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HomeMy WebLinkAbout1323A (7) � WORKERS'COMPENSATION DECLARATION ' � � ,� � � ' . - . �- � � � � I�hereby:sffirm that I have o certifiw�e of consent.fo self �� �� � � ' , � . ii,'.,ti�ie,or a certificato of Workers'Compensation Insurance,or , �bna<2n � ' � . . � � � a wrtified mpy rhereof.(Sec.3800,Lab C.) ce eoe�aEv d a„;��� , ��APPLIGATI�Of�t:�:FO.R� PERMIT � � Policy No.__ Company � � OOs � � ;� !�ce.�+f�ed copy is hereby furnished. SEWER - SEWAGE DISPOSAL .,�C rhfied copy is filed wi�th_t e counry building inspettion ": �. � GOUNTY OF LOS ANGELES BURDING AND3AFETY ���� � � � � � de t enl � � �y � . ��-. � �J�--Applicant �-:w�c� �__��✓ fOR APPUCANT TO FILL IN CONNECTION DATA � . � j CERTIFICATE OP EXEMPTION FROM WORKERS' AunDiNG COMPENSAiION INSURANCE . � no�aess � � ^!- STATION : �'/9 oevTH �,=�� (This seciion need not be completed�if ihe work involved 6y ihe n,wNHo�e eeFeaewce �� / UPVER . -5'� permit�s for one hundred dollars($100}or less.) iocnuTv iowea NEAP,EST C' TYPE OF(:CMNECTiON o LENGiH FROM - "r''I certify��hat in the performpnce of the work for which this ceosssr. e-l� ' E?, L�. y, cuea P.L M.LTOP.L ' �-pennit is issued,I sholl not employ any person in any manner - �- PC NO. ;�so as to 6ecome sobjed to the Workers'Compensotion.lows. ��ER 1 CO.IMP,NO. JOB fJO. � ��� � � MPA1 �� � �. �p IRU.VK PERMIT NG- ROAD PEkMIi NO- ' � . DtlfP. APPIiCa�t �', ADDRE55 _ t.. � '�� NOTlCE TO AGPlICAN7: If,��ofter makin tftis Certifirote Df - C � ) � '}C AFFNAVIT WAIVEP EASEMENT RCCORD.INSTR.NO. DATE g ' ciiv i C, lEL NO. / 1�., / .. Exemption, you �should become subject to 1he Workers' IEGn� �� Compensation provisions of ihe Labor code,you must forrhwith - _. nesceiPrioN ioTNo. � Hwv.oasT.wi�eNiN� � � comply with such provisions or ihis permit shail be deemed ' �o- ''7 '"iBVOkefl. ' , _ „^ BLOCK TRACT `,)� / STATEENCROhCHMENT � ' � LICENSEC�COMTRAC?ORS DEO_qRATiO�PI � r.x�.a�emcs. oearnir No- d SIZE oF tOt � f-' nIOW ON LOT �'9 hereby affirm thoi I'am licensed under provlsions of Chopte. r, �E�F � �9(commencing wilh$ection 7000)of Division 3 of the Busi- � ewtoiNGs cNnac,es - �nen and Professions Code,and my license is in full force and �� ��effec�. y J� a /n�7 � r.on�rAncTck �� '"' ` coNNeaiou cNaace cEE �, �LiCen5eNU1iIbEf�w W _LiC,CIO55L//�� : qDDRE55 �� REIMBIJRSEMEIJTFEE o' '.Contracfor.t�t � ` Dp18 . � i ��7y �� TELNO 71 ��' DISTRI�T NO. GROl/P MAP PROCESSED BV V �+� �y 1eK oG Z ' p�I am ezempt underSec _of 1he L.A.Co. �� LICENSE NO pC ")"l�� cins �'� "� L�a� .�.-^ O , PlumbingCodeandiorSea__ _ofihe M N� DESCRiPTIONOFWORK f�e �.ir�q� � •' HOUSE SEWER CONNECTING TO DATE VALID TION W . _ B.�&P.Code for the iollowing reason ,__ � �a Pusur sewea � y ". k, SEFi1CiAVK,SEEPAG�P;TOR FlNAi `t( 1 1 �_ '7�'. Da�e ,. PIiS AN�/OR ORAINFIELD - HOuSE SEWER CONNEGIING TO� 6Y pl� N`p ((� '',j.. =RIVA"F�ISPOSA:SYSTFM Signafure�_____ . � CONNECT n�plTl[JNAL 5lDG.OR � � OWNER-BUILDERDECLARATION i( W�kKro�+ousesewea LV'RF��W SF�PAc;E�T,URAINFIF(0 �l� :I hereby affirm that i am exempt from the Contracror's license �'� extN.,cessvoo�,ourweu,MANHoie �'' `Law for the fol�owing reason�Secton 7031.5,Buisness and Pro- � niiek REPaut oe aanNuoN HOuse � �':{: '����;�^,!'�.1e�. ' �, SEK'Ek CP.715,-vSA:_SYS:E,N , ��, ti: �❑�I,os owner of the properly;or my employees with woges os " , ' Iheir sole compensation,will do the work and the struct�re '°� ���� � :is not intended or offered for sale(Section 7044,6usiness �' �a Permit g Q '"a c""i ;i?3 A s''> and Professions Cade). ( OWNER`S � ❑;I,as owner of the properly,am ezclusively contracting wilh � AUTHORIZATION TOTAL FEE � �`� }�.c c o�m T C � r licensed coniroctors fo wnslru<t ihe projeU(Section 7044, �`. i Have nr rHis o.aTe a mNranct wiTH iHe HeReiN NaMeo coN aqCroa ra � - �'� ,8usiness and Professions Code). �; CONNECT ME ABOVE�ESCRIBEU E%ISTING DWEILMG TD THE PUOLIC SEWER � �,���'J�� � � CONSiRUCTION LENDING AGENCY ' '�� � I hereby affirm that there is a construction lending ogency :��' SIGNEDTHIS DAYOF _t9_ ► 3 ,; `'� �i��' � �;' for ihe periormance of fhe work inr which tnis permii is ','��" �'NFa�k � : OWNFRSl�GENI ' �j `issued(Sec.3097,Civ.C.). �� �����...Lj 6 �Lender's Name x� Ao�Ress _ i Lenders Address_ �,�;� .. � ;I ceriify ihaf I have read ihis application and stofe ihat ihe i" �above info�mation is cor�ed.I agree to comply with all Co�nty ��'.� - ,ordinanr.es and State lows regulating Plumbing and Sewers, �. � . ' a hereby authorize rapresentatives of ihis County to enter � , �-i u �n the obov meMi ed property for inspection purposes. t - � �.--.. �—;��_�Q "`" z,a Signafure of Permiflee Date . SEE REVERSE FOR EXPLANATORY LANGUAGE �� �'. „, .... . . ,. .. . 'A[i`.`^r^:.”.;:'..F� '.:. �,. ...�,v:.-. :5..: . . �� gN �� � �� c8 � - . . ... ., y^ za $p 'Y'` cn oi " gz �m' � o� Zm x .. w� zm o'�v° �- oi �� c � y 2� �n �c p m '� u ❑ �� OD ❑� o� 6 v U °p � �C ^ rK` p� � 70 Y'^�C, "�z N� � �-a-� �D � < y �06 ° � vr( �>Pj F �,� i N " � � � � � ` � � + • toi i v Q ' � � N � � !� m , 1 � � . ( � . . 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