HomeMy WebLinkAbout0898A (4) WORKERS'COMPENSATION DECLARATION
I hereby oH�rm that I have o cerrifimre of coasenr to self
insura,or a certiiitate of Workers'Compensation Insurance,or ��<70 'l���
a cerniied copy�hereof(Sec.3800,lab C.) .}
ceeae;sev.ve�i qppIICATION FOR PERMlT "
Policyallo.���`� Compony ��C1/tQ4 r
❑Cer�����reby furnished. SEWER • SEWAGE DISPOSAL
�-Certified copy is filad with the co�nty building inspcction COUNTY QF LOS ANGELES Bl1lL�iNG AHD SAFETY
deparrmenr.
Date_I�`�"F�rAppiimnt G(Jw � FpR APPLICANT TO FILL IN ,S CONNECTION DA7A
CERTIFICAQMPENSATIONOINNSURANCE RKERS' �noo�s�s / 07 wiII6W'4f4ei �f• Suna+ � eevrt�
�This section need not be completed if the work involved 6y the p�R
permil is for one hundred dallars(E100)or less.) LOV'��TY � ' '�k �N�E���� / �
I cenify fhar in the peAurmance of the wark for which Ihis �AREST TYffOFCONNECTION ¢r�cTHipon�, �.
CRO55 SF Y. NRB P.L. M l.TO P.L I
permif is issued,I shall no1 employ any penon in any monnar -
so os fo become subject to Ihe Worke�a'Compenwtion Laws. v.c No. � ;
owr,�a r Q f m.u�w.No. ,oe no. �
q��u ,� iRUM(PERMIS NO ROAO PERMI7 hq. �
Oote�Applitant � 1
NOTICE TO APPUCANT: if, after making rhis Certifimte of �ioww* wwrvee EASFMEN7 acmao iNsm.wo wie
Cltt IVi�C �. TElNO. 7/�- G�'O
Eaemptipn, you shauld 6ecome subject to ihe Workers'
Compenwtion provisions of the tobor code, ou must fonhwith ��µ
COT I wtIF1 Su[FI Y ��RIMION LOTNO NWY pRST.WIDENING
p y provisions or this permit shai)be deemed ` �
revoked. eiocK rwcT b SFATE ENCROAGHM[M �
LIGENSED CONTRACTORS DECIARATfON No.a e�s RRMI
�here6 affirm that 1 am licensed under stxeovioT HowoH�o* � , //� �,J
Y provisions of Chapler ��� c+�ET
9(commencing with Secifon 7pp0�of Division 3 of fhe 8usi- g�qp�µr�5 C�uRc�s
ness end Aofessions Code,ond my license is in fu�l force ond
��e�' t7 CONTRACTOR Q�,y p�� CONNERION 61P11GE FEE
License Number .Z���7 7 L�c.Class� ��� r�uaeucsc�wr r�e �
COnhO<�Or t t✓ �a�e �I I���O� ��TY TE�NO OISiYKT NO. GROUF �,�µp sy u
5IATE �
❑1 om ezempt under of the lA.Co. ��N�� ci�ss f' /33 O y
PfumbinpCodeond/or5at. ofiha �- �ESCRIPTIONOFWORK �E aNA� �
1 HOVSE 5EWER CONNERING TO
8.8 P.Code fo�the tollowing reasan PUBIIC SEWER �� � DATE !/_Z O �� YAtIDAT10N �u �
SEPTIC FANK.SEEPAGE Ptt pt N �
�,a PITSAND/ORIXtA1NFIEl FINA1 '. )^����.�
HOUSE SEWEN CONNECTING 10 0Y ....,2.'> . � �
PitrvAiE D�5 A •T
$iQ1101YfC CONNER ADDITIpNAI&OG.OG �4 t • P � '� �
OWNER-BUILOER DECIARATION �*o�+ouu s�wcR
I hereb affirm ihat 1 am exem t from the CoNroctor't ticense �RkOW SEEPA�%T,DRAMFlEID � , g��F:.
V P E%TN,CESSP�,DRYWELL MANHOIE
Law for rha iollowing reaeon'SBffOn TO31.S,BUISf1BSS OlIA PIO- AIiER,REPAIR OR ABANOO�J MOU$F _ �
fessiOns CO(�a�: SEWER OR MSv05��WSiEh� . � - '�,--S
❑I,of ownar of the property,or my empioyaes with wogee oe i �,;!4!_:�5� �
their w!e mmpensation,will do tbe wwk ond the snucrura -
ic noi in�snded or offered fo.sole(Settion 70A1,Buainess
and ProPaxions Code). OWNER'S Permit S D Sp
❑1,as owner af the property,am exclusively contracting with AUTHORIZATION TOTAI FEE 2 7 $�O
Ikensed mnrracrors to con:truct the project(Section JO44, �µ�yF qT M�g ppg p�pN}RACf WITM iHE MEREN NAMEU CONTRAQOR 70
B�sinesa and Professions Code). coNNect rHe neov[oescRie�o existwc ov.�wrac ro r�rue�K s�wea
CONSTRUCTION IENDING AGENCY ► �
I hereby offirm Ihat there is o construction lending agency 51GNEDTH15 DAVOF �q_
for the performance of Iha work for which this permil is ��R�
IS6VBd(SBC.3097,CiV.C.�. �A �'�RSAGENT
_ // A; A�DRE55
lendei s Name__ .N
lende/n Address
1 cenify lhoi 1 have read this applico�ion and state that Ihe
above informatioq is correct.I agree to comply with all Co�nty '
ordirwnces ond State laws ragulating Ptumbing and Sewers,
and hereby authorize rep�esentatives of this County�o enrer
upon the above-mentionad properry for inspetlion p�rpuea.
�� / S
�Sign of Permittee Data SEE RiVEIISE FO�EXMANATOM LANGUAGf
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