HomeMy Public PortalAbout6046 CAMELLIA AVE_Sewer__ WORKERS'COIMPENSATION DECLARATION
I'hefrlby affirm, that I have a certificate of consent to self
insure, o certificate of Workers'Compensation Insurance, or 7°A°�D
aCe1tMed copy thereof JSec. 3800, Lab C-) °�""' APPLICATION FOR PERMIT
C a. Company
El CM
❑ �rttfled copy Is hereby fumtahed. SEWER - SEWAGE DISPOSAL �j
❑ C knified copy is filed with the county building Inspection COUNTY OF LOS ANGELES BUILDING AND 1AFETY II JI
department.
Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPT" FROM WORKERS' eusdavG
COMPENSATION PENSATN INSU RMICF ADDRESS �ATPON H
(This section need not be completed If the work Involved by theMANN Lr a et
UPP
permit Is for one hundred dollars (=100)or lea.) =AL-
TYPE OF
CONNEItnON I certtfy that In the performance of the work for which this y t'1. I Y. aha . P.L. r�A.�To P.L.
permit Is Issued, I shall not employ any person In any manner P.C.NO.
to as to become-subject to the Workors'Compensation Laws. OW'M }_. . Co ".No. XM?4Q.
NALLFIS _
Date Applicant �Do�as 1ut�rac PeawT ria. ROAD PtsrwT ria.
NOTICE TO APPLICANT: If, after making this Certlficato of No � wAn62 PJ1gA5BJT RloORD.lJSTR No. DATE
Exemption, you should become subject to the Workers' LEGAL
Compensation pfovisions'of the Labor code,you must forthwith DESCRIPT)ON LOT NO. HWY.OR ST.WMEMNG
comply with such provisions or this porml-t shall be deemed
revoked. BLOCK TRACT STATE B11CROA3iW6E•Tr
LICENSED CONTRACTORS DECLARATION sag of Tor rx�w oN Tar S req.or nnoa. ParrvT ria.
L hereby affirm that I am liceni<ed underprovlatone of Chapter u�
9 (commencing with Section 7000) of Div(sion 3 of the Buss- BULD*KM C HAAGa6
now fired Professions Code, and my license Is in full force and
effect. _ oorrrEcrror�Carlos FEE
License NumberLIc.Case ADDRM
Contractor Date DMTR>ci Na GaOLIP hw P ROCESUD tY
QTY TTi.NO.
/IS7ATC LTC {�
SK PC,
El0 V �� L 1 Ctrs exempt under Sec. of the LA.Co. Lr�Se 2,p. CLAW �/� O
Plumbing Code and/or Sec of the NO. . DESCtRIFDON OF WOW FEE � U
OUSE SEWER wER CCt*49 To a12 �/ � �
a
VALIDATION
B. &P. Code for the following reason ueu
Pc�
MIM Pr�At
Date AOLJs SLE2 OD004eCrula To B WWL�.i
Signature CONNECT ADDnXX4AL UDG,OR U)
OWNER-BUILDER DECLARATION WORK TO HOM
I hereby affirm that I am exempt from the Contractors License OV6Aocrx AIV** E
Law for the following reason (Socton 7031.5, Bulsness and Pro- Haig 3347 .10
fesslons code): OR
VOID
El 1,as owner of the property,or my employees with wages as -
their sole compensation, wlII do the work and the structure ' M 1�
Is not Intended or offered for sale (Section 7044, Buslness Permit >< 1�
and Profeeowns of
code). AUTHORIZATION TOTAL FEE
owner of the property,am exclualvely contracting with w��-�• ,ya
Ilse contractors to construct the project (Section 7044, 1 FLAW AT THG DATE A CONTRACT WrrH TiTO - r744T■*
Buslnees ons Coded CONNECT THE ABC1%*4. MMD VUSTRJ6�DMSL]No To THE PLIKK SFMR . . .
CONSTRUCTION LENDING AGENCY ? 27.54
I hereby affirm that there Is a construction lending agency �44EEDD Y OF 001 IT $
OR
for the performance of the work for which this permit Is
A J Ar
issued (Sec. $097, Clv. C.� - TOTAL 27 .50
AnOQBs
Lenders Name �`.ECY 27.50
Lender's Acldrea � E .
I cortlfy Jhat I have read this application and state that the
00
above Information Is correct. I ogeee to comply with all Count'
ofditantes and State laws regulatl Plumbing and-Sewers, �y-�y� �y-�
a are esentativee this County to enter t�-OW1 10/ 5/39
e a t property for nspection purposes. 6474 1 19111Z39
r�
Perm Ittee Date f8 R1Nlf✓t POR LXPLANATOR`!LANGUAGE