HomeMy Public PortalAbout10209 OLIVE ST_Sewer__ WORKERS' COMPENSATION DECLARATION mil
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I �ereby aff.rm that I hapersO-pensation Insurance, 9r
hove a certificate of consent to self 2 t C` PNS 618
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! silrr �'eVor
c• iccoe
e, Ace,nf .at k � C �•'r•`t�'r'
b, copy th) ;eof �`Sw 380 , Lob C , J APPLICATION FOR PERMIT
Policy rva< :�� C ` f;r:r.,y_..,,..., "e .tC_ r.. SEWER - SEWAGE DISPOSAL
Certified copy IN herebyfurnished
Certified copy ,s filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
depjor+me t.�,+ W
Date.fes_`y ".J ,•�c nii:an+__ _t _-- FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF FKEMPTiON FROM WORKERS 3UrL[;irac ,c PTH
_pPv"iPE�+'SAfiif?N iti1SURANCE A�anFsS
d' r wTATI:�N
(This section need not be completed if the work involved b the � t UPPER
P Y LOCALITY MA^d$JLE REFERENCE E
permit is for one hundred dollars.($1OO) or less.) LOWER
NEAREST 7fi. TYPE OF CON ,E:TLON LENGTH FROM
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I cet+fy *hat in the peiformorice of ' e work for which this cPGs '
� y/' 17V v rcRp c l rn E TOP L
permit is issued, I snail not employ any person in any manner
LEGAL
so as to become subject to the Workers' Comp.ensotion Laws DE111CriPTION CO,T NO. enc
�, '.MV. NO1!�B M1Id
F3L0C>4 T'RAGT T i..:N1 PERMIT NO ROAD P€RNPIT NO
NOTICE TO APPLICANT If after making his Certifreate of ASSESSOR AIIFIDAvrr WAIVER FASCMENT Rfr-ERC !NSTR NCJ DATE
MAF 800K ,>>,:/✓:/.:.� PAGP •'ft,f PA:RCE;_ /46
Exemption, you should become svn;ect to the Workers NO.4F BLecs
Compensation provisions of the Labor code, you muat forthwith SIZE OF LO' NOW 0N Lc,T HWY GR T 'AIDENING
comply with Such provisions or this permit shall be deemed usC OF
revoked. BurLDiNG: STATE ENCPQAc,'nMNrT
LICENSED CONTRACTORS DECLARATION ER JirT
OWNER Rl t
I hereby offirrn that 1 am ilcensed under pr sicns of Chapter ✓
9 (commencing with Sect an 7E)0[)) of Division 3 of the Bi si a`LREeS f," "y 5 d& ��! �9 MARC s
nss Arid P afesciort :ode and mJ License sin full force and s Iy//yy
effect CITY ^�' ( �' 9 TL! hn. a ^'1 j JNNECT rFtARCF FEE
License Number 9` ✓!T?—i.ic CiasS_
.a ` ..=J "`�. ""� p S-R CT NO GROUP' MAP PROCESSED BY
(..UnfraCtor •i,J �? �1p4?._ :7 p,L`fJYF,» 8K PC;
i am exempt under Secthe efL.A.Co.
--- ---- / 31
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Plumbing Code aro/or Sec of the STATE ", NAa L7
LICENSE NO, 'f ')AT' W.Ac_Ass LiDATION._
B & P. Code for he'following reason Tao. MSCRIPTtONOFWORK FF£ � r p
_ s+ SUI
VER SER CONNEC'IryG T^, ,w'�t,6
Dote A PJBL C c Jv R 'Jw' I,Y
SEP?IC-TANK SEEPAGE F:T CIR CL
S ANO JR DAR r IELD
Sirgnature _ —_ ___ .— <!?
OWNER B!JILDER DECLARATION i OL Sc S1 WER C ONNECi INC.,Tu � z
PRIVATE DISPOSA5TEPA
hereby affirm that I am exempt from the Contractor's License CCNNECT ADPI IONA-B,DG OR
WORK TO HOUSE SEW€R.
i.avv for the follovi•irad reasdn (Becton 7ft3!.5, Buisnens and Pro-
CT,JRFLOW SEEPAGE PIT D+RAINF PLD
feSS?CnS Cade)', iXTN cF Si'OO� DP.Y'h E.L MANHO Lt
i REP1A R ABANDON
I ccs Owner of he property yr my employees w�!th vagesas AlA;ER SEWER R s cSAL SrSTF —
their sole compensation, wili dei the work and the siructure
is neat Intended or Offered for sole lSeCt.or, 7044, Business ' • >-
and Profession Cadet
1, as owner of the property, orn exclusively .ntra,iing with OWNER'S
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licensed cpntraCtors to construct tf}e protect ISe: Loi} 7044,
Busme"Fl and Profession,Code). AUTHORIZATIONTOTAL FEE � T
CONSTRUCTION LENDING AGENCY" HAVE At THII, DATE A cn w r+ H kE N Na.vEi PATPA _,R ;..
I hereby affirm dhat there Is a roc Sir;coon !ending agefLy nt'^1 vFCr hf ABOVE �ESCRiBth i g'NC [wu,HI ',L TO 7NE F-17c SEwFa
for the performance of the work for which this pern`ii iS T— --
7 �, SIGNED TI-O,
'AY OF 7V..._
slued (Sec. 309., Civ C r __—..-
OVYNf OR
Lender's Na. re---- ------ -------- _.�. OWNFRS AGENT__ __---___- —
Lender's Address—
AD''�T ESS
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,
certify that I have reod this application and state that the
above iriformatlan is correct, 1 agree to con}ply with all County
ordinances and Stare lows regulafing Plumbing aP d Sewers
and hereby authrt ze reinresentotires of this County to enter
upon the above-mentioned prop�,rjt, or inspeCtian purposes.
Sy afore of Perms?tee Dart, SEE REVERSE FOR EXPLANATORY G41ri(;tPAGE