HomeMy Public PortalAbout9407 GIDLEY ST_Sewer__ r .
tWORIJRS'COMPENSATION DECLARATION
` is refereby affirm that I have 0*CartHitate of consent to seff
fnsurb, or a certlflSgte Workers'Compensation Insurance, pr 7ene�
a certified copy th.fea csbc:3800,Lab C., 'a/.81, APPLICATION. FOR PERMIT
Policy No.—Company - ms
❑ Certified copy Is hereby furnished. SEWER - SEWAGE DISPOSAL
❑ Certified copy fs filed with the county building Inspection COUNTY OF LOS ANGELES BUILDING AND SAFM
department.
Date `Appl[cant- ��+�� � -FOR APPLICANT TO FILL IN CONNECTION DATA
CERUFICATE OF EXEMPRON-FROM.WORKER$' 1pp�
ADDRESSSTAnbf1 DEPTH
COMPENSATION INSURANCE S
(This section need not be completed If thework lrwolved by the. to[aurY 6 � µy.R.{pIP REF>�,
UPPER
Permit Is for one hundred dollai•s.($100)or Less 7
NEAREST TYPE OF 35iiE55NLENGTH FROM
I certify that In the performance of the work for which this CROSS ST. . Y. P.L M.t TO P.L
perrnit Is Issubd, L shall not employ grly person In qny manner
so as to become.subject to the Workers'Cpmpensgtloh Laws, OWNER P.c NO.fJ IIiY�i" :G* co.uw.No. roe No,
TRUNK PERJWT NO. ROAD F�RMfT NO. `
Date �B-.��nollcdnt : ����i SSI,^/ $.�.� I
NOTICE TO APPLICANTt If, after making this Certificate of Crry NO. 11,e
A-Dlvrr wArvER EAmmEN7 RECORD,'e4srR.No. DATE
Exemptlom, you should become subject to the Workers
Compensation provisions of the Laborcode, y64 must forthwith v gTpN LOT NO. Fiw1 oasT Wpe�NG
comply with such provlsiohs or this permit shall be deemed
revoked. a(OCK .TRACT - STATEvte+�v�lelrPER - .
'LICENSED CONTRACTORS DECLARATJON No.
U
1 hereby affltmr tHdt I am Ilceosed under proviiigns of Chapter USE
OFcor
9 (cornrnerxdnp with $bctlph 7000) of Dlvlslorr 3 of the Busk 9U�RDINGS-
CHARGES
nese and Professions Code, and my license Is IQ fulf force aad
effect. CONTRACTOR CONNECTION CHARGE FEE >y.
License Number Llc.Class ADDRESS d
O
Contractor DM7R NO. P MAP BY u
CITY NO. 6K PG
� �.
STATE
❑ �1 am exempt under SetCLC O
'. ofthe LA.Co. rp r
Plumbing Code and/or Sec. of the NO. DSCRI WORK FEE Rriu CONVALIDA N W
HOUSE SE`A?ER I�ECn NG TO DATE _
B. 8 P, Code for.the following rgcfsoh TA AQE PR OR R f
Ddte 4157—/�— PITS E 3E CCt*4ECTJDRAR*IaD 8 1 2 8 A
HOUSEs,=wst rQ
� A
41gnature� '',v- �-- WOW To HOUSE CTT"VFTIQ�UMQ..CO #.o`o o io r1 O -
ow�AaE PTr DRg1 NF$D
I hereby gfffrm that I am exempt from the Contractor's License ExTN MANHOLE -'- 21,50
Law for the following reasart(Secton 7031.5, Bulsness and Pro,- AL REPAIR CR AhMVEEN-Flerrpr
fessions Code): _ - s OR NSIOW SYSTEM o : 2A 5.0%
UIL�� ,o`o
I,6s owner of the property,or my employees with wages as
their sole'cpmpensation, will do the Work and the struourb 4.0 1•�5�_a 8 7
Is not Intended or offer for sale (Section 7044, Business �ElrtTklt :
and Professions Code). OWNER'S'
❑ I,qsowhgr ofthe property,Nom exclusively contTactinq with AUTHORIZATION TOTAL FEE
licensed contractors to construct the projed (S&dlon 7041, I WAVE ,A,T THLS DATE A vIrTN THE NamN t nh TO
Business and Professions Code). DWElinJG IQ THE WeuC SEWER- '
CONSTRUCTION LENDING AGENCY ,
I hereby affrrm that there It a construction lending agency S4GN�TH[S DAY Of 19—
for the peformance of the work for Which thin pArmlt is OWNER-OR • .
d
Issued (Sec. 3097, Qfv. C.). ,
ADDRESS
tendeds Name
Lender's Acadress
I cbrttfy that,I have read this application and state That the
above Information is correct. I agree to comply with all County
ordinances and State kwa regulating Plumbing and Sewers,
and hereby puthorfze repnesentatives of this County to enter
upon the abo'vve�-mentioned property for Inspectron purposes.
SI re of Date WeidaFOit q�LANATOR1f LANGUAGE