HomeMy WebLinkAbout0513A (4) WORKERS'COMPENSATION�ECIARATION
I hereby'affirm Ihat i hove a certificate of conaeM ro self ��0°°Zorwars� A
insure,or a certificme of Workers'Compenwtion Insurante,or ��bno ll
a�e,�y ihereof(Sec 3800,r(p � `E� APpLICATi�N FOR PERMIT �s
Policy No. Company. U��,�'\'3 0a
❑Certified copy is here6y furnished. SEWER - SEWAGE DISPOSAE
p�p 0 Certified copy is filed with the covnty building inspection GOUNTY OF LOS ANGELfS B�JILDING AND SAFETY
de ortmenf. -
�Daro�L`L$3Appl�mnt _.�: FOR APPLICANT TO FILL IN CONNECTION DATA
� CERTIFtCATE OF EXEMPTION fROM WORKERS' awiwrvc sinnor+ oe�H
COMPENSAi40N INSURANCE no[mess � `�
- g(This section need nnt he mmplatad if.the work inuolYed by the -� - �an�p�F a�FEyENCE uwea
�permit ia for one hundred dollars($100)ar�ess.} ����T� � - tOWER
i certify that in ihe performance of�he work for which�his ��aps�.sssi - iveEovcoNNcerioN �NCTHFRom
permit is issuad,�shall not employ any person in aoy manner C Y• CURB v.i. M t.ro v.t.
; so as ro become wbject ro the Workeri Compensation Laws. P���� n
owr�a �O-Iry1p,NO, JOB ND. v�
� MAII T2UNN PERMIi NO. ppAp P(pMIT NQ
- Date Appiicant ^o�� 4�
p AFFI�AVIT WpIVER E45EMENT RKORO.T15TR.NO. DATE
- NnTFCE 70 APPLICANT: If, after making this Certificate of �ir } C tei.No. 'p—�� ' ���
� ption, you should betomc subjec� to the Workerg' tEGnt . . '�. . . -
.pensotlonprorisioncof.ahelabo�toJe�youmustEorxbvai�h oes[p,oriov lOTNO. 11Wv ORST WIDENING
romply with suth provisions oc�his pe(mi/shall-be deemed (
reVoked. BLOCK TNACf ` � STAIEENCROACMMENT
LICENSED CONTRACTORS�ECLARATION " � tao.oF e�ocs PE4MIT NO
SIZE Of l07 NOW ON tpT
I hereby offirm fhat I om ticansed under provisions of Chapter ��
9(tommencing with Section 7000)of Divisian 3 of the Busi- Bu�iowcs � � CHARGES
ness and Professions Code,ond my license is in foli force and �
C��� � �OM1INERION CNAq�i{E
/ [OMRACTOR
license Number`� � . Lic.Ciass,4�l � }
I{s AOORE55 '�' ( . REiMBURSEMENi FEE O
COfitfOClOf!4J'�,�DOfC,��,_� ` DISTRICTNO GFOLIP MAP PROQSSEOBY (�
CfrY ( TEl NO . gK PG Z
SLATE IIC.
❑1 am ezempt under Sec. of�he L.A.Co. ur�Nse No. cu55 `� (�.,� �
�� DESCRIPTION Of WORK FEE F'
Plumbing Code and/or Sec. of the onri� � VqLIDA �N W
NOUSE SFWER CONNEC7ING 70 a
B.8 P.Gode for the follawing reoson P�g�����R �Z-����y�
Sf�TIC SANK.SfEPAGE PtT OR N1
PIiS ANO'OR DRAiNFIELD FINAI � Z �.
Date . tq��y�a cowNecrmie ro 8Y
PRIVATE DISGOSAL SVSTEM
SIOnOhlfe 1�. CONNECT AO�RIONAL BLDG OR � .
OWNER-Bt11lDER DECLARA?ION worzK ro r+oos€5[wEa ',,
OVERROW SEEPAGE FT,ORAiNFlEtO
1 hereby affkm thal I am eaempt irom ihe Coniraclor's License EXTN.,CESSFOOL,DRYWELL,MANHOLE
Ln�+.{or the follawing reason(Secton 7031.5�BVISfiC55 afld Pf0- AIiEB,REFAIR OR ABANOON IKKISF �
t tflb COd@�: SEwER pR DISPOSAL SYiTEM . .. . .. �
f
�J I,os owner af Ihe properry,or my employees with wages as c C V i�� 1
iheir sole compenwtion,will do Ihe work end the structure j
is not intended or offered far sale(Section 7044,Business !
and Professions Code). OWNER'S PermiT y SL., �;• • o • i L, �
�I,as owner af the property,am ezdusively coniractin9 with AUTHORIZATI�N TOTAL FEE � Q � •+�(5 7
�icensed mntmtlors to tonstruct�he projec�(Section 7044, �H,qyE p7 TH6 OATE A COtdi¢ACi WITN THE HEREIN NAMf�COM7RACTpp i0
BuSineA ond Profe55ion5 Co[JeJ. CONNK7 THE ABOVE OF,�CRIBEO fxISTING�WEIUNG i0 THE GUBLiC$EWER .�� .- -
CONSTRUCTION LEN�ING AGENCY th � � �r �'"`-�"
I he�e6y affirm thot fhere is a consiruction lending ogency 51GNEDTH15 DAVOF 19�
for the performance of the work fo� which this permit is ��R OR � ��Q 4-�'Fi
OWNERS.,GE�+, t
issued(Sec.3047,Civ.C.). E�� .` .�
�'�' ADDRE55
Lender's Name `-�^� i (CC7�d � �
Lender's Address i Ol5 �C?��'��QQ��
1 certify that 1 have read this ap licafion and stote that the
above informotion is corrett.I agree to comply with all County
ordinances and Siote Iows regulating Rlumbing and Sewers, i
and hereby authorize representatives of this Cvuniy to enter
upon ihe above-mentioned property for inspection purposes. �
�.C , `1-;a�-4� �
Signafu�e oE Permittee Da1C SEE REVFRSE fOR E]IYLANATORY LANGl1AGE j
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