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HomeMy WebLinkAbout0885A (4) WORKERS'COMPENSATION DECLARATION 1 hereby affirm that I have o cerlifica�e of consent �o self insure,or o certifiwte ai Warkers'Compansation Insurnnce,or ieae�zo . o�Q.�;f.�� ther of(Sec.3800,tob C.E CEBUB;REV.1/83! APPLiCATiON FOR PERMIT �� Pokicy No. � /3 Compony ..¢1f'�d�ig CJ/ ❑�;�;ed copY is hereby furnished. SEWER - SEWAGE DlSPOSAE � �Cerr�fied copy is filed wi�h the counry building�napection COUNTY OF LOS ANGELES BUILDING AND SAFETY deparlmeN. �. oo�B 1/;-?l�5�5�na,uca�+� FOR APPLICANT TO fill IN .�- r CONNECTION DATA , CERTIFtCAiE OF EXEMPiIOP!fROM WORKER eunpnG p� ''/Qw b ,� STATION �7�-'��/ oevn+ � i COMPENSATION INSURANCE po�Eu ! / �. (ihin sectien naed not bs comple�ed if the wor{e involved by the i�i�n, O(�/I@ 4 ���� /1 J � _ w R permit is for one hundred dollors(5100)or kss.) rypqppST � � TYPEOFCONtiECtION � �IJGTM FqMi I certify tha� in the perfo.mance of rhe work for which this cnosssT. r, cuaa P.L M.�.Tp►,�, � I permit is iuued,I shall nol employ any person in ony manner so aa to become subjecl b ehe Worken'Compensotion Laws. ��R v.c.ua. n i t d l co.�Ma.rao. ioa ruo. c� �010 Apptimnt MDeE55 /Q (p�� TRUNKiEfiMITNp. RORDPEqMITNO. NOTICE TO APPIICANT: If, after making this Certificme of �iTy Jt✓:�at T¢i-r+o /�/- �-a6 �pAVlt w�u�k FASFMENT at[Oxn rta5ix rq wTe Exemption, you should become subject fo ihe Workers' Compensa�ion prov�sians of the tabor tode,you must forthwi�h pExp���p.� �ot w. � HWY pq ST Wlp[NING comply with such provisions w�his permit shall be deemed �+ revokef�. BIOCK iRa�t J SiA7E F ACHMENT UCENSED CONTRACTQRS DECLARATION N0.OF BlDGS. RRMIS 1 hereby offirm that 1 am licensed under provisions of Chapier ��OFt�i �'aa�or /�jy us�or c'i(7 9(commencing with Secfion 7000)of Division 3 0#1he BU51- BUIIDINGS Q�g ness and Professions Code,and my license is in full force and BfSe[i. CONTCACIOR (�/kt� CONNERION GIARGE FfE Li[ense Num/be�r��27�tic.Class AODFE55 REIMBURSEMENT RE 6 � L Dme / 6 • oisraicr rro, crsouv � mnv moassFo ar Q � Contrador/'.E�G� arr rei no K � �� � Q 1 am exempt under5ec. of the L.A.Co. uT�Ns�rp. ci,�ss � � ,G E 33 � O � Plumbing Code ond�or Sec. of thg �� �SCRIPTION Of VJORK rE[ Fi� �K�cow�n�Ncm 7 � DATE I � VAllDATION � � 8.&P.Code for Ihe foliowing reoson SFPTIC TPNK.SEEPAGE PIT OR '�r �� y 3 � VITS nND/OR DRAMFIELD Fl� Z � FMtB IqUSE 5€WFR CONNfCTiNG TO BY � � P&IVATE�LSPOSAL SYS � �19fIG1UlB CONNERAWITIpNAI&DG.ON ,„ t � OWNER-BUII�ER OECLARATION WQRK TO MOUSE SEWER ��;„;;�'l, € OVEFFiOW SFEfAGE Gli,DNAINilELO � I heroby afflrm that 1 am esempt from the Comractor's License exru.,c[ssroa,oerwcu,r.u.r�mae �. • • . � �;: Law for the faflowing reason(Secton 7031.5,Buiartess and Ro- ntha.a�va�a oa qenHoow tious[ � �B�SionS Coda}: Sf WER OR DISPOSAL SYSiEM � y �� !.�)'r� ❑1,as owner of 1he property,or my employeea with woges as 1 rheir wle compensction,w�N do the work and the afrubure . � " -•: _ � is not intendad M offered for sale(Sottion 704d,Buainess g( � a�Professions Code). OWN�R'S Permit t /p ,fD .,.- !]I,os ownar of the property,am eztlusively conrrocting with AUiHORtZATION TOTAL FEE Q7 r0 f j /� ��CO�sB d COnhactors to[onsiruct t he projecl(S ection 7 044, i H�yE�T THR 0.5tE A CANTRAC7 WiTti 7NE�iERE1N NAMED CONTRACfOR Tp � BUS��lSS Ond PlOflSalOnS CAde�. CONNECf iHE A60VE DESCRIBED EXISTING OWEILiNG TO iXE RIBLIC SEWER CONSTRUCTION LENDING AGENCY � � I hara6y offirm that Ihere is o tonafrucfion lending agency S�GPIFDTHVS DAYOF 19_ fa• the performance oi the wark for wh�ch rhis parm+� is ��R� � /� pWNERS AGENi iilJOf�(S6C..����iV.�.�. ///// • 1 ADDFE55 Lender9 Name ;�� — Lraidar's Addresi 1�[erTify thn!f hove read this application and siata fhof iha above information is torrecf.I agree to comply with a!1 County ordinances and Slate laws regula�ing Plumbing and Sewen, and hereby a�thorize representotives of this County to en�er �pon Ihe obovrmsntioned properry for inspaction purpoaes. 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