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HomeMy WebLinkAbout0894A (6) 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. �`1' ��'�� �/•,�r�S l c;ti...tr �o_.�:.._' ppta SFENfVFRSEFqEIfPtANATORYLANGl1AC•[ r.�.:....o.,.�..��v�—._ % v ; 1 , I 1` 1� ' 1'1 , . . . . + � C' :,[4:-, c 5� �~` � �� � ` � • ' . , � :4 � ' ' � _c '"G �a C- L. �• ^� T ' ;3 � ' ° ' � . . , .� '-_= c• � - �� � � y r .. Ci- $ ' , . ' �^• � - _ �ar. .. . C.. ti _ ,. ' 1 � . rG C � _ ,� ;.r ~� ���F .. L � .. - �� ' . . •' Ef, � _ ,.f�c.'_ .' �-L^, '?�. .. .. - ` o ' s. � _ , G• '= . ��= C - a:: :� r � Y .;r A _`�~ ^�l�� y r--� '+. -' 's' '" � " r�Y � _ _ � C � - `r J C..�2. -. ^. „ _ „ � ... « `�; .• _ ' � y �.. • • . ��, � _ _. - ~c a ��~�'fi �,y _ �s = _ �� ,,..: . . 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