HomeMy Public PortalAbout10950 FREER ST_Sewer__ t WOR10 RS'COMPENSATION DECLARATION T
I hereby affirm that I rtificate of consent to self
Igsure, or atertlfi Compensation Insurance, or � �
fffflth Labs CE 801 ""' APPLICATION FOR PERMIT
,
pony esed copy Is hereby furnished. SEWER , SEWAGE DISPOSAL
ed copy h filed with the unty It In Inspection COUNTY OF LOS ANGELES BUILDING ANDSAFETY
d m t.
pli r FOR APPLICANT TO.FILL IN CONNECTION DATA
CERTIFICATE OF E?MNLPM PT10N FROM WORKE eutLDtrrG DEPTH
COMPENSATION INSURANCE ADDRESS041 /00
(This section need not be completed if the work Involved by the .� titers-taF t , {
permit is for one hundred dollars ($100)or less.)
LEtfROM
I certify that in the performance of the work for which this Y. CURB P.L. WL TTOO P
permit Is Issued, I shall not em lay ony person In any manrler
so as to become subject to the Workers'Corn on Laws r'6 No.
I p�1Otl owr81 Co.ttiw_No_ roe NO.
No. ROAD POVAIT No_
Dater Applicant ADDRESS,
NOTICE TO APPLICANT: If, after making this Certificate of 1E1-NO. AFFWVTT WAWM EIYMBJT .INVR-NO. DATE_
Exemptiorl, you should btcome sublect to the Workers
Compensation provisions of the Labor code, you must forthwith DESCRfPTK N LOTWDBs�
4omply with such provisions or this permit shall be deemed
revoked. TAT STATE DKROACHtiErT
LICENSEE)CONTRACTORS DECLARATIONI f•RA1TT NC.
srgoF LOT NNOo�w brr�lo�r
I hereby affirm that 1 am Ildensed under provisions of Chapter USE OF
9 (commencing with Section 7000) of Dlvlslon 3 of the Bush tipprGy CHAIRGU
ness and Professions Code, and my license Is In full force and
effect (� mNrw�crQa cor+�crtoN aiAuoE r$ d
LI Llt Class /�" Q
b
r ` BtSTTiICT NO. GROUP MAP BY
E]..I am exempt under Sec. of the LA.Co. Chis �� 3 O
Plumbing Code and/or Sec, of the DE5�1 RNx 1
HOUSE SF*KR Cot*,E-CrTNo TO DAM /Q VALIDATION ct
B. 8 P. Code for the following reason PUBUC SEvac
T PTT OR FNA&
PO ESEWER HOUSE CONNECTING TO DY �
Signature oONrECT ADDITYONAI BLDG.OR
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
I hereby affirm that I am exempt from the Contractors License I7(TT1 Pff SMR W 1� -
Law for the following reason (Secton 7031.5, Buisness and Pao- AL REPAR OR A k DON HOUSE —
fesslons Code): OR o+sPOGAL SYSTEM
AC� s
•T
❑ I,as owner of the property,or my employees with wages as -
their sole compensation, will do the work and the structure `* 07
Is not Iritended or offered for sale (Section 7044, Business Permit = f
and Professions Coded OWNER'S
❑ 1,as owner of the property,am exclusively contracting with AUTHORIZATION I TOTAL FEE TOTAL 27.50
licensed contractors to Construct the project (Section 7044, I HAVE AT THIS DATE A act1TRM.T wrrH THE FiEREN NAhI® To �4.��-(�''.�{(�
Business and Professions Code. COt*41CT THE ABOVE DES00BED EXISTING NAILING TO TFE KX%jC S-MR 1+1'CS:i� - 27.50
CONSTRUCTION LENDING AGENCY CHANE ■00
I hereby affirm that there I{ a construction lending agency SGN D THIS_DAY OF 19_ ,
for the performance of the work fpr which this permit Is CwrER OR
Issued (Sec. 3097, Clv. C'� AORERSAQRq
LR ar's Name ESS ODOD- pGD01 7I/ 6
87
Lender's Addreu 5515 1 Ah $:34
I certify th rt I have read this application and state that the
above Information Is correct. I agree to comply with all Couhty
ordinances and State laws regulating Pi u bing and Sewers,
and he» uthorize represents ves of Is County to enter
U abo>11b-menila pr for spectlon purpose&
Signature o Ittee M 15V ME DQtLANATO*Y LANG AGN
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