HomeMy WebLinkAbout0899A (6) 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
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