HomeMy WebLinkAbout0900A (4) WORKERS'COMPENSATION DECtARATION
I hereby oflirm tha� I hava a certificate of tonsent to salf `-�
ineure,or a certificate of Workera'Compensotion Ins�rance,or �6A612� �
o carrified copy rhereof(Sec.3800,Lo �., CE808;REY.1/&31 qppE�CATION FOR PERMtT
Policy No.� Company � O NFv"f
❑c:`��a�oPY i hereby furnished. SEWER - SEWAGE DISPOSAL
�Cerr'rfiad copy is iHed wi�b�he counry building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
dep/artment.
�1e I• �' �'°'PP�'�o^� W"'�Q"�/'z�� FOR APPLftANT TO Flll IN �- S' CONNECTION DATA
CERTIFICATE OF EXEMPTlON FROM WORKERS' euiipiNc g
COMPENSATION INSURAM1}CE �opr¢55 O� LCl:/ Qw�ik� �r� STATqN Q 3� ocnH
(This senion need not be completed if tha work involved by ihe O� �I Mlf�rylUJLE REfEREN� R
permit is fw one hundred dollors(s100)or Iass.J ` ��'��T� 'Q'� Q rs
NEAREST 1YPE OF CONNEC�qN
I certi thot in�he �ErrctH vRon�
pe ormance of fhe wak fo�which rhis �usT. r. cuRe r� M.t.TOP.I.
permil is issued,I ahoil not employ any person in ony manner � P C� p �
so as to become subject to Ihe Workers'Compensalion Lows. pw�R T�Od� CA.u�w.ta0. pa r�p. 7 Jr�
Hwn C� � �f: 1;
Date Applicant
A�RE� TRI/NK PERAVT Np RO/tDPFRMIT NO,
NOTICE TO APPUCANT: If, afte� mokin this Certificate of /`r�GQ,O O AffI0AVl7 wniveR EASEMENT RECORD.INSTR.NO. DATE
e arr rvt r 4 ,�-�
Exemption, you should becoma subject to ihe Workeri �
Compenaation provisions of�he Lobor code,yo�mvst forthwith pesca�io�u LOTNO. MWY.OpSi.WICENING
comply wiSh such provisions or this permit sholl be deamed '
(BVOkBd. BIOCK TRACT 3�L S STATE ENCiQO[IiMFM
UCENSED CONTRACiORS DECIARATION ro��&� ��'�'� � �;
I hereb offirm rhat I am licenced under ����� �W ON1m a,,���� ���
Y pro�isions of Chapter �
9(commancing with Section 7000)af Division 3 of the Busi- s�uiio�s �y�y�s ;
nesa ond Professions Code,ond my licenze is in full force ond i
/+ i
6HBCt. �����Qq �,J� Q{ � C CONNECTION CHARGE fEE
License Num6er x8 7 Lic Class �� ,�p�ss aeiMeuRseraENr r�e � j
�OIt�fOCfOF +� � �OI! //'�/��� CITY TEl NO. w5��� �� r? �P J D BY O �
5fA7E
bK Ka
1 om e.emp�under Sec. of the LA.Co. ii��Np cinss � ;3 �'�''��� �' �
Plumbing Cods and/w Ssc. o{�hQ �- DESCRIPTIDN OF WORK HE F�Nu 0 �
NOUSE Sf WEN CONf�CTING Tp //_ �O^�' �
B.8 P.Code for Ihe following reason �&K��'� /' �rE � VALIDATION ~ '
SEmIC IANK.SffPPtE RT OR � �
VIISAND/ORDRAINFIEID �A� � � '
�C HOVSE SEwER CONNEC7ING T� �7�.i-� y� I
FRIVATE DIS Y T 'l.'. " �) p
$iglWtur@ CONNECf ADDIS�ONN 9lLK 04 �
OWNER-BUIIDER DECLARATION WORK i0 HOUSE SEwEa s � r • � .� �
WEGftOW SFFiACi FIi,pRAINFIELO ~
1 here6y affirm ihat I am exempt from fhe Confroctor'a License [xiN.,[e55voot,oevweu,r.uNtrpie
Law for the fotlowing reason�SBUOII�O3I.S,BUi3r1G35 011d P!O- .41ER,REPAIN pF qBAMDIXJ HOUSE � � * �7.;.'�. `
fessioru Code): s[wew oa oisaosu svsteM - � �
• : — E
�,G5 owner of ihe praperty,or my employees with wages os �� � - }
iheir sole compensa�ion,will do the work and the struct�re €
is not intended or offered for sale(Sec�ion 7044,Busineu � �.��—�:'�� `
andProfeseionaCode�. OWMER'S PErmif S /a }
❑I,os owner of the properry,am exclusively contracting with AUTHO�i2/1T10N TOTAL FEE SO �
litensed contmctors�o construct the projed(SeUion 7044� I MAVE AT TNIS WtE R�pNTRAC7 W�TH THE F1EflE1N NMAEP CONTRACfOR TO
BualnE35 antl PloFessions COde�. CONNECT TNE ABOVF DESCAIBED EXISTING OWELtING TO THE PU&IC SEWER �
CONSiRUCT10N IENDING AGENCY � �
I here6y offirm ihat ihere is a construciio� lending agenty SIGNEDTHIS DAVOF 19_
for ihe performance of the work for which this permit is �+'�R°R
1l7YBd(SBC.�.INJ,CIV.C.�. OWNERSAGENT !
Lendar's Nome i�,� ���
lender's Addrass
1 cartify that I hava read this application and atate that the
obove Informqtion ia corrad.1 agrae to comply wifh all County
ordirwnces and State laws reguloring Plumbing a�d Sewe�s, �
and hereby outFwrize rep�esentatives of this County eo enter
upon rhe above•mantioned p.oprrty for cnapecrion purposes.
l.C� //-2/�.S �
Signotur Perminee Dote SEEpEVEiSEfOREX/I.ANATOMYtANGUAGE �
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