HomeMy Public PortalAbout9409 GARIBALDI AVE_Sewer__ WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent'-o self
Insure, or a certlflc�pte of Wocken'Cor�pensation IruufaiTce, or 76Ad4
a certified ropy thereof (S. 3800, Lab C.) Cz"Xv.B/a,). APPLICATION FOR PERMIT
I, Policy No. Company- As SEWER - SEWAGE DISPOSAL
�ertifled copy Is hereby furnished. •
❑ Certified copy Is filed with the county building Inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
department.
Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WQRKERS' MJMNG ' r
COMPENSATK)N INSURANCE ADDRESS 1SSTATION DOTH
O
(This section need not be completed If the'work Involved by theLOGAtrTY ��+ M44401_2 RUERINCE UPPER
permlt'Is for one hundred dollars (;l()0)or leas.) r�AREEr TYPE OF Cora BZTI N LENGTH FROM
I certify that In the performance of the work for which this OzOss ST, v. Curet P.L. A&L TO P.L. >_
permit Is issued, I shall not employ any person Irr any manner d
to as to become subject to the Workers'Compensation Laws. P.C.No. O
MkIL i CO.MSP.NO. !OB NO. V
hMD TRUNK PEIZWT NO. ROAD PBLWT NO.
f Date Applicant - �
NOTICE TO APPLICANT: If, after making this Certificate of � TEINo. AJ+ZAvrr wAJVER EA.SlMENT RECORD'.rant NO. DATE V
Exemption, ybu should become subject to the Workers LEGAL - W
Compensation provisions of the Labor code, you must forthwith PTK)N LOT NO. FMy OR ST WIDENNG O.
comply with such provisions or thls permit shall be deemed N
revokod. BLOCK TRACT STATE ENCROACFLYIENT z
LKENSED CONTRACTORS DECLARATION No.oP mDoE. No.
I hereby affirm that I am licensed under provisions of Chapter ME OF LOT NOW ON LOT
usE
9 (commencing with Section 7000) of Division 3 of the Dual- BUILDN36
nese and Professions Code, and my license Is In full force and
effect. CONNECnOq.CHA.RG1E FEE
License Number Llc.Class ADDRESS
Contractor DateDaAP
TR$CT NO, GROUP M
CITY 'TEL,NO. , BK PG
❑ I am exempt under Secof the L.A.Co. STATELICENSE NO CLASS
Plumbing Code and/or Sec of the No. • DESCRIFTION OF wORK FEE
HOUSE Sri CCtREC7rNG TO 2 _ �
�� VALIDATION
S
B. 8 P. Code for the following reason PURK WC
AI
SEEPAGE PIT OR
MIM DRAW41`9..D
Date Hxm wYvm aw ELm NG TO BY
PRTVATF
Signature cora•Etn ADOTrtONAt BLDO.'OR
OWNER•BUILIXR DECLARATION g S
ro Hog
I hereby affirm that i am exempt from the Contractors LicenseOM&LOW KTDRAJNFIELD
MANI-101.1i J
Low for the following reason (Secton 7031.5, Bulsness and Pro- AlTSi,REPAIR OR ABA14 DN HOUSEST
fassions Code): SEYAR OR DMPC AL SYEM
El1,as owner of the property,or my employees with wages as
their sole compensation, wIG do the work and the structureIs not Intended or offered for sale (Section 7044, Business
and Professions Code). OWNER'S Permlt $ 2 9 0 a b A
❑ I,as owner of the property, am exclusively contracting wtth AUTHORIZATION TOTAL FEE BY
licensed contractor) 10 construct the (Section 7'044, 1 HAVE AT THIS DATE A CONTRACT YAH THE H6tIIN NAA4t� TO # o 0 0 o-1 0
Business and Professions Code). CONNECT THE ABOVE DESOUND VGSTING DNEILING TO THE PIZLIC SEwETt Z+o o `Z 1.50
CO UCfIOtJ' AGENCY
I hereby affirm thb a construction lending agency ISDAY OF 19_ , o'o - 2.1,-5.03
OWNER OR
for the performQnce a work for which this peFmlt is
Issued (Sec. 3097 . C� ADDRESS O~l, 1 4-83
Lenders Name
Lenders Addrass
I certify that I have toad this appllootion and state that the
above Irrformatioh Is correct. I agree to comply with all County
ordinances and State laws regulating Plumbing and Sewers,
and hereby �flauthorize representatives of this County to enter
u the abov entlo opectlo pu
1
Signature of Permittee 10 PMVUU FOR DXPLARATORY LANG AW