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HomeMy WebLinkAbout0899A WORKERS'COMVENSATION DEQARATION I heraby offirm thot I have a wrtifiwte of caisent �o sslf `'� insure,or a certifimte of Workera'Compenwtion Insurance,or ��6�Z� II o cenifiad copy�hereoi(See.3800,ta C.) CE B091REY vea; t) Po,;F�ry�lrti.ON Company �.kt APPLICATION FOR PERMIT �Certi(ied copy is hereby furnished SEWER - SEWAGE DISPOSAL .�Certified copy is fiiled with the counry building Inapection COUNTY OF LOS ANGELES SUILDING AND SAFETY depor�menl. oate//'ZI-SS qpp��co�i_�+�/�'��t.rP_rw FOR APPLICANT TO FILL 1A1 ,s" CONNEC?ION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' �iioi� r� COMPENSATION INSURANCE noo�ss I �IJ �:� oQ:G� ST°T� Q o�m� (This se<non nsed not be comp4eted if the wark inva4ved 6y the � ���� � µ4ryF�plEREFERENCE � u°°ER permit is for one hundred dol{ara($)00)or lese.} ��'��TM I cenify thot in the performance of�he work for which this C�vuST trvEaFca�^�criori IEI�GfNFNOM Y. CVRB P. M.LTOP.L. p6rmit is issued,I ahpll not employ any person in any monner ��� so os ro become su6ject�o the Warkers'Gompensatian Laws. pW�R- �.�( co.xi�v NO. �oe r o- , Date Applicant AOORE55 (��O. � �L TRUNK fEkMR Hp. ROAD PFRMIT ND �, NOTICE TO APPLICANT: If, afrer makin 1hi3 CG��ifiCOfC of AFFIOAVIi WAIYER EASEMENT RECORO INSTR NO DATE i 9 ut. rr..< C�-. �.w 7iv- 6Go-oG6p E.emplion, you should become subject io the Workers' tecu Compenwtion pmvisians of the labor code,ynu must fonhwith pEKRiar�pa �ot r�o. ]O Hwr.at sr wioewr� � comply with auch provieions or this permit shpll 6e deemed I rovoked. eiocK *a�cr 33b s SfATE FNCRpACH/J(NT � UCENSED CONTRACfORS DECIARAiION b.oc a�n�s. reR iT N° � i P 5�ff��o, �W�.o, �l�lI-z� 1 here6y affirm ihat I om licensed unde�provi�ions of Cho ler �� i 9(comrnencing with Soclio�7000�of Divisioa 3 of ihe Busi- gunOrnGS CH�cCES � nass and Professions Code,and my license is in full forte and i affecr. �! �T��� Q��a„� CONNECTKKJ CFIARGF fEE LicenseNumber ���7 lic.Class� ± pppp[5S RE�MBUP$EMENT FEE � aiiToia rq. caoun µw Comractor�Dare 1/-�-I-�S ary TEi.r�o. �� sseo ar 0 sTare uc u � ❑I am exempt under Sec, of the L.A.Co. i���� �i� � p� C �,3 � HO. �SCRIPTION OF WORK FEF � G Plombing C6de and/or Sec. oi�he riNµ � Q "°"s�s�"'E"�°""En'"�To °"h i YAtIDATiON F" i 6.&P.Code for the following reason vusuc sewcR /7 — ,��Z p_�� t,i � SEPnC TANK,$EEY�GF ViT OR W I PITSAND/OR WlAINFIELD F� 6' I Daie !q{J$�gWER CONNECTING TO Br � "hj PRNl1T�015 SAl YSTE i� - SlgnCfU!@ COwVECT A001TIpNp1 gIOG.OR � OWNER-BUILDER DECIARATION P✓OrtK TO NOUSE SEWER ' WERFLOW$[EPAGE ViT DIlqINF1ELD I hare6y affirm that I om e.empt from the Confractor's License exTN,cesswoi oavJ,rtu M.cNnoie ( Law for the following raaaon(Sec�on 7031.5,Bui6nBS5 Ond Pro- AITER,REiAiR OR A9�NWnr HOUSF �"�'��4�`%�� i fefsions Code': sExha OR oisaDS�t Sv51EM �; � . . . i !; 1 ❑I,as owner of ihe property,ar my employees with wages os - � �beir eole mmpensation,will do Ihe work and the siructure y�;,/., is nol iqf�nded or offered for sole(Section 7044,Business � ' ( and Profeu�ons Code�. (3WNER'S Pef��� S O S � - - - � ❑1,as ownar of the proper�y,am exclusirely coMracting wi�h AUTNORIZA710N TOTAC FEE a,7 S� -� '�' '" ; liceosed comractors to wnstruct the project(Sec�ion 7044� {NAVE AT MIS�ATE A CONiYACT WITH THE MEREIN NAMEU CONTRACTOII TO BusineSs and Professions Code�. COnINECT TNE ABOVF IXSCRiBED E%i57iNG DWELIiNG TO tHE PUBUC SEWFN. I �._i—�}` , CONSLRUCTION IENDING AGENCY � I hereby offirm Ihol thera is a conslrucfion lending agency SIGNEDTHIS DAYOF 19_ for the performance of the work for whith this parmil is ��R� OWNERSAGENT issued(Sec.3097,Civ.C.j. ��/,A �y ,�� Lender's Name lond�r's Addrezs !tertify thot 1 hove read this opplimtion and srote that fhe obove infwmation ia cwrect.I agree to comply with all County ordinantes ond State lows reg�lating Plum6ing and Sewers, . and hareby authorixe representotires of fhis County to enter upon the above-menHoned propeny lor inapecfion purposas. ) ' .� ature of Parmil � Dot� SfE REVERSE►OR EXIIAl41TORY IANGUAGi I ! ,` � \ _ �� � '� \ �. . ::s�-_ ._ ; � , , . C ,! _.:{.y-. " y" ` ( .\ c .� ' ,5.,• ' \� � y , � �-L' �_�4 . . G, ' \f1'� F M," f~ •T`. ' ^J, i `C. ; - ,\ �� \ . �� ��a�^.� . ir. •» M' _ 'LY„ r.. 4� - � , ✓` �'1� ��t� ='��`'� ,. ,�`^:J.V^ 'N �y , . '';, G — — — ' t,,,=„_i=..._ .. _ ^:r... , � "i �' "'C�C� G. ���� ,. 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