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HomeMy Public PortalAbout10252 GREEN ST_Sewer__ WORKERS'COMPENSATKM oEaARAnoN I hereby affirm that I have a c•rtffkate of consent to self Insure, ora cargfktte of Wgrlc•ri'Comp•nsatlon Insurance, or 92-0002 DPWB/e7 Po,cy N�WM� �� Core. �� APPLICATION FOR PERMIT ❑'Ceri fieri copy is hereby f"Ished. SEWER . SEWAGE.DISPOSAL ❑ Ceelfted copy Is filed wlth'the county building inspection COUNTY OF LOS ANGELES DEPT.OF'PUBLIC WORKS BUILDING AND SAFETY dDMSION epartrnent. . , Dat.12-2 i.—9C1Applicant-P UL ROBERTS FOR APPLICANT t0 FILL IN C01�1NECTION DATA <�RT1FICATE OF E)CE PTION FROM WOWt"' COMPENSATION INSURANCE - v STAncN DAH fThis s•ctlgn-need not be completed If the work involved by the � � to MAWXE Rte permit is for a" hundred c Ijart ($100)or low) t&40TH PROOF I certify, that to the perf"n"no Fe of the work for y Ichma this C9M,ST. Y. TYR � P.L AlL TO P.L permit Is ls4Lred, I shall not emp joy arty person In arty manner P.C.ria. + so as to beeorhe subject to the Workers'CompeinatIon laver. oyK� J ao Cy Co.LW.No. roe Na Dor © .� E 3 TRUM Psw NO. RAO PmwT w: ~,---� �ot - A"DAW I WANE! EASIVIOU RECORD.kaTR W. _ DATC NoTtCE TO,APPLIGNT: If, after making this CArttflcahe of Cft Ta N0 Exbmptbn,, you should b•com'e Subject to the Workers' pu Compensation provisions of the Labor cock,you>nve forthwith- D I. Lor No. OR a. cgrnply with syth provisions or this pwmit shall be cle6med revoked. eLooc TRACT STATE.M40POACHA�M LIED CONTRACTORS DEC�TK)F ria.or BLDtls tSrvY No SM or car aN LOT I hereby offirrn that-1-am llcer"d under provisions of appter 4 (comrrowK1 Sg with$action 7000) of Dlvislon 3 of Ow Buil BCU DDt" RESIDENCE CHARM' riep and,Profoestons Cone, and my license Is In full force and effect. ii ROBERTS aorrtcn OiARGE rm Lic•nseNumb•r5611 33 Vt aq. C-42�, $ EED AV"RME cash«ioI'4 V lI RQB, T a to 3-17,-91 QTY ROS Tui.No.7 98-0 725 ❑ ro am exempt under Sec:- _ of the L A-Co. tnA ,,D 5 6119 3 a�i>a C—42 PI m I and/ NaP11ON OF WORK RE �DL� u .b ng Cade pr.Sec, of the HOCISE a a�nrio DATE ).VALIDATION pue4c B. d P. Coda f9r.Ih•faIIowl rig reason' RT a�AL f'rTb VV U/ DRAtrre..D - Date_ HCAM S&NER ccteecriNGTO BY AU DWKM%L SYSTEM SignatureNNINIECT ADomctvAt BLDG.oR OWNER$UILDER DECLARATON WORK TO HOW EElM6! I hereby affirm that I am exempt from the Conh•actoet Licgnse ocTrr MAraipr Low foe the following reason (Secfon 7031.3, Bulsnew acid Pro- ALTet T H(XW 1Q fees b ns Cod•):, SYSTEM. - �T o JL El I,an owner of the ptoperty,or my employees with wages as - their sole compensation, Will do the worse and the structure 33073� .50 Is not infee0ad or offered for sale(Section 7044, gusldess' and Profs(islons Code). OWNEn I Permit $1 IOU 0 1 ITEM ❑ I,os owner of-the property,am exclusively controcting with AUTHORIZATION 1,101AL FEly TOTAL .� � licensed cbntraciors to corufivct the project (Section 7(144, I WAVE AT THts DATE A cONrTR.Acr wrH THE HBON Buslnens arid Professions Coded coNf THE ABOW DSD®baStM DYORLNb TO n-=11 34.50CONSTRUCTION LENDING AGENCY I hereby affbn that thre Is a consMrction lending agency peperformance at thgqWyytN�IEtDTHIS_ DAY OF 19_ raj f�YMSLS� for the performance 3ne work for which this penult Is �GaJr , Issued (Se097, Civ. C) Lender's Name ADDRESS 0004-0001 $/2O/90 Leroders Address 2473 1 ASI 9:10 1 certify that 1 have rood this application and state that the above t on It•convd. I ogee to complywfth all County oral State laws regulating Plumbing and-Sewers, and autborixe repcosenlatives of tfils County to ant the ve-rnentior»d property far trnpection tgngture of Pot.. Date SM F VNM FOR taPLAHAroRY LANOUAdt