HomeMy Public PortalAbout5117 GOLDEN WEST AVE_Sewer__ T � _
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RS'COMPENSATION DECLARATION
h.nQlthat„I hwe a cwlIfIooto of cons.nI- to self
.,Insure, d� of Worker'Compensaidon Insurance,or 76' AM
a certlfled thereof (Set:. 3800, tab G) CE°°°[KV1,-P APPLICATION FOR PERMIT
Policy No. Company C. Ryd Tr15.
}Certified copy Is hereby furnished. ;SEWER - SEWAGE DISPOSAL
31 Certified copy Is filed with the county building Inspection COUNTY Of LOS ANGELES BUILDING AND SAFUY
department.
Date] 11,19_� Applicant B3339rfl Clzr - Cb- FOR APPLICANT TO FILL IN 'CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM(WORKERS' eusntt G 5H7 GaIdM t
qOM tNSATION i NSU RANGE ADORESS AT 139"
(This section need not be completed rf the work Involved by theLST M NH( E R043EN f u�
permit Is fpr one hundred dollars ($100)or less )
I ceglify that'Irl the performance of the work for whlth thi* _NEAREST iY �. CURBLENGTH�
It I( Issued, I shall not'*m I -any person Jn dny manner Y P.L.P µUro P L
to as td become sub ett to the orkeri Com osation Lows. �y��7� �'�No.
Pe Owt•6t rl,d,n CO.WVP,NO. JOe NO.
Date Applicant A 5U7 Q��M-st TRUMC POUKT NO. ROAD PEJUAT NO.
NOTICE TO APPLICANT: If, after making this Cirtlflcate of crY Ta.NO, 81
AFFtoAvit wAtvEA EAffASM IRECORIDDATE
Exemption, you should become subject to the Workers' LEGAL
Compensctlon provisions of the Labor code, you must forthwith DmanPnON LOT NO. IY. OR ST WMENING
comply with such pfovliidns or this permll sh411 be deemed
revoked. eLOCtc TRACT STATE ENCROA ZHAWNT
LICEL7
NSED CONTRA0RS DECLARATION NO.of PER�ut
I hereby affirm that I dim licensed under provisions of.Chtpr ppage LOr Now ON OT
LLm .
9 (commencing with Stiction 7000) of Division 3 of the Busk IwtiDwcs ' a�AGEs
nese and Professions Code)and my license Is In full force and
effect, CONTRACTOR $3C 0 7IM Cb. COr+*t rroN CHARGE I
License NUmbpr 425570 • Lic.Class B ADDRESS '19760 E. Cbhrmi Rid r$
Contractor BSD �" �8te ll—� � DtSTR1CT NO. GROUP hva PROPMSED BY
QTY Ta-NO. 8W 8
[� 1 am exempt under Sec- of the L.A.Co. ucsw. 425570 edeas B
DESCRIPT{ONOFWORK FaFr
Ptumbrng Code and/or Sec. of The NO. HOL1A SP4et CONNECTING DAlu
B. i P. Code for the following reason KMx � VALIDA N
SEEFOZE Prr OR R
. Date PfTa Ar,D/ DRAIJ'ELD
HOLME SEA"COtd•!CTTNG TO kzzz�,
PWYA
DY
SlgnatUre COtli{'T ADDfl-K)dAL&DG.OR 1
OWNER-BUILDER DECLARAT" WORK TO HOUSE WA" 1
185T2A
I hereby affirm thdt I am exempt from the Controcfor's License bcm.
Low for the following reason(Secton 7031.5,Bufsness and Pro- ALYM RPAJR OR AWA>CN HOUSE # 1 0
fealons Code): o 0 0 o
❑ I,as,oWTW of the property,or my employees with wages as o 0 2150
their sole compensation, will do the'work and the structure
Is not Intended or offered•for sale (Section 7041, Business o e.0 2.1.5 0 6
and Profesions Code). OWNER'S Permit f to
Elerty,am exclusively contracting with I,as owner of the propAUTHORIZATION TOTAL FEE O �� Q $
licensed oontrcc to construct the project (SectLS ion 7044, I HAVE AT THDATE A CONTRACT WtTH THE HEREIN NAMED OONTvwcroR TO
Business and Professions Code): CONNECT THE ADOVE DEECREED EXrsnNO DWELLING TO Tri"Jic WMR
CONSTRUCTION LENDING AGENCY
I hereby afflrrn that there h a construction lending agency SK3"DTHIs -DAY OF 19_ ,
fU OR
or the perfcr once of the work for which this permit Is OWNSM AGtNT
Issued (Sec- 3097, Cie. C)
ADORES
Lendoes TJame
Lender's Address
I certify thaf I have read this application and state that Ithe
abojoe Informptlon Is carrW. I agree io comply with all County
and State fawn reguloting Plumblrrg and Sewers,
a aU ze representatives of this County to stnter
u n a oned properly for Inspe�tlon purposes.
Slgrxrturb of Perm Mee Date M hffVEtM POR RMANATORY LAPSGUA0I1