HomeMy WebLinkAbout2148AWORKERS' CONI PEN SATION DECLARATION 76AG42D
CE 808 (2-80)
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance, or
a certib oSee. 3800
Policy (mpany E � `1—a
Certified copy is hereby furnished.
IV Certified copy is filed with the county building inspection
de artrneI ��W �C ,
Date _p li Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the work involved
by the permit is for one hundred dollars ($100) or less.)
I certify that in the performance of the work for which this
permit is issued, 1 shall not employ any person in any manner
so as to become subject to the Workers' Compensation Laws.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be
deemed revoked.
LICENSED CONTRACTORS DECLARATION
I hereby- affirm that I am licensed under provisions of Chapter
9 (commencing with Section 7000) of Division 3 of the Busi
ness and Professions Code, and my license is in full farce and
effect.
License Number Lie. Class—_./-1___/_
Contractor ate T,; 0
l am exempt from the licensing requirements as 1 am a
licensed architect or a registered professional engineer
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code).
Lie. or Reg. No. Date
HOME OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section 7031.5. Busi- -
neas and Professions Code):
0 1, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section
1044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency
'or the performance of the work for which this permit is
slued (Sec. 3091, (Iv. C.).
ettder's Name
-enders Address
1 certify that I have read this application and state that the
above information is correct. t akree to comply with all County
ordinances and State laws regulating Plumbing and Sewers,
and
hereby authorize representatives of this County to enter �r
laZZ
ntion jl property for inspech purposes. 6
_ �V� - .�%
73ignature of Permitte Daty
APPLICATION FOR PERMIT
SEWER -SEWAGE DISPOSAL
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN
CONNECTION DATA
B UILOING
I�
STATION /
DEPTH
ADDRESS
P
LOCALITY TT'
km
I�wland Hl t
M H FE NCE
(O
(�� T�..�.{..,J
CROSS ST. Colima & 1AMM NEAR ST
TYPE OF C NNECTI
Y. CURB P.
LENGTH FROM
M.L. TO P.L.
T�.� r
OWNER Ol southem CA
�Y
ryes
CO. IMP. NamMAIL
}OB NO. 9�/per
QBapns
ADDRESS 4600 Dr.
TRUNK PERMIT NO.
ROAD PERMIT NO.
CITY UctBch TEL. NO. 54 500
IFIOAVIT I
WANERsEME
cow.. TR. .0.
DATE
LEGAL
DESCRIPTION LOT NO.
70
HWY. OR ST. WIDENING
BLOCK TRACT33636B
STATE ENCROACHMENT
PERMIT NO.
NO, OF BLDGS.
SIZE OF LOT NOW ON LOT
USE OF
CHARGES
BUILDINGS
CONTRACTOR AaGM, inr
CONNECTION CHARGE FEE
ADDRESS Vild]_W Way
REIMBURSEMENT FEE
CITY Santa Ana TEL. NO. 972-9656
STRICT NO.
o«
"3
EN MAP PG
tr
�C.. �s
PRD=EasED ..
J
yjF✓'�
STATE LIC.
LICENSE NO. CLASS A
NO.
DESCRIPTION OF WORK FEE
FINAL DATE
VALIDATION
«NE=T,N�op
_
TANK, T —
R:`h:`Eco
FINAL
O
BY
it ®sw • � l^.
.2 2.
OWNER'S Permit
AUTHORIZATION TOTAL FEE
T YRIE D H THE HENEIn NAMED CGN-
TRACTOwTO C E
Ae DYE DESCRIBED eal�Na
P
TD THE UDLIC SEWER.
SIGNED THIS DAY OF tg
xrw.EN a
+s
SEE REVERSE FOR EXPLANATORY LANGUAGE
}
0
U
O
F-
U
W
to
to
z
v
c i i
�ooc.�oeovgi x „ezo°'ij lu
y O S M O b 0 O 3 C %,
o v o,
Bt
O
uov�
o� �C3z~
o
c°Notihss
v
o Q c s t n E
W
a~o oi.` 4o ana tpc" ��o°mac
n
N V n" e
�CIS
.a
bi
gtl y a ro
y i
?
d a o orn
fi p` w.^, of r Z° p
OF
,a
Y •� b y C y u ' „ -p n
b b o, o� •+"t..
,,� 1O� 1}O.
O 'Y ti Q y � y� ••�V C C C h .� � .a � +: G -C O�
w
., b
o ti
c C y � V O O 'c i ea "! V 3` C o= �c `.,,
o
a
'�
T ""� a � ,�, � � " ` •O U O O �
E
d_ c usOy c e cr �a4
22
e
z
z
fN
v:
•
J
U
�I
N
,
w
F
O
J
ouj
c: U uJ
Ye
J
Q ,a0:
w
u"> QW
Qa
J Y J iZ
3
wN rn�r
O�;
Q, w, °o IwLL
�'
>'
NaI
U�
w 03 N?
Q'
�O' a:
O
(L
Q¢'Co.
O Z�
17
JO
a� US
ZZp
vwi--
JF-
�,UZ;Q�
Q o : w- U
0
¢�
i(D zo
wa
= Z�
~aU
°-
wQ oZ
Y a
ZJ
N
H3 mQ
Uw
mown
Z �m'cwn¢
U
Qvwil ❑G.