HomeMy WebLinkAbout0894A (4) WORKERS'COMPENSATION DECLARATION
I haraby affirm that 1 have a certificote of conaent to self
insure,or a cenificote of Workers'Compemolio�Inevrante,or ��+�+�� ,7�
acartifiedcopy thereof(Sec.3800,La �, �EBOB.REv„�; APPLiCAT10N FOR PERMIT �
Policy No��q�Company�xa.a.�
0 ca°�a�f�6 here6y 4wnished. SEWER - SEWAGE DISPOSAL
�'Certifisd copy�s f�led with Iha to�nty b�ildi�g inspection COUNTY OF LOS ANGFLfiS BUILDING AND SAFFTY
deparlment.
Da�e ��'��'S� App���om W"/���.�'�/ -r FOR AAPIIGANT TO NLL 1N f-�}� CONNECTION DATA
CERTIFtCATE OF E%EMPTION fROM WORKERS' g����
COMPENSATION INSURANCE rou�s5 � OI L{JJ AW(�q� �r RATION t G� ocviN
(This section need not 6e complatad if�he work involved 6y the i��n, �a 4 Ny{NFplf PEFERENCE � �R
permit is for one hundred dollars(5100)or(ess.)
r�at�sr nce or cora+Eaan �r+c7H woM
I certify thot in tbe performance of the work for which this cvoss sT Y. CURB i.L ML TO P.L.
permit is issued,I sholl not emplay any person in ony monner - P C� ���
so os�o become subjecf to the Workeri Compenwtion Laws. pwwEq �tl� CA uw.r10, pe mp.
AODRESS O KJ TRUM(iERMIi N0. AQM PE4IMT ND.
Uale Applicant � �
AFFIDAVIi WAIVER EASfI.�ENT 4EC04�.INSTB.NO. DI.TE
NOTICE TO ACVUCANT: If, ofter making lhis Certifimte of �itY�f ' rEi-up / -(e(�O-D�ili
Exemption, you shonld become subjac� �o �he Workers' iF�i
Compemation proviaione of�he labor code,yoo must forthwith p[$�RIFf10N, lOT NO �� ywr.ae sr.wioemnlc �
comply wirh such provisions or this permi�shulF be deemed �.
revoked. azocc iN�CT Si�iE E�'KNOACNMENT
,K
LICENSED CONTRACTORS DECIARATION ���&��
PFRMrt
size or toT Now ori im
I Nere6y affirm thnt I am licensed under provisions oi Chaprer �� /� j
9(commencing with Sectlon 7000)of Division 3 of the Busi- ��ipi� ��5 a
neas and Professio�s Code,ond my license is in full force and r
BffeCt. (///���� I CONTR4C70R J {„� �({f CONNECTION CHARGE FEE �
Litense Num6er � 7 �ic.[Ioss� ADORESS REIMBURSEMENT F{E 6 �
n o�SmK'�NO. G�+Wv MAP
ConKacfor �✓ Da�e ���.7-�-ZJ� �ITY TEl NO. pr1 D Bv � �
.2 (�K PG
❑i am ezempt under Sec. of Ihe L.A.Co. ���� cuss � J �� �;��, Cuq.�ty� O 7
NO OESCRIPTIpNpF WpRK FEE
PlumbingCodea�d/orSec. oftAe qNu / � �
MOUSE SEWFF CANI�CfING TO //��'F`�� �
ruauc s�wea / � °AiE � VALIDATION u�
B.&P.Code for the following reason / �-c.� �
s[rT�xawK.SEeoaGc wr Ort
�re VITS AND/OR D9AINFIELD F��
FqUSE SEWFR WNNECTING TO BY � ._ :,`-Y G I�L, �
PRIVA7E�ISPOSAI SYS?E
Signature CONNECf PDD�7�W�u�etW ON h s s • a � `�
OWNER•BUILDER DECLARATION xroRK To erous�s['^'E°
OVERFLOW$FEiAGE%T,DpAINF1EL�
f he�eby affirm that 1 om exempt from the Coniroclor's License exm. assroa.�arweu.nn.aNHae f - ' ��
Law for the following reoson(Secton 7031.5,Buisneu and Pro- urtR aev�ip pc ngnHppN Hous[ ` ' ''"
feuions Code): s[w[a a+asaas��srSTe.�n a . -�,_
❑I,09 owner af the property,or my employee5 with wapes os ` � � '� � �
their sole compensation,wiil do iha wwk and the snut�uro ( i,i�-�•{ �
it no1 inrended or offered for wle(Section 7044,B��ineu �
and Profeuione Code). OWNER'S Pefmii S b O
❑I,as ov/nar of�he property,om ezclua�vely tontracting with AUTHORIZATION TOTAL FEE 2 Sa
licensed contracron to consrruct rhe project(Sect�on JW4, �H�yE AT TNIS DA�E A CONiRAR WITM TNE HERE�N NAMEU CONTGAROR TO
Business ond Professions Code). con+r+Ecr r�aeovc oesc¢ie�o ezisr�nic owewnic ro mc vueuc s�urtc.
CONSTRl1CTtON LENDING AGENCY �
I hereby offirm that there is a consfruction lending agenty SIGNEDTHIS DAVOF i9_
for the performance of 1he work for which this permi� is rn�ERoa
issued(Sec.3097,Civ.C.).
OWNERS AGEN7
Lender'a Name /t�/� ���
lendw'e Addreas
�
1 certify fhaf 1 have read this opplication and state thot the
ubave informaiion is correct.1 ag�ee to comply with all County
ordinonces und State laws regulating Pl�mbing and Sewars,
and hereby aulhorize representelives of ehis Co�nty ta enter f
upon the obove-mentioned propeny(or inapetlion p�rposes.
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