HomeMy WebLinkAboutNo Permit Number WORKERS'COMPENSATION DECIARATION -� - � � � � � � . �t
1 hereby affirm that 1 have a certificate of consen�to self
inx�re,�or o cartificate of Workeri Compensation Insurance,or 1&46'�° G1 rl i
a certifiad copy thereof(Sec.3800,Lab C.) �E�e,REv.,:e3, qppLICATI4N F�R PERMIT
Policy No. T.7A�z�r��
❑Certified copy is haroby fvrnished. - . . ,eIIlTllty ' SEWER - SEWAGE DISPOSAL �
�]�'rlified copy is filed with the counry bui 'ng inspec000 COUNTY OF LOS ANGELES BUILDING AND SAfETY
dapartmenl, �
Da�e��pp�iconr_� FOR APPLICANT TO FILL IN CONNECTION DATA
CE I b�J(EMPTION F' TEkS' gui�o�r.�
COMPENSATION INSURANCE nooaess 337�. Armitos Place $TATION oerrN
(This section need not be completed if the work involved by the iaAi�r� Diamond�. $ar naNHoie rs�Feaeric[ uvv�e
permir is for one hundred dollars(;IOO)or less.) �
I certify ihat in the performance of the work for which this CROSSSSC TYYEOFCONNECTION �r.�rH�ppk,
. � Y. NR! � D.L. M.LTOP.I.
pe�mit is iswed,I shall nm employ any person in ony manner .SOUtI1 COU.T1tT CiOT v.c.No.
so as to become sobject to the Workers'Compensation Laws. owr�e y . P' CO.IMV.NO. ' JO6 NO.
��� TRUNK CERMIT NO. ROAD PERMIT NO.
Date Applicpnt A�ORESS
AFFIDAVIi WAIVER EASEMENT RECORO.INSTR.NO� DArE
NOTICE TO APPUCANT: If, afler making �his Cenificaie of arr � � � Te�.No.
F�mption, you should become wbject to ihe Worken' iE�Ai . - .
� penwtion provisions of�he tabor code,you must for�hwi�h oescqivriori �wTrio, 11 Hwr.ors sr.wioewr�
__,ply wiih such provisions or this permit shall be deemed 42584 & gJr .
fevOklCJ. � ' BLOCIC iRACT SiAiE ENCROACNMENT
. . . Fq.OF BLDGS. PERMIT NO.
LICENSED GONTRA[TORS DELLARATION srze or ior NOW ON 10T
f hereby affirm Ihat I am Ifcensed under provisions of Chopter u5e Or
9 (commencing wilh Section 7000)04 Division 3 af the BUSi- BUILDINGS 12.esidential �Hqp�s
ness and Professions Code,ond my liconse is In full force and -
BIIBC�. . CONiRACTOR CONNE[f1ON CHARGE fEE
LicenseNumbei���{I}C.C�O55 (� �J ADWtE55 12 85 �Ma nolia� Ave. 'REIMBURSEMENTFEE �y
""`^'r��] U�J 6 • DISTRICT NO� GROIIP MAP PROCESSE�BY 0
COf111pCtOf � V�l� ' CI7Y Riversiiie ,E�:,,�.� 371-5000 �0 BK K"i � V
�" SiAtE IIC.
❑1 am exempt under Sec. of�he L.A. o. uceas�No. unss a
O
Plumbing Code and/or Sec. of�he NO. DESCRIP710N OF WORK Re F��� V
HOUSE SEWEN CONNEQING TO �„_ DATE —7 VALIDATION W
PUBIIC SFWLR
B.8 P.Code for the following�eason � I�a� 4
IC ANK,SFEoqpE PIT OR N
� pITS AND/OR DRAINFIELO fINAL � � ' , a'
DO19 p�VATE D�R CA�I YSTEING i0 BY ;�✓ y-,J-�
�GG�/
$igrlalUfB CANNECT ADOIiIONFl9L�G.OR �
OWNER-BUIIDER DECLARATION WORK TO HOUSE SEWER
OVERFIOW SfEPAGE GIT,DRAINFIEID
1 heroby affirm�hat I am axempt from�he Contrador's license exrN.,ce55voot.oavweu,mnrvHoie
Low for the following reoson(Secton 7031.5,Baisnass ond Pro• utea,Reaaie qi aB�ivooN House
�ipn5[Ode�: SEWER OR DISPOSAI SMSiEM
I,as owner of the proparty,or my employaes with wages as
. fheir sole compensation,will do rhe wo�k and ihe structure �� 2 7�� A
is not iNended or offered for sole(Section 7044,Business �
andProfessionsCode). OWNER�$ PBfTiT S U #• • •�• � Q
❑I,os awner ot�he p.operry,om exclusively conrracting with AUTHORIZATION TOTAL fEE ^' ,S 1 • •2 7,5 0
IicenSad contractors to consiruct the project(Section 7O4d, I HAVE AT TNIS DATE A CONTRACT WIiH TNE HEREIN NAMED WNTRACTOR i0 '
BU81fIC55 Oltd PIOfe55i0I15 COdC�. -CONNER THE A60VE PESCRIBED fk15TING OWELLING TO TME PUBL�C SFWER. ' '� • •2 7,5 p U
CONSTRUCTION LENDING AGENCY � �
I he�eby affirm thai there is a conshuclion landing agency SIGNEDTHIS �AYOF 19_, ► Q�,� � -85
for �he performance of �he work for which �his parmit is °wNEa oa �
OWNERS AGENT
issuad(Sec.3097,Civ.C.).
ACORE55
Lender's Name
Lender's Address �
I certify ihat 1 have read rhis application ond state that the
abova informa�ion is correc�.I agree to camply with all Co�nty
ordinances and Siate bws regulating Plumbing and Sawe�s, � �
and here6y authorize representa�ives af this Counfy to enter
u n t e above-mention proper for apettion purposes. �
�. .R. sy: �O.�Q��6/21/85
Si9notore of Permit�ee Dc�e SEE REVFIISE FOR EX►LANATORY I�NGVAOE
� D n n....-. .
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; � __ i�ro�•s rrovea ' OVi':V'ER•�!'iL4I�R 1?[iGLASit'fDO:�
. ._ ._.___.._. ,�_.�.�..�.-_..+..
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h°'i�C)b�LS � � ' ^ '-^�=.'+�""'"� - -- -...�. -�_-..--__-- —. � �"..�. .� 1 l�erehy��IYirm.that 1 am exawtpt frun�the Gontrac�or's
' �n.0 ,,, _.�.uc . . . . 'Licensc Law fur the Adluwdnq rs�on(9rrtean 7p31-.5, � ..
_ _. —_-.�— --.-.—`_ � � .&uxuacrs,aud Professian,s€:odo)'Auy cik or c �whceh
� ���'` r� '� � �� �� � ' . � re ires a n��t m constroct allcr,un ave, �
�
i.c r� r r j�:.� . . � . . _ .. � . . . 9�+ ,.Per' Pr Arm�'As or
. ��, r� v qs -�--�---� ' ----- � - . rcK+a�r ow,�sNuc(ure,prinr[i f e:.��uext. a.� eq�eiree!be . '
o-rye or.. �e:o � �-- i.�--� --- -- --- -- �,apyhceHt frw sueb po»eit ro fele a si�ra�d sh�+rmtir�thn[he es
esa 2❑ c�v-n.O �4 . . . - - --- ' --- --.— , lirensed pwsuent!n !ba provrsmms of tlhr C�+kru,-,ror'�
. ��.ine v+,�iv>�r:�s.•c.-._=� --'". � ' . , _ .. , . . . . Gicrrase Law(Chaytrr 9/coarme»ri+�F�tk Sechon 70W)of
I�. c Y �. �� -- � -- 'Divesio�i.�oflke Iiu�utesa nnd Profe csinae Code)nr tl�1 h..is'
i-...�c i ��r o. '� T .. .. — . . . . . . ..� exerx�l therEjrr m o�1he 8pa�s/w 1he ulM,qed Rse�rrp4da. ,
p9A �N H E S..V � - � . �-� � �� .. •� . Ar.y iiolatios nf Sechox 7831.5 by any applicme fi�r a permi( �
t_,, u -r�-qti j _.�_. _-,___-�___—.,.._...___� . . . .� . _ .' ._ . . subJc<[i!he appt ant!n rs cn•if pmutL}qj nol wore tkau fis¢ �
:[°. �. ❑ c�� �b,.s.i � .� ____.- _ -._.-----�— ---�---��------�-'•-- 'hua�dr�ed dolFars(�5pf1).: "
._.,...o..._.........,....,..�,.._..a....«>.-.....,„.._....._..,...,....�...,.._......._.,..._, . . . . � .� �1,as the o»wer of lhc penpecti will ciu tln�H�ork,and
' .. . � � ^ � ..--- -�---i--- — tMe sEructore is not intendcd or oRt+e�!firr salr.
. . � , . . . . -- - - --- � (Sec.704�i,Busi�rss m�d PreJF's.s�r Codr:Ths Crmtrartnr's� ..
, � . . . Lieen.ee I.aw�daes itol�apply to ux oti�uer af qropv'(y r" .
. . . ' _ � � � . . . .. br�ilus or improves fhereoq,mx!h�ha drws such worA brin. -
- �- � � � � _` provrded the[such improvrmenu are nrx i»ter+d�ed or o,f'f'n�ed
� . . . ..� . . . . � . . . . . for snk.lf�huwcws,tbe 6rilaW�g or iaty�ow�rtt is.vold
� .. - � � . � _.______-_.__._—__--.___.__-____—_. wi!{�in onr year af com.pletiaR,tbe nx•iier.buiWer nill have the
. . . . . .. � . . . . . � . b�ardcit nf prnrixg that hit did not 6w�Fd ar imprane fer the
. . . . . . . . . _T - — purpn.rc nf sak.1� � . .
_ ------- ------- I am esen�pE undrsr Sec. �._�_
----- B&P.C.fiir lhes,reamn _
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------ ON ner _
� nes�croes yores l--- _
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