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HomeMy WebLinkAbout0900A (6) 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 �CCerr'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 � � '�, ;� . �� : .. . - ... _ -- � _ .! ;�, . r �.' . . _.. - i ' • .,". �'' _ ' � �` � -- ;. ' . ` �,%'- 'i. c:. - c; 2= _Y '. • _ ' ,. d, - _ �'" _ ' .. � ,- - , ��i% '�i-� � ' ".3 •� '�'c' -i�„_� I � � y~ _ . • 'r� � �' " � .. ,J. - �.. _ _ ' = . •` .S C_:.,_ ' � ti •/^. .. .. .� C' .. . 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