HomeMy Public PortalAbout6027 CAMELLIA AVE_Sewer__ WORKERS'COMPENSATION DECLARATION
I hereby_afflrm that I have a certificate of consent to self
Insure, oc a.certiflcate of Workers'Com.ID, tfon Insurance, or 7GA442D
certified`°�''"9ef°°f(Sc. �°°, ,;,� 2-0°°'°P""' APPLICATION FOR PERMIT
Policy No. f` byfum SEWER - SEWAGE-DVSPQSAL
Cer►ffied copy Is hereby fumUhed.
Cefff lod copy is filed with the u LlWdlnspect COUNTY OF LOS ANGELES BUILDING AND SAFETY
department.
Dote 1Appllcant FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF FROM ' STATIO DEPTH
COMPENSATION INSURANCE AsuDo�RtrsE
(This section need not be cofipleted If the work Involved by theLOCAn MA�sott�� UPPER
permit Is for one hundred dollars (ilbo)or)ew ) TYPEoF Lalk"rRoM
I certify that in the performance of the work for which this QOEE ET,
Y. CURD P.L WL TO P.L
permit b �� Comp P.C_NO
issued, I shall not he peIn arty manner
b subject .
as t0 become subject to the 1�AyICompensation Laws. 0— M hw.� "N.
MAl TRUNK PERM'T Na ROAD PERWT NO.
Date—Applicant_ AooRT15
AEFDAvrr I wANR EA_VAwu REcosm.raTa.No. DATE -
NOT10E TO APPLICANT: '{f after makltrg this Certificate of
Exemption, you should become subject to the Workers'
Compensation provislons of the Labor code, you must fgrthwlth rro
comply with such provisions or this permit shall be deemed
invY.aRsr.woeallo
revoked. BLCXX TIIACT STATE ENCRCA410VFNT
LICB`15FD CONTRACTORS DECLARATION WE OF LOT � NOW ON LOT PEWAIT NO.
I hereby affirm that I-am licensed under provisions of Chapter «
9 (commerK4rTg with Sectloo 7000) of Dly(slon 3 of kha Bust- 6l u" CHARM
nese and Profeniors Code,'and my Ilce46 Is In full force.and
effect. CCNTRA43OR CHARM FEE
Aw
License Number%gr492071.Class ADDRs7E
Contro Date— :ZR2 CITY TB NO.
DrSTRICT N0 OROIP MAP BY
❑ I am exempt under Secof She LA Co. �L�N N0. UC_CLA
Plumbing Code and/or Sec. of the NO. DBCRIPCION RrA1 U /f t7
�
s ER ID
CONNEPING TO DATE V ATION tai)
B. ✓i P. Code for the following reason SEMkM MT OR Z
Rti APD BY
Date HOUR ftw6tC0NP4BCTM TO
PWYATE
Signature CONNECT ADDMONAL RLDO.OR
OWNER$U.ILDER DECLARATION WORK TO fine SEWER
I hereby affirm thdf I am exempt from the.Contractorrs License ocrN
Law for the following reason (Sectoe 7031.5, Buisneas and Pro- ALTeL�APANDON15��HOLM
fessions CodeY sr�v6!
Ell,as owrw of the property,or my employees with wages as - ACCT.4 .
their sole compensation, will do the work and the structure 7
Is not Intended or offered for sale (Section 7044, Businea Pefmlt >l � �
and Professions Code}. OWNER'S1 �TQfS
❑ I,as owner of the property,am exclusively cgntrocl N with AUTHORIZATION TOTAL FEE �y /y�
licensed contractors to constructHE the project (Section 7044, 1 HAVE AT TDAT!A CONTRACT WfT}i TH!FHaBN NAM® 'TOTAL 34_
F' 4.50
Baines and Professions Code): CCM!!CT Tie ABOVE DE9CR em Ex tnNG DWELM TO THE"Lr-WY
CXMISTRUCTION LENI)gNG AGENCY GECK '. 54.50
1 hereby affirm that there It a construction lending agency SI®THIS DAY 19
for the_performance of the work for which this permit Is a'"�2AOBdT , •00
CMRBtf
Issued (Sec 3097, Cly. C.� '
ADDR!'SS
Lenders Name .
t00 �0-0001 4/12/90
Lenders Addros / � M 1 AM10:31
I certify that I haw rood this application and state that the
obovp Information is correct. I ogree to comply with all County
ordinances and State, laws reg sting Plumbing and-Sewers,
and h autlaflze repress Ives of this County to enter
upon T 7ntioned for Inspection purposes.
r •
Fe o Date 91111 2111YOU POe LXF4 ANATOeY LANGU^Gl