HomeMy WebLinkAbout3333 BREA CANYON RD (6)WORKERS' COMPENSATION DECIARATIOM
I hereby al4irm hat I have a certifitote of tonaenl fo self
insure, oi o ceriifimie of Workers' Compenwtion Insuranca, or p
a e.,E ed oPY,e,aot c5e. , ab .> E ^ QE B,B, . qppLICATION FOR PERMITPolicyNo. Compony 0s
Cenified topy is hereby fu niahed. SEWER - SEWAGE DISPOSALI
Ce t'rfied copy is filed with the counry build ng impeaion COUNTY OF LOS ANGELES BUILDING AND SAFETY .
daportmenL - _
Doro ApplicoN FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE ass jF,p sintiOr+ / 'i^ , oevtH .
This settion need nol be completed if he work involvad 6y iha i inY d u w E yEryt[r[E Q spelmifisforooehundreddoilon (S10D) or Iess.J
I tertify tha in the pelformonce of ihe work for which Ihis qEssT. /' tY°EaCO+rtt tqr
permi is iuued, I fhoil not employ ony perwn in arry monne '
Y/ cuke a.
so os o become subjec lo the Wor •' Comperoo ion L F
7
owr v GrS to. iMc. rao.
iUate •7"Os-rlpplim J A oo a[ss .TD .E( Yi. Q6 raur cc qnurra.
NOTICE TO APPIICANT pfrer mak g Ihw Cenifi re oi Ty ! _
Q( AffIDAV1I WAIVER [ns¢Nr
id ' TEL. NO. 4JExempion, yov a bacoma su6ject o he orkan'
i i .
Compenaotion provisions of the Lobor code, you mvat onhwith , ptscmrtipa iOtr+O. Hwy. op 57. wioeNrtaccomplywithschproviaionsarihispermilshallbedeemed
IBVOk9d. BIIXK TRACT SiAiEEfJ ROACNMENi
LICENSED CONTRACTOR5 DECLARATION ' ruo a eiocs. r RMii tao.
I heroby affirm }ho) I om licenud under provisions o/ Chopfer
S iEO tOt rvOw Ow lor
9(commencing wirh Section 7000) of Divislon 3 of tbe Buai- e uii i s a
ness and Profsssions Code, ond my licen e i in full force ond
affecf. '` cp,RR, f / CONNECTIW CHAYGE FEE
Litense Number i 7 Lic. Cloas
p qttn eURse%M FE
CORIIOCfOf • ! (! ia 1 • 8Z GTY i up u / IEl.NO. 13 v DISiR R NO. GAOUP
I am exempt under Sec. of the L.A. Co. a r,p. 'Q jj%` nAu '
Plumbing Code and/o 5ac. of ihe `R PTION OF WORK E
RN,u
HIX/5E SEWER CONN[CiING i0 ' l O O DATE I B. & P. Code for the (ollowing eoson ' °ue K g"'ERIWK. a Pliql
fINAtA't5 AND/pR ORANVflE1D '
HOUSE $EWFY CONNEI'111VG 10 BY
PRIVAi I Y
SignatUr caNrJER AOD nOr0i4 lluG. a+ .
OWNER-BU RATIO ^'` T R
I h y offirm fbot I om exemp from ha C ntractor's License E RF CES+i001 PRVWEII fN
low fw the following reason (Sec oo 7031.5, Boltneu and Pro- xteq. pf ip qa M wOd HpuSE .
fesxions Code): 3YST^
1, os owner oF the property, o my employees wilh wagea as •
Iheir sole compensafion, will do Ihe work ond ha afrucfurs
is no inlended or oKered for wle (Seclion 70d4, Business
ond Profeuions Code. OWNER'S Permil ; jQ Sa .
I, as owner of the p operty, am ez<lusively conlratting wi h AUTH RIZATIDN TpTAI FEE :; ' O
licensed cootroUors to conshuct fhe project (Seciion 7Od4, I HAVE AT THIS DATE A CpJiiACt WITM TME 14i(IN NM'ED COMYALrOG.lO
Business and Professions Code). corrNecr iH[ eove oescR eeo [xis*nc oweuiNG io iN[ wxic s[v+ea ,
CONSTRUCTION LENDING AGENCY (,' ,
I hereby affirm thot ihera is o consfrutlion lending agency 51GNEDTNIS DAVOF I9u
for Iha perfvrmanca of ihe work for which lhis peimit is A O4 '
OWt RS AGENTiSSUld ($GC. .IM] CIV. C.j.
Lender's Name
E
lender's Addreu
I certify ihat 1 have reod this opplitotion and storo thot the
obove informorion is correcl. I ogree to comply with oll Counry
ordinonces ond Srole lows regula ing Plumbinq and Sewere, '
and hereby o horize epresenfofives of his Couny lo ente1
upon f v-meNioned propmfy for f, tion orposes. .
w.. ! — .
Signalure of Peroai o e S[E REVERSE f0e F%PUNATORY IANGUAGE ,
FNGTM FNOM
M.t. 10 P.l.
P.C. NO. ios ra. 6`
NWD PERMIT NO.
4940A
27.5
2Z5p
1213-8
L-
i7
U
L
n
V
iHsr:cro s t.orEs
NEW HOUSE SCh2R 'I C/ yr./ , . .
NNNE'T ADOIiID JAI
BU S ING Or2 \YOCK - -' ' -
SEPTIC iAh'K, SfEF, PIT(5) . - _ '
ANO/OR DFA:NFiEL _. .. .. . . '
ccssroo oanvcu . . . . . -
ALTER, FEPAIR, SE'N R OR
SEWAGEOI<GOSALSVSIEAy -
DISCONNER iWG PN ./ .
ASAN ON HOIJ.: SELh':^n .. _
BACKFi!! SEFIIC I<NKS , ' .
sEev, vir sf cesscpo s O -
t",
IhSPEROR'S tlOTES
k ,
OS1'NL:R-liUI7.DEF llECLAF AT'ION .,
I hcrcSy a[iir: i tLct I ar.i c<cmp. from t5c Con[tactor's
I.iccr.:c La c fo: chc follon.•ing rca.n (.;ction 7031.5,
Iiesine.c: ._r.d Pmfrssin.0 C?,'J: dny ei _v or rouxty
st)ic{ stq'rirrs a fr-n'if 1n consf-r+ct, nitcr, intprat c,
t(lic?, r rn;'- L•; Sf/[cJt Yc. fI: r fn iif 1SfI:6nCe.
afso rcge:iresrtbe a,nlirar,t fnr sac! pvrmit su fi7c a
si,qacd stetnrrcr.t eLe! Lr is li:cnscd pe rsi ant ro t5e
pme•isiorrs f tf,: Codtrce!or> Liecr sr Lav (Cha trr 9
roniv:cnci ,r„ mith .ticction 70G0J , D:c ision 3 nf thc
Buxrncrs csd ProJrs:7or r Cndzl nr that hc fs ammpt
tberrJrn >: cr.;1 tbe i acicJor fSe llrqed rsenaptinrs. Any
riolcrion nJSrrtios i 3I.5 by a-} ar,+licar.tJnr apennit
subjrrls td e c; flicac! m c eiri/ fcr.alf f on! rnnrc tF.an
Jirr Gi:r.drrd dnli.:n (rSDOJ.:
01; :s tF.c on ucr ot t:c prnpc:ry n ill do [hc work, nnd
ihc structurc i; not intc•ndr.l or offcred for salc.
Src 7044, I?«si;rrrs ond Prq;cssinr.r Cndc: Thc Con-
trcctm's Liccrosr Let dncs rint cpplv tn nr. na ncr of
property u 1.n hur(. or improvcs tl crcon, and wbo docs
sLt1 norb. f inr^el;'rrnrided L at saeL in j mucncnfs
cre r:n: intrncad r,r o,f.rcd for scic. If, bo:rcvcr, tbc
baiildir.g o >r,l,>u mvef i-s lJ ¢i:hin one yrar of
nn:plctron, tbe o cr-beildor mrll . bare iGr burden
vf j-oring ti+at 1< di:l not breild or imf rore for ibc
r,:., a.e ; s r.
I arti ezempt ander S c: ,
I3 : P.C. fcr this reason
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