HomeMy Public PortalAbout6035 CAMELLIA AVE_Sewer__ WORKM'COMPBJSATION DECLARATION
I hereby offirm.that I have a certificate of consent to sell
Insure, or d certificate of Workers'Compensation Insurance, or '�d1lD
a certifled�thereof (Set. 3W0,�b c.)� � DM APPLICATION FOR PERMIT
Polley No. _Companybyfum�hQ� SEWER - SEWAGE DISPOSAL
CertHted.copy Is herby fumishid.
❑Certified copy is filed with the county bu I COUNTY OF LOS ANGELES BUILbING AND SAFETY
Date�Ent.
ApplIW'Jt FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF FROM WORKERS' Su sDIPs3
StAT1ClN DlgTl�
COAAPEN$A INSURANCE ADOREfS
(This section need Act be completed If the Work Irtvofved by the LOC.AUTforE RB%td! E UPPBt
permit Is for one handred doljors(=100)or less.) NEAMT TrPeor UN('M FRC
I cert that In the nce of the work for whlth this �AaaT
CRC1S5 ST. � Y. CkiRS P.L AOL L TO P.L
permit Is Issued, I shall not employ any person Jnr any mariner PTt
so as to become subject tis the Workers'Compensation Laws. ap.M.No. . COs MO.
TRUNKT06AfT NO, RW PStMTT NO.
Date Appl loam
I NOTICE TOAPPLICANT,. If, after making thIt Cer4tfioat; of �YIT WAN- � +T REODRD.r�arR,NaDATE
-Exemption, tyou "uld betptne subject to the Workerir' . 01
Compernation'provlslons of the Labor code,you must-forthwith. D rrdN LOT PIC1. 04hePnvY.OR ST.WOEMNO
comply with such prbvislorts or this permit shall be deemed
revoked. BLCXX TRACT arTte elr
LKINSEP ODNTRACTORS DECLARATION SDs pF LOT row aN LOT
I hereby,affirm that I-om,llcensed under provisions of Chapter r
Ur
9 (cam enclog with Section 7000) of Divislon 3 of the Busk o«iaas CHARM
nese and Professions Code, and my License is in fall forts and
effect. yy AOR o0rilCriON CHAAO!rd
L(c"Numbeck4o Lic.Clpst ADDRMs
Contractor P�—A✓fTE,_M0� CITY ` 7 DiLTUCTh10. CsreOh� MAF px
❑ 5K RG
I am exempt under Sec. 'of the LA.Co. STATE No. 4 ,D
plumbing Code'and/or Sed of the NO. Plan comsis:nNG To DATE VA D/rT�ON
B. &P. Code for the following reoson ASMI —�
Prr OR FNAs
r'rTS APD DRA AID .
HOUE•swet COPNECnNo To By
Sionaturo CON+eC.T ADDMONAL ND0.OR
OWNr3R$U(LPER DECLARATION WORK TO Nous Sit
ovsftow
I hereby affirm that I ism exempt from the Contractors Lld'erhse DCTPt MANHOLE 10
Law for the following reason (Secton 7031.5,Buisness and Pro- RHMR CIR ABANDON PQ1lz
fesslons,Code): OR DtaPOSAL SYSTEM AMA
❑ I,as owner of the prop",-or my employees with wages as =7 34■50
their sale tompersatron, will do the wbrjc and the shiKture
Is not Intended or'offrred for sale (Section 7044, Business PArRllt tj 1 ITM
ssl
and Profeons Code). OWNER'S. TOTS 4 �
❑
I. as owner of the property,am.excluslvefy tontractAUTHORIZATION Ing with tOTA1 FEE
licensed gontroctors to construct the prpject (Section 7044, ONTRscTpR 34.50
Business and Prolesaloru Code}. THE A E DUSTMOweLING TO THE?JN K 5Ewt3L
CONSTRUCTION LENDING AGENCY % [
I hereby affirm that th►re Is a obnatructlon lending agency Sri THIS Y OP 19'
for the performance of tine work for whichthlt permit Is OR
ClyftARS Aar OOXKW 1 4/19190
Issued (Sec. 3097, Civ. C.). Aoot+l�s
Lender's Name -0069 1- MI10 M
Lenders Address-
I ceritfy that I have rpod thts application and state that the
above Informatio Is correct. I agree to comply with all County
'4mna tah laws regolatlng Plumbing and-Sewers,
u ze tattves of this County to enter
ve- for Inst e*Olgn purposes.o ttee Dote M RRVV=FOR ECMANATORY LANGUAG[