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HomeMy Public PortalAbout10121 GREEN ST_Sewer__ WORKERS'COMPENSATION DECLARAMN 0002 I hereby.crfflrm that I have a certificate of content to self DPW 3,10 Insure a Wtfigate'otrWorkers-CbmperNallon Insurance, or 7&Ah4M a certlf copy thereof (Sec 3800, Lab C.) �°°°' APPLICATION FOR PERMIT Policy No.10—©4S9.60Ampany GNA Inn, t.n �s ❑ .Certified copy Is hereby furnished. SEWER - SEWAGE DISPOSAL J1 Certified copy 1s filed with the county bulldln9 Inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY department. " bate 1-1-9-0 Appllcon0wL-n Bros- Pliimhing FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF D(EMPTION FROM WORKERS' DURDING COMPENSATION INSURANCE ANIONSSTATION DEPTH (This-section need net be completed If the work Involved by ther MANHOLE RI permit Is for one hundred dollars (;1-00)or leu. LOCALITY 1 certify that In thb perfotmance of the work for which this. � TYPE OF LENGTH FROM Y. CURD P.L. M.L,TO R.L permlt,l; Issued,-1 shall not employ any person in any manngr P.C.NO. so as to becbme pubjecl to theWorkers'Compensation Laws. OWr$I Owed DevelO taent OD.SAP.NO. Xoe 40- MAL 1RII NK PBWJT NO. ROAD PHLwT NO. Dale . Appllcant. ADDS NOTICE TO APPLICANT: If, after making this Certificate pf an TELNO. AFaoAvrr I WAN EASEMENT RECORD.RNSTR.MO. DA.Tt E=xemption, you should become subject to the Workers LEGAL Compensation provlplons of the labor code, you must forthwith. DESMPnoN LOT NO. Ry, OR STM,IFIDENING Comply with such provlslorls or this permit shall be agembd revoked. - BLOC( TRACT STATE R4CR T . No.Or DLDGS. 'LICENSED CONTRACTORS D6CLARATJON sly OFPaRW.T NO.LOT raW�Lbr 'I hereby affiral that 1 am licensed under provisions of Chapter 9 (commencing with Section 7000)-of dlvlslon 3 of rhe Bust- 8111 LdfJGIS non and Pro'fesslons-Code; and my license Is In full force and effect. QO NTRACTORr Owen'Bros. Plumbing, Inc. CONNECTION`HARX FE!E LlcenseNumbbr 23.1-7.4.1 llc.Clans mf)—?n A,DDRM 4265 N. Baldwin Ave. RRMAkTRSEMR4T FK IL Contractor, DateICT NO. GROUP MAP BY r) gTY Ta.NO. 441-0078 Z ❑ Iamexempt under Sec. + rofthe LA.Co. Lu�rsENo. 231-741 CCAs Q3 —20 �� PG Plum/lrlg+Code and/brSec. of the NO. CL HOUSE SEYOU �VVORK W NG TO B. &P. Code for'the following reason Pu9LIC VADATN SEBIA�KT OR Cn X7.1&DRAJNs:11ED E1tNA1 Z HOUSE SEYOER COrr[Gu G TO - BY Slgdature CONNECT ADDRTICNAl OWNER-BUILDER DECLARATION woarc Nous , I hereby afflrrri that I am exempt from the Contractor's License EXTN. SPOOL DRr MANHOLE Law for the following reason (Secton 7031..5, Bulsness and Pro- A1TT3t REPAIR OR Aas,No HOUSE 10 fessions Code): SeWB2 OR X7105AL SYSTEM _.. A ❑ t,as owner of tbe.property,army emplbyeeswith wages as ACCT.r tflblr sole compensation, will'dothe wort(and The structure r307 - 27.50r� Ls not Intehclad or offered for sale (Section 7044, Business and Professlons Code). OWNER'S Perrnit s 1 ITM ❑ I,as owner of the property,-am excl4srvely contracting with AUTHORIZATION TOTAL FEt TOTAL 27. 50 licensed cohtractors to construct the project (Settlon 7044, 1 ttAVT AT TH15 DATE A CONTRAqT THE HERBN NAMED CONTRACTORS TO Business and Professlons Code). CorrEtT THE ABOVE DlSQSIND MSrING DYAU G TO TFE Pueuc UECK 27.50 CONSTRUCTION LENDING AGENCY ,r� I hereby affirm that them Is a ConstrocHon lending agency SIIGGt� IS DAY OF 19= '�lL .00 for the performance of the.work for which this permit Is OV&JRR Issued(Sec 3097, Civ. C.). OWNERS AQe1ff Ag°"ffi' 0000-0401 Lenders Name 1/10/90 �i Lender's Addtaw , . 519 1 A 111:56 - I certify tfwt J have read this appllcatloo and state that the above Information Is correct. I ogres to comply with all County ordlnanpee and State laws regulatlnq Plumbing and Sewers, -and eroby uthorize representatives of this County to enter the entloM11 or Inspection purposes.. � 51gnaTuro of Perml Dafe fS WVME FOR OUPLA"T00 LANGUAGE / - WORKERS'/OAAPE �'-� 1.lCl..�.l•'1l AMN I h�reb affirm 1hhatlilJhave as certificdteAof consent to self , d*a certificate of tb Workers'Compansan Insurance, or T{A UD a ff APPLICATION FOR PERMIT PbllcyV. mP.nY SEWER SEWAGE DISPOSAL El Ified copy l ` ttfied copy Is fled wltfr the ty�u1 d� Inspection COUNTY OF LOS ANGELES BUILD114G AND SAFETY t. Date d Ilcont—v FOR APPLICANT TO FILL IN CONNECTION DATA CATE OF DMMPTION FROM WORKERS' RJSDLNti / = i COMPENSATION INSURANCE S1ATTON oePrrl {This section need not be completed if the work Involved by the rim MANHOLE�� Uri permit Is for one hundred dol{ars (;100)or less.) NEARETYPE OF LENGTH FROM I cert that In the performance of the work for which this CROSS S tfy perfo CROSS ST. Y. C>� M.L.TO P.L Issued,permit Is I shall not employ any person In any manner P.c K%a so as to become subject to the Workers'Compensation Laws. py,r� Ir Co.VAP,"a JOB NO. MA`L Tk"PERM O NO. ROAD PERMIT NO. Date' Applicant ADDRESS NOTICE.-TO APPLICANT: If, after making this Certificate of CTS c Td No r 2� AaTtkvrr wAtvsL EASEMerT Rt CORD.R+STit No. DATEExemption, you should became subject to the Workers' LM CompensWlon provisions of the Labor code, you must forthwith DaCRiPTON LOT NO. HWY,OR n.WIDENING comply. with such provisions or this permit shall be deemed revoked. BLOCK TRALTja. STATE D03nAOiME rT UCENSED CONTRACTORS DECLARATION nto.of ttmG6. PeRMTT NO. Sig OF LOT NOW ON LOT I hereby affirm that I-am licensed under provisions of Chapter USE OF 9 (commencing with Section 7000) of Division 3 of the Bust- BunDOI06 CHAli36 i neas and Profsralofs Code, and my license as In full force and affect. oONTRA,CTOR CCt&4CT10N C}iARGE Pa License Number L Llc ClassADORE Contractor /1.r- Date /0' �, DIfTRICT NO. GROUP MAA PRGC'�.6Y Lsc PG } ElATE L, I am exempt under Sec, of the L.A.Co. �jXg�NO Qy6 5 v D- O Plumbing Code and/or Sec_ of the NO. Haat Swf CON14ECTM Tv DAR VALI AnON (U(� B. 8 P. Code for the following reason O patePrta Al o BY HOUSE SEWERTO 6Y W Signature CONNECT ADDMONAL BLLxi.OR U) CONM43LJILDER DECLARATION WORK TO HOUSE SEWER , Z OVERFLOW 11193-�Kr DFL� I hereby affirm that I am exempt from the Contractor's License. DUN MAN!HCU ry Law for the following reason (Secton 7031.5, Buisness and Pro- AL AN1X*1 HOUSE 1V fwlona Code): ❑ 1,as owner of the prop ,or my employees with wages as ACCT.i erty their sole compensation, will do the work and the structure3W7 154.00Is not Intended or offered for sale (Section 7044, Business Permit ; 1 ITEMS and Professions Code). OWNER'S El 1,as 4wrTe*of the property,am exclusively contractingAUT140RlzwnoN ctlnq with TOTAL FEE licensed contTnctgrs to construct the project (Section 7044, i HAVE AT Trwa DATE A CONTRACT vmH THE HETt13tJ_NAhW CON4TRACTOR To TUTAL 154.00 Business and Profma!pns Coded CONNeCT THE ABOYE DESCRIBED EXISTING DWELNG TO THE POMC WWM DECK 154■aD CONSTRUCTION LENDING AGa CY , I .hereby affirm that there is a construction lentG ding agency SNH)THIS_DAY OF 19_ as for the performance of the work far which this permit Is osT Issued (Sec. 3097, civ. C.) Lenders Name ADPRESS _ . 001010--0ao1 ta�ryib/�9 Lender's Addreas 6M 1 AM11: 3 I certify thatmofl5ermiffee ad this application and state that the' above irrf rrect. I agree to comply with bll County ordInon aws regulating Plumbing and-Sewer, and h tctIVes of this County to enter u an property for Inspectlon u Slgnatu Data M R1VM1 KM 10MA ATO4Y LAHOUAW