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HomeMy WebLinkAbout7244AWORKERS' COMPENSATION DECLARATION I" I hereby affirm :that I have a certificate of consent 10 self2�Dz PW'" insure, oT°o certificate of.Workers' Compensation Insurance, :or a certified copy thereof (Sec. 3800, Lab C.) e s FPLICATION FOR PERMIT Polley No.� ornpony RA ❑ Certified copy:is hereby. furnished._ A E m E IS®SAL Certified copy is filed with the county building insp oni A 0 N LOS ANGELES BUILDING AND SAFETY dep rtmen Date Applicont Bramalea Ca,_Inc. FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS Aol©R�ss S. Leyland I3r. . STATION DEPTH COMPENSATION 'INSURANCE "i� (This section need.n of be completed if the work involved by the e.l�amond Bar mills MANHOLE REFERENCE UPPER permit is for one `hundred dollars ($100) or less.) LOCALITY LOWER NEAREST TYPE OF CONNECTION LENGTH FROM - 1 certify :that in the. performance of the work for which this CROSS ST. Y. CURB P.L. M,I TO P.L. permit ls.issued,.:I.Shall not empl O.y.any person In any manner r-+ RC NO. so as to �become..Subject to the Workers' Compensation Laws. OWNER Bramaiea Ca, Inc. CO. IMP, NO. JOB Date Applicant B ai la d Ca, Inc . bpRESs 3151 Airway Ste . N TRUNK PERMIT NO. ROAD PERMIT NO. - AFFIDAVIT WAIVER EASEMENT RECORD. ENSTR, NO DATE NOTICE TO.APPLICANT: I# offer. making this Certificate of C€TYCpsta Mesa 9262�6 NO. 850-1001 Exemption, you :should ;becomesubject.. to t.he; Workers' LEGAL Tpensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. 11 HWY, OR ST. WIDENING .ply with such provisions or this permi! shall be deemed revoked.. BLOCK TRACT STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION NO. OF BLDGS, PERMIT No. S€ZE OF LOT NOW ON LOT I hereby. `,affirm: that I am aice.nsed .under; provisions. of Chapter USE OF 9 (commencing :with Secii.on 7000) of Division 3_.of. 1he..: Busi- BUILDINGS CHARGES ness and Professions Code, and my license. is In full force and effect. CONTRACTOR Brama-lea Cap Inc. CONNECTION CHARGE FEE License Number. 4.r0-96-14. Class B ADDRESS 3151 Airway .Ste. N REIMBURSEMENT FEE Con tract af Bramalea Ca, t}�L'LJ�..» ,-- CITY Costa Mesa 9262 iEt. NO. 850-1001 DISTRICT NO, GROUP MAP PROCESSED BY BKPG ❑ 1 am.exempt under Sec, of the L.A. Co. LICENSE NO. 409610 CLASS B 10+07 Plumbing Code and/or Sec. of the ND. DESCRIPTION OF WORK FEE FINAL : HOUSE SEWER CONNECTING TO —""" DATE VALI ATION 8. 8 P. Code forthe following reason Puatic SEWER SEPTIC TANK, SEEPAGE PIT OR FINAL PITS AND/DR DRAINFIEID 6Y Date HOUSE SEWER CONNECTING TO ,r�`✓` .,? s PRIVATE DISPOSAL SYSTEM 5tgnature � � �w e CONNECT ADDITIONAL BWG. OR OWNER -BUILDER DECLARATION WORK TO HOUSE SEWER OVERFLOW SEEPAGE PIT, DRAINF€€LD I hereby- ,affirm that I am exempt from:the Contractor's License - EXIN., CESSPOOL, DRYWELL, MANHOLE Law for the following reason (Secton .7031.5, Bulsness and Pro- ALTER, REPAIR OR ABANDON HOUSE fession s: Code): -.` SEWER OR DISPOSAL SYSTEM I, as:owner of.1he property, or my employees with wages as their sole compensation, will do the work and the structure is not intended or;offered for sole (Section 7044, Business and Professions Code). OWNER'S Permit $ 56.. ElI, as . ownerofthe property, amAUTHORIZATION .exclusively contracting with TOTAL FEE licensed:.contractors to,'consiruct the 'project _(Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO Business and Profess.lom Code). CONNECT. THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. CONSTRUCTION LENDING AGENCY��, l I hereby affirm that there is a construction:SIGNED THIS DAY OF lending agency -� OWNER OR for the performance Of the work for. which €his. permit is .. OWNERS AGENT Brainalea Ca • InC • .. issued (Sec 3097-C€v. C.). a Lender's:Nome Toronto Dominion Bank AODRLss�i51 Airway Ste. ?,Costa Mesa 9262 Lender's.Address San Francisco; :CA I certify ;that.(..have read this application. -.and state that the above' information is corred. l agree to comply .with all County ordinances and State laws regulating Plumbing .and Sewers, and hereby authorize representatives of :This County to'enter ' upon the above-menti�ropertyr. inspedio purposes. Signature of Permittee`,` Date SEE REVERSE FOR EXPLANATORY LANGUAGE