HomeMy WebLinkAbout1268A �-�w� _ _ - ,,.�.�� t �;'7'� � ..-.�+,'�'►
_ , ��WORKERS'CO �iJ�ATIOM�ECLARATION . , ti�1' �
1 hereby affirm thot I hove C certifimte of consant ta saff � �
� insure,or a certifitpte of Workers'Compensotion Insurance,or 7eabaso .
; a certified topy,thereof lSec.3800,La6 C.) CEBOB(REV e/81) qpp�ICATION FOR PERMIT
� Policy nWpRF,'i21'�i�Pa�YFremont Indemnity . �. -
' ❑ce���f�ed�oPY is hereby fumished. S�WER • SEWAGE DISPOSAL
]Ce�tified copy is filed with the coumy buil �g�nspection S3 D� COUNTY OF LOS ANGELES BUILDING AND SAFETY
� x deportmen�.
I Date.�g�,Applimnt �. �_ FOR APPLICANTTO FILL IN . CONNECTION DATA
CERTI ICATE OF EXEMPTION FROM ORKERS' euaoiNG
�� COMPENSATION INSURANCE � nooRess ATL171tOS � sTanon� ocarH
� (This section need not be compleied if the work involved by the D1gmOT1C� B8Y � n�,NHoie aereeeNce �'PER
�� permit is for ane hundred dollon(a1001 or less.) ��P'��'Y �owea
NEAREST Cj0 en prings arpio TYPEOFCONNECfION IENGTHFROM �
I ter�ify fhot�in the performance of ihe work for whith this caoss st. v, WRg P.l M.L TO P.L.
�+ permit is issued,I sholl not employ any persan in any manner . /
{ so as to become su6ject to ihe Workers'Compensation lows. owNee co.vaa.No. ��oe No. /0�3
�� '��� � ' TRUNKPERMITNO. ROADGERMITNO.
.. 4pte Applimnt nooaess 1 Parkview Dr.
�" � AfFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. �AiE
710E TO APPLICANT: If, after making �his Certifimta of �iTY (iOV1T18 �"��TE�;-j�,9�]7�9rJ�FT.
_..wnption, you should become subjecl to Ihe Workers' i�Ai �
� Compensation provisions of the Labor code,you must forihwilh oescaiPnoN �oi��o. �`c��! � hwv.oe 57.wip[wrvc
. comply with such prov(sfons or this permit shall be deemed
fE40It0d. BLOCK TR i STATE ENCROACHMENi
LICENSED CONTRACTORS DECLARATION , .oF eiocs. � �RMiT rvo.
� SRE OF�OT , W ON lOi
, I hereby affirm thot I om licensed under provisions of Chapter use oF � � �
9(commencing with Sec�ion 7DOO)of Division 3 of the Busi- euaoiNcs Residential CHARGES
ness and Professions Code,and my license is in f�ll force and
effect. mNrancroa R•C�.R. P umbing� ITLC. CONNECTION CHARGE FEE }
License Number��.�,a__Lic.Class�3 fr_ � � �aeiMsuRs�Mer+T Fee �
nooeess p
COn��O[fO�Dl�D 'D�v�in}vir�DOfB ��I�I�A _F� � DISiRI�TNO. GROUP MAP CROCESSEDBY V
Q CIiV . TEI.NO. �� eK Po'i Z
❑I am exempt under Sec. of the l.A.Co. uC Nse no. ewss L O
PlumbingCodeand/or5ec. o{�he �O. DESCRIPTIpNOFWpRK r�e � � FiNA� �"j
HOUSE SiWER CONNECTING TO DATE VALIDATION d
8.8 P.Code far rhe following reason PUBIIG SEWER I� - N
SEPTIC TANK,SEEPAGE PIT OR FINAI � � �
PITS AND/OR ORAINFIEI�
�O1e HOVSf SEWER CONNECTING TO BY
PRIVATE DISPOSAI SYSTEM
� $ignOtUle CONNECT AO�iTiONAI BLOG.Ok ►
� OWNER-BUILDER DECLARATION . woeK io House sewee �
i"''�reby affirm fhat I om exempt from the Comroc�or's License �N.,��CE55�POOLGDRYWEOLRAMANHoie �
' i for the followin9 reason�SCtf00�O3�.S,BUI511C55 OfICI PIO- AITER,REFAIR OR ABANDON HOUSE �
te55ion5 Cotle�: SEWER OR DISPOSAL SYSTEM
❑I,as owner of the properly,or my employees with woges os
Iheir sole compensation,will do the wo�k ond the strudure � �.- � G{�,�;�y
is not intended or offered for wle�Section 7044,Businass
and Professions Code). OWNER'$ PernSit S 'a �(J' � �0 4 0 � � Q
❑I,os owner of the property,am exclusively contracting wlth A1�TH�RIZATION TOTAL FEE r C I
�i[e�sed Can1�aC�o�S 10 COns7�UC1 if10 projecf(Settion 7p44, i HAVE AT TNIS DAtE A CONT2ACT WIiH THE HEREIN NAMED CONTRACTOR TO �f ��� E��'"�`�
BVSI�E55�fICI PfOfE5510f15 CO(JBJ. CONNECT iHE ABOVE DESCRIBEp E%ISTING DWEIIING TO TNE PUBIIC SEWER.
CONSTRUCTION IENDWG AGENCY � °^` `<�7=��C`-ao
I here6y offirm thot there is o conslruction lending aqency SIGNED7H15 OAVOF � Iq„_ J`
�. for �he performance of ihe work for which ihis permii is owNea Oa . l)��',.L �(�
OWNERS AGENT
i, issoed(Sec.3097,Civ.C.).
nPORess
lender's Name �
Lender's Addross �
I certify thal I have raod ihis opplication and s�ate ihqt the
a6ove information is correcf.I agree to camply with all County �
ordinances and Stote laws raguloting Plum6ing and Sewers, .
and heraby authorae rapresentatives af lhis Counry�o ente�
I upon the abov entioned pro eny for inspection purposes. .
RCR BY��Ah�IU�p-8/14/86
Signolure of Pormitfee Date SEE REVERSE FOR EX►IANATORY LAN4UAGE
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iNsrKro�rs Nores OLi'1vER-BETII.D�F:AECLARATIE)N
!►PPROVplS �^T�f. ��T���+�T� IherebyaSfir�:ths:�ar.scx.W�tfec::theContzuctor's
NEW HOUSE SEWER � . y,�„'I E , Liceus�Laa�for tt;r foling�ing rPa.ron/SatJoR 7031.5,
Bntr�ers a�d!i»j�urora Codr��Arry clly m c�riy
odr
NNNECT A�ORIONAL f(JllIC`f M%f'BS a /�t(i Cp1yl�'Ydt,pl�
Bl11lDING OR WORK - � � ��
A D/OR ORA N!E�LD��5j �i*b��'Y�O�i.'acy aM�saJorr.�to TO imrrencr, �
�aqn' app�+�Jrs� p�rn+:r ro}ife a
sig�ar6 st.lvearwt ahw b.i u Ji�wa�d parawawt&r 6$s
.tcsevooi❑ atrwrtt❑ Aroe�i+i�w'�tLe Cesa�s�s b:.vrar 6ww F��Dbr 9
ona
s�ewa'c�os�'aow svsr� � � /c'o�wwnu'ir�wi�b S�atinw 76B0I al�*3 oj tbr
� br�cixaes�aud Arajrwskwr Cedy1 os tbrt br;s areonpt
w��c�us[sE�wgx � � .tberofinnc and tlw ha.:xfor tbr
aU�wi wmpeiuw,Aeiy
aac u s�ric rAuxs � . +tioloaee of SreNo+r 7091.5 by ary appJbcaatfov a ponnit
sar,r�ris>❑ CtS5P0045 snBjB,:ds ihe tg?Qdk6Ni to a Ciwil�rr/IGy�of noF 1qus�r t&!7i
. . jHre be«wdnd dollwa($SflfiJl:
❑I,ac t5e uw-ner of t`r.e gropeatq wilt de t6e we�� �cd
. . . � tt�e straduee ic noY it�teoded ar offrrtd far sele.
/Src. 7044.B�crw�ec ard Rr�imu Codu Tlr'Car-
. . � . . � d�ector's Lieva+a Lau+d�ws nnt qbply to aR wwrrr of
� � A�A�9 wbo Erifdr or iaopnoem tbs�w.asd w!m dors �
sxcb umk ba�r#A�tl�aocb in�pim+wnewp
�rnar,�e:»x+,rdrd ac aj�ruwd Jur aaiir.If,bavuirwr,rhe
�- d'uililnrg or i�rprnwrnswt is sold wip6ua an�a yam'of
- � cor»plaeoor, tLe o�unen8eu8irs wiiY!ww ILr i�rrd�tr
� , . . . , of prn�g tlwt be did+resr brild ow i'xx¢raor fer tEe
kb�+�f+ak.l
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Date
Ove�ner
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