } 1�a . SV � � � . � .. / � � r tl . � � � � � � u�"s � 1 , �% 4 . . { .' �` O . � � t , ! '� � . � � � � .� � ?i El ' � � � � = � 1 i �+ � � � . i �, �I y I � '' i ' i � `� ? , � i w. � � � , , � � ; ��. � E :: � `n A iy��' ITSL" . �7 . � ' �� �a c+{��� y m a„ r'., 6 e.< C�13 rn by .�i C�q Ct�{l^��O��O� � �� O � yj� n "' /i � . .�`'`° .Z..� e�s C �•, n ^1 LJ��•p m �� �.p, ° ``C cxs vs, M � . j'� '�"�'��� °�� v � r"�'�, .��, � . � �•,, :^ " m . . - . � \�` � � � � :� A C �+pq tl'c��^�-�p.��R.4 p � A � y .Aa.w'a� � °'`4 � .* � � a � a -s t+�.-.. c �`% c�'�wax o �s � z �ci.g �" �. . . � -� . '. ..�` �'� t�p .� :� proq aR a' a „s �..`�a�", w O A'�a m.�1.A'�`•.a ,t �n so n �. c. w a co �' �S Si+�� +�� 24`�tT'�.� 4 � �, �� � � � mA��� w2 � d' � w 3�Q 't° ..�' AQ`o,7'� '��' � . �.,..z. m b, A � g m � � p n o m.,,�� .* �hS A ;a m � to ' � O � S O.� A.�p ��� � .,E a .'� 4„� Cn 0�b,�� �g y ra,re �rt ,. . . ���� { �! ^� ta Y ,�q�^��c��. �^o-on^n."�'p�i .�S �'�'.i2 p o A aro `d � . �''�.- ,` '~y % � ! � � s"� °c � a� rt �o u "`� � 'a a.���:� 0 5 tp7p( . L ' i�, l6 N `�R W 9 i1 tl S' /+e .. � � � � ` � Ca. �,:�,�.`���"� a.�o.,d o�.�"� c^, n e,� " a t)a•� ! � �4 � p'» a �'� " 'C1 a.a •• �.4 s�° .v.'�^`...o�,n°�,o aap � ' �.. � �, � t 1 � t6; « A,�,�a� o'=.° m b �.o y`�r"° � � �'=;ro � „`.J'. ,� Cea {k� @'� u C9 �N aw�q ,rs.. ro eR F, `O N'� � rw i �. i } i � 8 f)� R C ^: .g�^ N O�w° � ro O � �n �:3 .�-'p "4 C�e a a -x c n � o � i�/_...-�---'-Cl� } � � � � �� �� "`' s-°`�' o'n 2 .K,"c�+�: h.``"w �,a"�.`.�,.ti � � Y - ' � .. . .. . 9 �,y ' � � � ' 'o �.� m ��y w � �`��iY.L�`l�m Rg'�� �� �" . . i �' i � q . � o`� G�y c �m � � �"� '° >�,'.l.to �` . f � ; '_'S� �. ({ � V, a a'`w�'°� o o ca a' ��� �,�'� ;� �e ;o�i�*eS �.�1 .. . . � 1 �t (p � `1 i � .''`x� � � .� p�'! � o, � m.o' a:9 °•7"'� �'7 y � � � 1 'b S�� s a v, `'. �r-'.� �*`° w $ � i i�+y o a. ° °Zr �� �+ '� � ��,�,' s r. �'� ,.�,`^ ry . , r � � 1 . C �"m � o O �� o A O iE w Fz � �'tl.O n C, � S _ S :'^v,�y,� m � 6� N � �°�p ro`�r� ��'� o � :"O .. , ! 1 � � .. ^A"Y cS'`� w a � p, � i:`2�� �co a ro A`Z u m f � .. vj ; �,� i ; � m�°,m � �,�" ' ����� �; � � � _.4.�`�'„���5' (e 1—=_._r ��o