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HomeMy WebLinkAbout0896A (6) WORKERS'COMPENSATION DECLARATION � I hereby affirm �hat I have o cartifitate of consent ta self S'� insure,or o certifico�e of Workers'Compensation Insura�ce,or 16Ad°Zo U o canified m y rhereof(Sec.3800, b C.) CE BOe:RfV i/83; Poficy ���� �om��� APPLICATION FOR PERMIT ❑ '�� SEWER - SEWAGE DISP05AL Cenified copy is hereby furnished. � .�Cenified copy ia filed with the coonty boilding inspection COIlNTY OF LOS ANGELES SUILDING AND SAFETY , department. ' Date�„�Appl�cant FON APPLICANT TO FILL 1N f S CONNEGTION DATA I CERtIFICATE OF EXEMVTION FROM WORKERS' g�iiw� p I CAMPENSATION INSURANCE ��ss O W��IOMr tc6� J7Y ST°'tww /D f� °Evr� i � (Tbis secfion need not be completed if Ihe work involved by the nwrx�E�FF�tEr�E uwER I permit ia fw one h�ndred do4lars(j106)or lass.) � �«P'��� � � 1 cenify that in�he performonce of�he work fw which this �utpss 5T. - Trff oF[anr�crion ��T„p� � permit is issued,I shall not employ ony person in any monner r� cuae v i. �tL.io Pt. � w as lo become subject fo the Workera'Compenwtion Lows. owNEk t C d' pp iµp dp, ��� �7a7 . Dote Applicanf ADD�AESS �0/J 7 Z. 7RVNK RrtMIT N� NOA�PERMfT NO NOTICE TO APPLICANi: If, ofter makin this Certificate of ��oawr WANER EASEMF,Ni acmao.insm.rao P,..h � e ��,Y .�:.� G. ,��.� � -GGd-d o Exemplion, yeu ahould betome subjecl to the Workari • Compensn�ion provisions of tha labor code,yoo m�st forthwiih oaccl�'vtloni IAT NO. HWT.OR ST.Wlp[NIIJG � • eomply wi�A sueh provisions or ehis permit aboN be deamed / ( c (EVOItGCI. BIOCK TRACI {p�/.,7 STATF FfJCGQACMNFNT LICENSED CONTRACTORS DECIARATION r.p,pc�ocs. veam r rvo $$$ SIZF OF LOT Npw ON LOT .�, /. ,n pI � I here6y offirm that 1 om Vitensed under provisions of Ehapter �� aC0 9(commencing wilh Seclioa 7000�of Division 3 oE the Busi- gui�on�s anitc.�s ness and Wofessions Code,and my license is in full 4orce and - effect. /��}p 1 / ��Tp,qROp �k,�y CONNECTION CHARGE fEE license Numbero�r J� Y �ic.Class � I �ys REIMBURSEMENI FEE g • Contracfor � �r' Dofe ' wSTRKT NO GAWv MAV �Q gY O6 � Cltt TEI.NO ❑I am ezempr under Sec. of rhe LA.Co. srnte uc. p� 3 Y � ����. «� � �'3 Et 33 � '- P1O. DESCRIptION OF YJQRK ffE � • Plumbing Code and/or Sec. of the crNai O 1 MOUSE SEWFR Q7NNECTING TO oo.r� r— YALiDATIpN �' r vuatK stw�re 7 �(—Z O-b� � s� B.8 P.Cods for�ha follrnvfng reason � 5[PfIC Tq�.gFPAGF PR OR PITS NJD%OR�RAINfIELO FlNA� y : DOtG 4q�5E SEWEQ GONNKSING TO eY Z � PRIVATE�15Pp$Al YS1E j Signature cpwJECSOpp�i�OP1Mg�pG py � OWNER-BUILDER DEQARATtON '�'O�K TO NOlISE SFNER . WERFtOW$EEFAGE%T,D4AINfIflO F � I hereby affirm ehot i om axempi from the Caneractor's license F%iN..CESSPOOt,ORYWELL,MANMOLE � low for the following reason(Setton 7031.5,Buisness and Pro- urta,rstveia op ne�wpow`qu5¢ t ; fess�ons Code?: s�wEa oc o�svosu svs�n � ,- ar.r.0 � ' ❑1,as owner of the property.or my employeas wifh wages as - „ - { . their sole compensotion,will do the work ond the sMvtturo � . is no�intended w offered for sole(Seciion 704-0,Businesa 1:� • • • � '. _ ond 7rofeu+ons Code). OWNER'S Permit S (p ,(�O � I � �275;, ❑f,as owner of�he properry,am eadosively contructing with AUTF40RIZATION TQTAL fEE . ,S'D � , licemed commcrors to tonstruc��he projed(Sec�ion JO44, �qp,y[qT TMq pptE A CaNTRACf WITH iHF HEqEIN NAMED COIViRACTOIi TO Business and Profasaions Coda�. coNr�ct ir+e aewe oexaieeo eaisnne owewrvc ro T�ouatK sewea. • � ".':. ��.�. �.i�- �€ CONSTRUCTION LENDING AGENCY � � � ��_��� � 1 hereby affirm ihat there is a construction lending agency SIGNEDTHIS DAYOf Iq_ - tor ehe performanca of Ihe work for which fhis permit is ��R� owr�uas n�tNr issuod(Sec.3097,Civ.C.). ,J�� � Lander's Name N �E� � Lender's Address 1 I cartify that I have read this opplication and stote�hnt the j a6ove informmion is cwreU.I agree�o comply with all Co�nry ordinances and State lows regutating Plumbing and Sewers, � o�d hereby authori:e representolives of this Counfy lo enter upon the obove-menfianed property fw inspec�ion purposea. 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